Insulin Resistance and Metabolic Syndrome with Dr. Ben Bikman

as Jack mentioned this is metabolic classroom 2.0 and it's something that I have long missed from those days when this was coming to you weekly uh I really enjoyed that part of my professional aspiration has been and still is this desire to take ideas that are really discovered in Laboratories and find ways to share them with the public you know many of these ideas when a neat Discovery is made it is published and it is in a peer-reviewed science journal behind a pay wall written in a scientific jargon that most people won't really appreciate and

be able to understand that's what this is then the metabolic classroom is an opportunity to Simply step over that hurdle and uh share the information directly with you people who want to learn and that's why I call it a classroom from here and forever on out it's because I I like the idea of me being your professor for a brief period of time I'm teaching you these principles and then you're able to remember them understand them and hopefully um come to some lifestyle changes at the back end now as Jack mentioned the title for today

um is focusing on insulin resistance in the metabolic syndrome and I could describe that another way which is just kind of understanding metabolic health and that's uh that's at the heart of what I wanted to focus on for the time that we have during the lesson itself and again please submit any questions nothing Thrills a professor more than getting a lot of questions so make sure that you get those in and I am happy to address them as as the as we have time and I'm and we're going to have plenty of time so get

them in all right so first of all metabolic Health we've all heard the term metabolism a lot it is it is a buzzword it is a word that we hear perhaps too often and even even to the point that it's often misused metabolism just to be very precise is the balance of all of the chemical reactions that are happening in the body there are biochemical reactions in every cell that are trying to build up molecules those are called anabolic reactions or anabolism and there are chemical biochemical processes that are degrading molecules breaking them down that

is catabolism and metabolism is the fusion or the balance of all of those things the sum of all of those reactions now with metabolic Health uh now we're starting to get more specific to the topic there are generally in my mind two ways that we can Define metabolic Health perhaps Others May May submit that there are other ways to interpret that term let's just stick with two and I think this encompasses any real iteration that we would come up with with metabolic Health any def definition so the first definition is simply defining metabolic health or

explaining it through the lens looking at it through the lens of the metabolic syndrome you've certainly heard of metabolic syndrome before and it's nice to start with metabolic syndrome because that gives us some of the best statistics as much as we're going to invoke and invite other ideas and principles throughout this lesson Unfortunately they are a little more obscure to the point that there just isn't as much population or Global level data so if we start with the definition of metabolic Health as some aspect of the metabolic syndrome it helps us understand the scope of

the problem which is significant the metabolic syndrome affects roughly half of all adults across the entire planet that makes the metabolic syndrome the single most prevalent disease or health disorder in the world that's why this top IC matters so much it's why I have why I feel so Justified and even gratified in having focused on metabolic Health as a scientist for my profession because it matters so much the scope of the problem is so vast whether I'm giving a talk in Southeast Asia or in the Middle East or in South America in every one of

these areas and Beyond I know that this problem metabolic syndrome is the main Health disorder that these people are experiencing now what is the metabolic syndrome you've certainly heard of it but let's be very precise in identifying it in so far as metabolic syndrome is one way of defining metabolic Health metabolic syndrome is a cluster of complications in particular five disorders that were noticed over the years to always Clump together they are in no particular order a bunch of highs and a low so high blood gluc ose High waste circumference high triglycerides high blood pressure

those are the highs the four highs and then lastly the one low low HDL so let's just revisit those each very very briefly so the high glucose that's no surprise that's a sign of poor metabolic Health your body's having a hard time clearing the glucose as you eat it as you put it in your body it's just lingering too long and chronic hyperg glycemia is pathogenic it will certainly hurt the body it can damage blood vessels and it can damage neurons and more so that's important high waist circumference that invokes or evokes rather this idea

of storing fat more centrally particularly in the visceral space and in future metabolic classrooms we will revisit that topic talking more about fat Depot where we store fat and why that matters um but more visceral fat is reflective of or contributes to higher inflammation and more General poor metabolic Health high triglycerides is a feature of the metabolic syndrome that's the next one and it is a very very good predictor of heart disease risk that's influenced by metabolic Health as the as the liver starts to suffer uh it begins to overproduce triglycerides at the same time

skipping one down it starts to increase the clearance of HDL cholesterol reducing HDL levels considered to be the good or the beneficial version or carrier of cholesterol and then lastly it was the high blood pressure which is directly related and and a consequence directly derivative of metabolic health so those are the five the cluster of complications that make up the metabolic syndrome now at first glance those don't appear to have anything in common that you can't see how they're related but just like all the fingers of my hand that I was just acting up all

the fingers come from one hand so too all of these complications of the metabolic syndrome come from or share one common point which is insulin resistance insulin resistance is at the heart of the metabolic syndrome in fact so much so that what we call the metabolic syndrome used to be called the insul resistance syndrome that was in its very first iteration one of its earliest names when it was first discovered that these problems tended to Clump together insulin resistance was known to be the mediating factor or the the thing connecting them all I actually prefer

that term W that we could go back in time and never change the name to the metabolic syndrome and keep it as insulin resistance syndrome now I get it metabolic syndrome is a much more compelling name it's going to attract much more attention but it is also more vague uh you can't hear the term metabolic syndrome and know what you could do about it when you hear the term insulin resistance syndrome then you could still identify all of those distinct disorders um each in their own um but acknowledge that there's one common variable so let's

address that one common variable of course namely the insulin resistance so with that in mind let me take a moment and Define insulin resistance this is something that we're going to talk about not only pretty heavily this month for the upcoming three metabolic classrooms through the rest of January but this is also a topic that we will revisit a lot throughout this entire um metabolic classroom um forever every episode from time to time you're going to hear me mention insulin resistance whether it's indirectly or whether whether it is directly part of the topic as we

go through chronic diseases um insulin resistance is just that important again the prevalence I've already mentioned which is reflected in the prevalence of the metabolic syndrome but it also it is so important because of its relevance where every single chronic disease is in some way influenced by insulin resistance where insulin resistance is either directly causing the disorder or it is facilitating the disorder and we will revisit that in future episodes so I'd mentioned a moment ago let's Define insulin resistance a definition that is very important for you to remember as you hear more and more

people talking about this it's very common that I hear people describing it or defining it incorrectly let's be precise insulin resistance is a disorder with really two parts I like to invoke the analogy where insulin resistance is like a coin if I were holding a coin in my hand and I say this coin is insulin resistance well the coin has two sides so too does insulin resistance one part of insulin resistance is the actual resistance to the signal of insulin insulin is a peptide hormone made from the beta cells of the pancreas you know that

and as it circulates in the blood it will come and bind on receptors of every single cell of the body that's one of the reasons insulin is so unique as a peptide hormone it is that every single cell of the body from brain cells to bone cells from lung cells to liver cells and every cell in between they all have insulin receptors and so the receptor is essentially a doorway that is built for insulin to come and knock on an insulin will knock on every door of every cell so this is the insulin resistance part

of it though where some of these cells aren't responding to insulin anymore as well as they used to they've become resist istant to that knock so once upon a time insulin would come and knock on the door of the cell let's say the liver cell and the door if you will would open right up and liver would respond appropriately it would do what insulin asked it to do however over time due to insults that we will talk about next in next episode the knock falls on deaf ears and and the liver cell doesn't open the

door all the time or maybe it'll open at a crack it doesn't actually do everything insulin wants it to do that is the resistance part of insulin resistance now please notice the deliberate use of language here not every cell becomes insulin resistant this this is not a universal phenomenon within the body some cells of the body fail to respond to insulin as effectively as they used to or as sensitively as with as as the the the response that you would expect now we can flip that coin over because there's another aspect of insulin resistance and

this is the part that is so totally overlooked and that is that in every instance of insulin resistance with one exception that we'll talk about at a future classroom insulin levels will also be elevated in the blood so if we are now going from the level of the cell to the level of the whole body at the cell there was this selective insulin resistance at the whole body level this is manifested as an elevated insulin level insulin resistance and hyperinsulinemia which is the technical term for elevated blood insulin are inseparable they will always occur together

just like two sides of a coin you can't get rid of one side they're always going to be part of that coin so too is insulin resistance and hyperinsulinemia now that hyperinsulinemia part is relevant because remember there are some cells that still respond to insulin as well as well as they used to as well as they ever did they're still insulin sensitive so you have a handful of cells that are insulin resistant so even though insulin levels are elevated they're not responding that well to it and so it's It generally is just a muted response

anyway however the cells that are as insulin sensitive as ever are now overstimulated there's too much response to the insulin because there's too much insulin relative to normal healthy insulin sensitive levels all right so that is insulin resistance some cells aren't responding to insulin anymore and at the whole body level blood insulin levels are higher than they should be all right now let's move on to the second part of how we can Define metabolic Health as you'll recall the first way of defining metabolic health is through the lens of metabolic syndrome the alternative or an

additional method of defining metabolic health is looking at it as a problem of metabolic flexibility you might have heard this term too I'm even a little surprised at how often it's invoked I actually just as a point of Interest remember when that first manuscript um coming out of the University of Pittsburgh was first published that identified and elaborated um uh this process or this phenomenon in people referred to as metabolic inflexibility so metabolic flexibility let's start with that definition first metabolic flexibility is the ability of the body to shift very readily between the two primary

fuel sources now the cells of the body actually have several fuel sources but the primary fuel sources are fats and glucose so at any moment the body is either primarily fat burning or it's a mix of fat burning and if you will sugar burning or blood sugar or blood glucose to be more prec precise I'll just say sugar burning it just has a good ring to it so at any moment that is the the the primary source of fuel for the body and it shifts there are times when the body is primarily fat burning and

there are other times when the body is primarily sugar burning for example if you were to eat a mixed macronutrient meal it has carbs and fats and proteins because of the carbs most especially you should expect that if you were measuring fuel use in the body the body would shift primarily to Sugar burning of course that would be even more the case if you just ate pure carb the body would heavily shift to Sugar burning now give the body six hours or so get into a fasted State and you should shift over quite substantially to

fat burning so the body will shift that would be a healthy response when you're eating food after that period of time that you've eaten in that post prandial State or the post eating State you would shift to Sugar burning give your body a couple hours or wake up the next day and you'll be in fat burning mode um that is metabolic flexibility what this manuscript noted um the that first identified metabolic inflexibility is that there were some people who even when they were in what should be a fasted State they weren't transitioning out of sugar

burning they were staying in that Sugar burning State not entering into the fat burning State even though the metabolic situation had changed they hadn't been eating they are fasted it has been it had been the same number of hours whereas other study subjects had already gone to fat burning they were still stuck primarily in Sugar burning in other words their metabolism was inflexible it it had become rigid the gears of the metabolic engine had become gummed up and stuck if you will now why of course that's the next question now that you understand what metabolic

inflexibility is it is in fact the why of it is answered once again by invoking insulin resistance or in this case to be very precise just elevated insulin insulin is in fact the director of which fuel is going to be used if insulin is elevated the body is obligatorily in Sugar burning mode if insulin is reduced if insulin is low then the body goes to fat burning mode that is the single most important variable or the dictator in which fuel is going to be used it's all about insulin and again to say that again low

insulin leads to fat burning elevated insulin leads to Sugar burning now let's come back to those people who that were published in this report that were metabolically inflexible can you see why they might be stuck in Sugar burning mode even when it had been hours since they'd eaten and others had long since moved moved into the state of fat burning why were those people stuck in Sugar burning if elevated insulin is determining fuel use elevated insulin in fact in this case was the cause these are people who are insulin resistant and as you'll recall one

of the features of insulin resistance is elevated indeed chronically elevated blood insulin insulin is just staying too high all the time that is such an important point and and when we will talk about more next week and in future episodes as well but that is to sum it up that extra that that additional way of defining or considering metabolic Health cons looking at it as a problem of metabolic flexibility and then you knowing now and remembering that metabolic inflexibility is really a manifestation once again just like the metabolic syndrome is of insulin resistance now one

interesting um tip tidbit um from this and in an interesting aspect of metabolism is that the longer insulin is reduced and the body is in fat burning the more the body begins to burn more fat than it needs in order to meet its metabolic needs specifically if we look at the liver if insulin has been reduced for a substantial period of time the liver like many cells of the body is primarily burning fat for fuel it's in fat burning mode and in fact the fat burning goes on so much that it it because of the

low insulin the liver in a way can't stop burning fat and normally a cell will burn as much energy as it needs ATP I'm I'm getting a little bit off topic here but eight or or to say that another way the cell will burn as much energy as it needs to do work you know so the cell has a certain work demand and it will burn enough energy to meet that demand but if insulin is low for an extended period of time the body the liver in particular continues to burn so much fat that it

starts to burn more than it needs to meet its own energetic needs and that excess is essentially what becomes ketones now my point in bringing that kind of complicated description and introduction to ketones up is only that that can become a bit of a surrogate marker if you were with regards to your metabolic flexibility or metabolic Health if you have fasted for let's say 16 hours and you have a way of measuring your ketones and you find that your blood Ketone levels are still really low um or undetectable that suggests that you have high insulin

levels because insulin would stop if insulin is high it would stop the fat burning which would stop the production of ketones a process that is called ketogenesis insulin inhibits ketogenesis and so if you've entered a what should be a fasted state but your insulin is still sufficiently high to inhibit ketogenesis so your ketones are low you have poor metabolic flexibility or in other words you metabolically inflexible in contrast if you've fasted for about 16 or so hours certainly um this would be the case with even longer fasts and you do see that you have entered

into a higher level of ketones whether you're measuring it in your breath or your urine or your blood with a finger stick then you can be pretty confident that you have good metabolic flexibility that in this fasted State you had shifted to fat burning and to say that all another way you'd have good confidence that you are that you have good insulin sensitivity now the final point that I want to make um in the lesson in this first lesson talking about insulin resistance and again the other lessons in the metabolic classroom this month the next

few episodes will also talk about insulin resistance in different ways including the causes and consequence but the last part of the lesson I wanted to discuss today is just to um revisit this idea of how common the problem is why is it that insulin resistance has been has become the single most common health problem worldwide there are two things that I want to touch on the first is that we that our general medical or biomedical View and approach and the clinical approach to insulin resistance has actually inadvertently made the problem worse so in this case

we've sort of selectively looked at certain aspects of the science surrounding insulin resistance and unwittingly accelerated the problem now that's a kind of leading way of describing it but when most medically trained individuals or average individuals as well who have no formal medical training hear the term insulin resistance or even when they just hear the word insulin they immediately think of one thing in fact I'm curious what's the one thing you would think of when you hear the word insulin you think of glucose you think of diabetes every time in fact just as a point

of Interest you'll notice over my shoulder for those of you that are watching I have a copy of my book why we get sick that book is as a Shameless plug all about insulin resistance including everything we're talking about this month why didn't I call it insulin resistance why it matters and what to do about it because I knew nobody would buy it they would immediately look at that title and just assume this was a book about diabetes and they would think well I don't have diabetes so I don't care that's not the case but

that is why the partly why the problem has become so prevalent it's that we look at insulin resistance as a glucose problem but earlier in my description and my definition of insulin resistance what did I say was elevated did I say that the glucose is elevated in insulin resistance no I didn't I said that the insulin is elevated in insulin resistance and that therein lies the problem that insulin resistance also known as pre-diabetes is a state where insulin levels are higher by necessity because insulin isn't working very well and it also is elevated insulin is

both cause and consequence and we'll revisit that next week but elevated insulin is a cardinal feature of insulin resistance the body has to work harder insulin has to work harder and high in order to keep glucose levels in check but it is capable of keeping glucose levels in check and so you have an individual who may be manifesting year overy year as they come into their clinic for their annual visit with various signs and symptoms of insulin resistance like for example all of the features save the high glucose of the metabolic syndrome they have higher

blood pressure they have dyslipidemia they have elevated waist circumference and the clinician is only measuring the glucose which is coming up as normal every time and so they say everything's fine however if they were to expand their view of the problem to include insulin as a marker they would find that insulin levels can be elevated up to 20 years before glucose levels ever start to change so as I'm pantomiming this out for those that are watching or just those that are listening and I'll explain it the insulin levels are going up higher and higher and

higher over the years it is the canary in the coal mine or the early warning that something is wrong but throughout all of this time as insulin has to work higher and harder to keep the glucose normal glucose is indeed staying in a normal level and thus our glucose Centric Paradigm or glucose obsessed view of metabolic Health misses the problem because as far as glucose is concerned everything is fine if we had rather than a glucos Centric Paradigm an insulin Centric perspective we would have detected the problem at its earliest stages remember that is the

early warning system that we want to look for we want to have our antenna focused more on insulin as a marker of insulin resistance than glucose not only has our failure to focus on insulin resulted in our inability to diagnose the problem as early as we could it has also inadvertently resulted in therapeutic interventions that make the problem worse for example if you have a person who now is struggling with their glucose levels they now actually have high glucose this type two diabetic now that has insulin resistance that has gone to the point where insulin

has gotten really high to try to control the glucose but now even that elevated insulin which may be four or five times higher than it used to be is no longer sufficient to keep the glucose in check now the glucose starts to climb then it sets sets off the radar it gets pinged on the clinicians perspective and then they say okay we have to lower that glucose and do you know what lowers glucose insulin and so unfortunately what they will do is take this person who already has high insulin and give them more insulin by

either giving giving them just direct insulin injections through insulin therapy or giving them these oral medications called sulon uras which is a drug that will actually Force the pancreas to make more insulin so they push the insulin up even higher and it does lower the glucose so the clinician feels better about that but who does not feel better is the patient those interventions that increase insulin in order to control glucose make the insulin resistance worse and all of the chronic diseases that we're going to discuss in future episodes also get worse including heart disease Alzheimer's

disease Cancers and ultimately weight gain and death because insulin resistance is the key is the key problem it's not the elevated glucose so that's one reason why insulin resistance has become so common because we look at it incorrectly and then lastly it's simply just our lifestyle and as we'll discuss more next time talking about the causes we've created you'll see that we've created this perfect metabolic storm where we have a host of variables specifically working against us specifically that is our dietary habits and our sleep habits with diet um the food we eat and how

frequently we eat it is exacerbating or triggering in the first place the insulin resistance and this whole problem is compounded by things like poor sleep in particular and again as I mentioned we will revisit those primary and even secondary causes and I'll outline those in in an upcoming immediate upcoming episode to understand the origins of insulin resistance and then but but again that helps us understand why the problem has become so substantial okay you guys thank you so much for listening I hope you found this insightful um that you can recall and share with friends

or loved ones um who you suspect may be suffering from insim resistance um maybe just as a concluding thought um I let me just briefly um leave you with an idea of how you might know whether you have insulin resistance I'd already mentioned the one um where uh you could look at your Ketone levels after about a 16 or so hour fast but also you can just look or let alone the the symptoms of the or the the problems of the metabolic syndrome if you've been told you have high blood pressure that's very likely a

sign of insulin resistance but also your skin one thing you can look at is your skin not everyone manifests with this but particularly around the Ring of the neck the collar level of the neck um two things to look for one is acanthosis nigin which is when the texture and color of the skin changes now due to inherent differences in complexion the darkening of the skin might not be noticeable if someone has a darker complexion already but even still you'll be able to see and feel this kind of crinkled tissue paper texture to the skin

that's the acanthosis nigricans and a second one that can come with it or be on its own is skin tags skin tags are these little kind of mushroom like stocks of skin it's not a big kind of rounded Hill it is like a little column that is sticking straight up albeit very small you know what I'm talking about you've seen them skin tags and acanthosis nigin are both essentially Pro proof positive of insulin resistance so you have a little homework in that regard just to try to understand where you are or your loved one the

person you're thinking of perhaps with where they are with regards to their insulin resistance status and with that the lesson's over if there's any questions or comments I'm glad to get to them