Can you give us your interpretation of what the main role of insulin in our bodies is?
My approach is trying to keep things simple. I try not to over-complicate things, but from a clinical practice of internal medicine, obesity medicine and keto medicine, insulin is actually pretty complicated; it’s hard to boil it down to just one thing.
I think in the big picture view, you’d want to think of insulin as something that’s essential for type 1 diabetes, as a drug. Otherwise, it’s something that you don’t want much of – so, even shots of insulin that you get for type 2 diabetes or the insulin your body secretes in response to having sugar and starches (which get digested to sugar). I’m going to avoid type 1 diabetes – that’s where you don’t make any insulin at all and you need injections. Let’s just talk about people in general and then type 2 diabetes.
You don’t want much insulin inside your body all day long. You want to have episodes of going up or maybe even not much at all. It turns out insulin is a growth hormone; it promotes growth of muscles, it promotes growth of fat cells, it promotes growth of cancers. So, because it’s in that growth hormone category, it also means that it’s pro-inflammation, because inflammation is part of this whole category of chemicals that you need to repair muscle. Did you know that when you work out at the gym and you get sore, that’s actually inflammation happening to repair things and make you stronger? There are even times when you are trying to get that kind of inflammatory response, but generally speaking, you don’t want insulin around to push your body towards excessive growth, especially fat cell growth and inflammation.
We often hear the term ‘insulin resistance’ and ‘insulin sensitivity’ – what is the difference?
Well now, did you notice that when I described insulin, I didn’t mention blood sugars? It is a hormone that can lower blood sugars, and that’s what I’ve been trained in; how great insulin is, ‘Isn’t it wonderful?’, and well, it really isn’t designed to do that. How do I know this? Well, it’s something that we in the keto community have looked at and talked about for a long time. If you weren’t eating much sugar and starch at all, you wouldn’t need much insulin at all. You would need some insulin to help growth in the muscle cells. So, most of us have the idea that the idea of insulin is to lower blood sugar; that’s really not what it’s supposed to do, but our bodies use it for that, and that’s where insulin resistance comes in – your body doesn’t want all that sugar going into the cells, and insulin helps the sugar into the cells, so basically, it turns down the volume, so to speak, or the effect of the insulin. That’s what is called insulin resistance, when really, it’s just a normal response to having too much sugar around.
Again, I’m trained in internal medicine, obesity medicine, keto medicine, and we were all trained that there’s some abnormality in the middle of the cell that causes the insulin resistance and it sends out signals to the cell wall, but really, that’s in response to having too much glucose coming into the cell. So, if you look at it from another perspective, insulin resistance is a form of “carbohydrate intolerance,” meaning your cells are trying to keep the sugar out of the cell, turning down the ability of insulin to bring it in. So, the endocrinology model of internal medicine is to just give more insulin, when insulin doesn’t work well. Did you know that there are now such concentrated amounts of insulin in a vial, you used to only get what’s called U-100 with 100 units per milliliter, now it’s U-500. In fact, they’re trying to make even more concentrated insulin so that you could just keep pushing the glucose into the cell. The problem is there’s too much glucose already!
Let me explain it in a different way. When people with elevated blood sugars were examined (they had type 2 diabetes), the insulin in the blood was already high. Remember, this is not type 1 diabetes, where people don’t have insulin at all and need insulin. (Generally that’s in childhood, but some adults have type 1 now.) With type 2, people had high blood sugars, but their insulin was already too high. So, this is where the idea of insulin resistance came out – where if the blood sugar is too high and you have a lot of insulin, it must be that the insulin doesn’t work right, and that’s the abnormality, so let’s give more insulin – without thinking that maybe the problem is that there’s way too much sugar around in the first place.
This is where obesity medicine and keto medicine breaks from the traditional endocrinology and traditional internal medicine. Remember, I’m at Duke University, I’m past president of the Obesity Medicine Association, I’ve been in the mainstream medical community for my entire career – 30 years at Duke. I don’t say this lightly. In fact, it’s taken me 15 years of using this kind of approach to speak with the confidence that I do, even though I know there are other doctors who don’t understand this and speak against what we’re saying.
So, insulin is already high if you have type 2 diabetes – I think the last thing you want to do is to take an insulin shot for type 2 diabetes, which then makes you gain weight and puts you on a path of always having type 2 diabetes. So now I’m at this point of conflict with patients coming to me telling me, ‘My doctor says I have diabetes and they want to put me on insulin and I’m overweight.’ They understand that maybe there’s another way. So, I just explain that if I can help you lose weight, change your lifestyle, you don’t need to go on insulin. So, that’s often the point at which some people come to me for help, because they don’t want to go on the insulin shots – they know that their family member went on insulin and they didn’t really have a good outcome. This would all be great if insulin fixed everything, but it really doesn’t.
So, unless you have type 1 diabetes, you don’t want to have much insulin around.
What about insulin sensitivity?
Insulin resistance and insulin sensitivity are really the same thing, just calling it something from a different perspective. So, to increase your insulin sensitivity, you want to reduce the glucose going into your bloodstream and lose weight. It turns out that abdominal obesity – if you have extra weight – actually causes and contributes to the insulin resistance, meaning not insulin sensitivity, but lower insulin insensitivity.
It all comes together in the low-carb/keto world, because there’s really no better diet and better lifestyle approach to lower insulin levels than to take sugar and starch out of the food. Really, on a keto diet, you’re eating foods that don’t raise the blood glucose and don’t raise the insulin levels – that helps insulin sensitivity improve, or the insulin resistance to reduce.
A lot of the time, a doctor will check your hemoglobin A1c or HbA1c before they check fasting insulin. Isn’t it true that fasting insulin can tell us a lot about where a patient is headed, before they even have an elevated A1c?
The reality today is that many people come to me already on insulin and already on these other medications for diabetes,and I get to help them get off these. I would rather have you think about this before you go down that path any further. So, let’s say you’re otherwise healthy and you have a normal weight – it turns out that’s not going to give you the best indication of your tendency towards diabetes and towards an unhealthy metabolic state.
So, measuring a fasting glucose and fasting insulin and even your response to a sugar load (to see how far the blood sugar and the insulin go up) are all important indicators that your metabolism is going down that path, towards type 2 diabetes. So, you can get early indicators that you’re susceptible to that and it’s important to do so if you’re worried about long-term health – maybe you need to be convinced about why you need to restrict carbohydrates and sugar. Well, you get the fasting sugar, the A1c, your fasting insulin, and if those are elevated, it means you’re going to do better with less carbohydrate, less sugar and starch in the food you’re eating. The whole medical field is shifting from avoiding food that has fat to avoiding food and drinks that have sugar.
Is there a range that people can look out for? What is the normal range of what the fasting insulin should be? Is there a range beyond that, that you would be concerned about?
You can actually look up a range in milligrams per deciliter or a millimole (depending on where you live); we use milligrams per deciliter in the U.S. for blood glucose – anything under 100 mg/dL is normal. The interesting thing is that the sugar level itself doesn’t tell you how much insulin it takes to keep the blood sugar down. So, even after a meal – say you eat a big apple and your blood sugar goes up, you have a big insulin response, which keeps the blood sugar down, you’re not going to know that you had this big insulin response. We believe that that insulin response is not good. It means you’re going down that insulin resistance pathway. So, you want to have some kind of evaluation that includes blood glucose and blood insulin levels.
But if someone comes to me to start a keto diet, I don’t really need to do all these tests, because I know it’s going to get better on a keto diet. But, if you’re not sure, or you need to be persuaded that your metabolism needs something like this, these are useful tests.
For people who are not following a keto diet – those eating between 300 and 500 grams of carbs a day – would you say that type 2 diabetes and obesity are progressive conditions for them?
This is one of the sources of confusion – doctors often say that diabetes is a chronic progression. But that’s only if you’re eating a bad diet and have a bad lifestyle, which is causing diabetes itself. It’s like saying you can never cure this infectious disease, because you always have the infection around. Well, that’s true! So, let’s take you away from the place where the infection is – if you treat the infection, you don’t have it again. Doctors and endocrinologists will say that you will always have diabetes, because they assume you’re always going to be eating a very high-carb, high-sugar diet that caused the diabetes in the first place.
I hope we get to a day where the doctor will at least give you a choice, where they say, ‘Well, it looks like the diabetes is getting worse and I need to put you on this pill, OR, you could talk to that lifestyle guy down the street.’ The problem is that most doctors assume it’s hard to do; they haven’t been taught how to teach people. Doctors have been taught to just use medicines. But a growing number of doctors are seeing that the lifestyle approach, however you do it – it doesn’t have to be keto – just getting the carbs down and getting the sugar out can be so helpful for many people.
Will your simple, non-surgical solution of sticking to no more than 20 grams total carbs per day eliminate sugar spikes, and therefore, insulin spikes?
Let’s move onto a couple of questions. Jess asks: ‘I’m currently insulin resistant, if I start your program, is it possible to eventually become insulin sensitive again?’
Yes! There’s a timing that’s important to know – it may not happen overnight! When you do a keto diet, there are two things that are happening: one is, you’re taking away the food and drink contribution to the blood sugar and insulin on the first day, so there’s this big effect. In fact, I have to reduce people’s insulin on the first day, because it can be dangerous if they’re taking all the insulin to cover the carbs and then you cut the carbs without the insulin being reduced, which can lead to low blood sugar spells.
The second thing that happens on a keto diet is that the weight comes off, the extra fat weight, and that contributes to insulin resistance as well. So, in my practice, most people will have immediate improvements, but I still have some people who still have insulin resistance a few years into it, because they started at 400 pounds (181 kg), but they’ve still made great improvements in it. So how fast it will improve depends on where you are in terms of severity.
Katrin asks: ‘Your method you use to treat folks with type 2 diabetes – is it a cure or a remission?’
Well, this is really semantic, meaning, it’s just about how you want to phrase it. In the U.S. at the moment, if you say something is “cured,” you come under scrutiny of the federal regulators, and there are a lot of people who use the word ‘cure’ inappropriately – people trying to swindle you, especially in the cancer world.
A “cure” of diabetes is defined as having normal blood sugars and no evidence of diabetes for five years. That’s been the standard article in the medical literature. You can say “in remission” or “reversed,” and it doesn’t come under that same scrutiny. So, what we like to say is that you can reverse diabetes, meaning you get off the insulin, your blood sugars are normalized, and you have no evidence of diabetes. When that is maintained for five years, then yes, that’s a “cure.”
The interesting thing is that most other doctors who don’t use these approaches have no idea that you can cure diabetes. They don’t know how to do it; they feel like they need to follow guidelines that push you towards medications like insulin, so that’s the conundrum that we’re in.
Tia asks: ‘What is your success rate for reversing obesity and type 2 diabetes in your clinic?’
Well, it’s a hard number to get at, the success rate. Pretty much, if you do it and you follow it, it’s almost 100%. So, when you look at the success rates, you’re also looking at how well people follow it. If you put people in a metabolic ward (sequestered in a hospital where all your food is provided and you don’t have access to any outside food), and these studies were done back in 2004-2005, it works for everyone, because you’re in a metabolic ward and you make people do it, they have no choice. You come to a residential program, like in Durham, there are several residential programs where you can move and stay here, and if you follow it, it works 100%.
So, the problem is getting people to be able to do it in their real-world, real life. In the clinic, where people come to me from various stages of disease, it’s not 100%, because people can’t follow it 100% at home when they have all of the distractions and holidays and things like that. So, how do I turn that around? I basically say, ‘This is like a pill. The pill has been studied and it works, and it would be FDA-approved if there were a process for it. So if you follow it, it will work. But, I can’t make you swallow the pill!’ So, yes, it works, but I’m not perfect in getting everyone to follow it. This is where support groups and even addiction groups are helpful to get people started. It’s pretty amazing how effective it can be.