Imagine if we could predict who might develop insulin resistance and type 2 diabetes long before your pancreas stops working?!?! Imagine if we could intervene long before the progression of insulin resistance to frank type 2 diabetes and the associated chronic disease burden that comes with it? Would you modify certain food groups or change your lifestyle to gain back years of disease-free living? I imagine that most of you will answer yes to this. The issue is that we are often not told that something is wrong. Don’t assume that all doctors know this. Besides, we are not told what simple strategies we could employ to help ourselves. This post is going to change that. Knowledge is empowering. Many people will change their lifestyle if they know why they need to do it and how to accomplish it.
I have been an Orthopedic Surgeon for nearly 25 years. While I have returned many athletes to the playing field with my knife and replaced more knee than I can count, I am often most pleased by being able to dramatically help entire families improve their health with lifestyle and dietary modification. Those are, by far the biggest success stories in my practice. Returning people to a path of being metabolically healthy will impact their entire life and the lives of those they bring along on their journey.
Contrary to popular belief among some of my peers, people will often engage if they understand why they should and how to accomplish it. Over the last decade, I have chosen to optimize my own overall health and the overall health of those I treat. What often becomes evident in my interactions with you is that most of you actually do want to change your diets (within reason) and do want to exercise more. No one wants to continue their march down a path towards heart disease, stroke or neurocognitive decline and disability. Information is empowering. Knowing why we need to change and how our actions can affect that change is very powerful and often very motivating.
If we could intervene early in the process of hyperinsulinemia (too much insulin in your blood) and insulin resistance (less insulin function per unit amount in your blood) then we theoretically could stop a very predictable path towards numerous chronic diseases associated with these processes. That would allow us to intervene while your pancreas function (insulin production) is salvageable.
In turn that might spare you a life of living with a substantial chronic disease burden.
What are insulin resistance and hyperinsulinemia?
Hyperinsulinemia occurs when there are excess levels of insulin circulating in your blood. Most of your tissues require insulin to allow your cells to take glucose into them to use as a food source. The insulin binds to a Glut4 transporter in the cell’s wall, and that opens a gate and allows the glucose into your cell. Yes, muscles can take some glucose in without insulin, but that occurs mostly during exercise. If you are starting to require more insulin in your body to accomplish to the same amount of glucose uptake into your cells then you have insulin resistance. If you have insulin resistant tissues, then your pancreas will need to make more insulin to maintain the same glucose levels in your blood. That is what we refer to as hyperinsulinemia.
Why are insulin resistance and hyperinsulinemia bad for your health?
Identifying people with high amounts of insulin in their blood and tissues that are resistant to the effects of insulin is very important. This should be called the pre-pre type2 diabetes stage. That means that you may not have hyperglycemia or high glucose levels yet. It also means that your hemoglobin A1c is still in a normal range. THIS is the stage that you want to intervene and help people become more metabolically fit. Why? Because your pancreas has beta cells. Those beta cells make insulin. After years of churning out too much insulin, they may grow tired and worn out. Once those beta cells stop working they may never come back. That is why some people with Type 2 Diabetes require insulin injections.
Hyperinsulinemia causes your kidneys to retain sodium. That means you need to keep more fluid in your blood to dilute the sodium. That is but one reason why you have hypertension. In addition, hyperinsulinemia is associated with metabolic syndrome: hypertension, obesity, abnormal lipids, and glucose intolerance.
Your Triglyceride/HDL ratio and what it tells you
Well… guess what!! We can often predict who is at high risk for hyperinsulinemia and thus Type 2 Diabetes. We can tell if you are in the pre-pre-type 2 diabetic stages. For many of you we have the ability to recognize this process very early on. How?
Take out your last blood tests. What were your triglycerides (Trigs) and your HDL values?
Divide your Trigs by your HDL… What is the number you get? It should be less than 3.5.
Example… My Trigs were 110, and my HDL is 65: that means that my TriG/HDL ratio is 1.7 or so.
What if your level is above 3.5? What does that mean, why is that happening and what can you do about it?
Two really important caveats must be stated.
- This ratio works best if your BMI is + or > 25 kg/m2.
- The African American population tends to have lower Trig levels. Therefore, different screening tools are needed (Oral OGTT). A normal Trig/HDL ratio does not rule out insulin resistance in African Americans.
Ok… let’s keep going. Now we are going to discuss:
- Why this ratio helps predict risk… and once you understand that,
- What you can do to improve that ratio and decrease your odds of living with diseases associated with insulin resistance and hyperinsulinemia.
Sugar (glucose) and its effect on your triglyceride levels
Lipids (fats) and sugar don’t mix … and this association is not logical to many of you. You’re not alone. This is not an intuitive issue for many people. Most of you associate triglycerides with fat. That is far more logical. Most do not understand that quite often there is a direct relationship between carbohydrate or glucose and your triglyceride levels. Therefore, let’s review a little basic physiology and show you how sugar increases your triglyceride levels.
The liver is a highly complex organ. Glucose is necessary to maintain life. Your brain takes up 25+% of all the glucose in your body for energy use. Your liver and pancreas work in concert to maintain your glucose level in a tight range. If the liver has more glucose than it needs to maintain your blood glucose level then it has to do something with it. The liver and pancreas cannot simply allow your glucose levels in your blood to rise too high. So your liver will store glucose, or package a glucose load it sees coming from the intestines after a meal or a snack. When we eat a meal with carbohydrates the liver can:
- Use glucose as energy.
- Store the glucose internally as glycogen (after exercise, or a period of fasting).
- Convert the glucose to triglycerides, package them into a VLDL, and send it out in the bloodstream for other tissues to use.
- Convert the glucose to fat and store it internally.
VLDL stands for very-low-density lipoprotein. Your liver makes VLDL particles and releases them into your bloodstream. The VLDL particles mainly carry triglycerides to your tissues. VLDL is similar to LDL cholesterol, but LDL mainly carries cholesterol to your tissues instead of triglycerides
When the VLDL particle containing the triglycerides gets into the blood, it can release the triglycerides at various target tissues:
- Trigs can be taken up by muscle and stored as intramuscular triglyceride for energy storage.
- Trigs can be taken up by muscle, broken down via a process called lipolysis and used for current energy needs.
- Trigs can be taken up by the fat cells (adipose tissue) and stored in your adipose tissue for later use.
Intramuscular triglyceride can be used by the muscle as an energy source via a process known as oxidation. This will become important later as we discuss the role of exercise and the importance of muscle mass.
As you can see, glucose (sugar) and lipid metabolism are tightly linked to one another. The hallmark of impaired glucose metabolism is a process we call insulin resistance. This is a very complex topic that is actually very hard to precisely define. In essence, people with insulin resistance still retain the function of their beta cells in the pancreas. Those are the cells that make insulin. The issue is that each unit of insulin no longer has the same magnitude of effect on many of the tissues in your body. Thus it requires more and more insulin in your bloodstream to have the same effect as someone with less insulin resistance. Eventually, your beta cells in your pancreas will exhaust themselves and cease functioning. That is when people with insulin resistance and secondary type 2 diabetes require insulin injections to keep their blood sugar under control.
What does it mean if my Triglyceride/HDL ratio is above 3.5?
If your number is above 3.5 then you are at high risk for developing Type 2 Diabetes and the chronic diseases associated with it. Those diseases include heart disease, dementia, strokes, fatty liver, etc. All of these diseases reflect the presence of a metabolic abnormality that has existed in your body for decades. Yes, these diseases can stay relatively silent for a long time. Unfortunately, the earliest signs of atherosclerosis are now showing up in children! Imagine if we let that process simmer for decades before acting on it? Therefore, the sooner you start paying attention and addressing this issue, the sooner you will be on the path towards wellness and hopefully a longer, healthier life.
What is the root cause of elevated Trigs? The answer is often carbs. Our liver turns the carbohydrates it receives from the intestines into Trigs. Triglycerides are then transported around our body in a VLDL. High triglyceride levels can have other deleterious effects as well. High trigs levels can cause elevated LDL small particles which are probably more atherogenic than larger LDL particles. Elevated trigs can also cause a decrease in your HDL, or high density lipoproteins. HDLs transport the cholesterol away from your tissues and take it back to the liver. This is the process known as reverse cholesterol transport.
Ok… now that I have your attention. We know that carbohydrates can cause elevated trigs, and that those of us with an elevated ratio is at risk for serious chronic diseases. What can we do to address this and minimize our risk going forward?
You can do this…
1. Addressing our carbohydrate intake
First, for most of you, all carbohydrates aren’t bad. Keto and low carb diets are all the rage now. Don’t’ get lost in the weeds. We need to get our house in order, and that takes high-level broad changes. You can always dive deeper and refine your new lifestyle changes at a later time.
Not all carbs are as “harmful” as others. The carbs we need to avoid are simple, highly processed carbs such as white bread, white rice, potatoes, sugar, pasta, bagels, cookies, etc. Complex carbs such as natural whole grains, beans, legumes or nuts within moderation are not going to cause a significantly elevated triglyceride level in most of us.
2. How to increase the amount of carbs our bodies burn for energy.
We need to look at how to deal with carbs in four ways.
A. What takes glucose or sugar out of your bloodstream?
By far the biggest sink for carb storage is your muscles! Muscles store glucose for activity and to burn for current energy needs. So it stands to reason that the larger our muscles are the more glucose they can hold and the more glucose they will burn for energy. How do we get larger muscles? We push or pull heavy things! Even an 80-year-old will respond and grow more muscle from one bout of resistance exercise. Resistance exercise has also been shown to improve how your body processes and manages glucose.
It cannot be overstated how important resistance exercise is for our overall health. I will cover this in a post at a later time, but having larger stronger muscles can improve our longevity and healthspan considerably. Stronger muscles take up and burn more energy or calories. Stronger muscles help minimize our risk of falling as we age. Stronger muscles also help us recover faster from surgery or injuries following a fall. There are only a few of you out there who can’t (because of doctors advice) perform resistance exercises. Talk to your doctor if you are concerned about your risk. Talk to a trainer or physical therapist if you need guidance. The muscles that matter most are your legs. So exercises like squats, getting out of a chair without using your arms, calf raises, and so on are what you should be concentrating on. You can perform upper body exercises too, but you should emphasize leg exercises.
B. Putting fewer carbs into our bloodstream.
So we can increase our muscle mass to take more glucose out of our bloodstream. But we also need to put fewer carbs into our bloodstream!! The less glucose your liver has to process, the fewer triglycerides there will be flowing through your blood. That will decrease the number of Trigs in your body that your liver produces.
So we need to reduce simple carbs : bread, rice, cookies, and any added sugar. This can be a daunting issue for many. Some can handle abrupt changes, many more cannot. All of you can simply pick one food group to eliminate this week and another group next week, and so on. For example, don’t start your day with a bagel… white bread is literally the worst offender. In addition, breakfast is not your most important meal of the day. If you are on a moderate or high carbohydrate diet then you will crave food in the morning. That will diminish over a short period of time if you do not feed yourself simple carbs. People on low carb diets will not have those cravings. So you can skip breakfast altogether… or you can have a few eggs and some whole-grain toast.
C. Make your day a little harder.
A resistance exercise program and building muscle mass is a crucial step for improving our metabolism. Aerobic exercise or increasing our net activity is also very important. Granted, most of you are not going to purchase running shoes and bolt out the front door. What other strategies can we employ to increase your aerobic activity each and every day? Enter the concept of making your day a little harder. Instead of circling a parking lot to find a close spot, just head to the spot that is farthest away. These extra steps add up very quickly. Don’t print to the printer closest to you. Use a bathroom in another part of the building you work in. Do you need to go upstairs or downstairs? Great, take the stairs. Unless there is a medical reason not to do this then take the stairs up two flights or down three. Leave elevators for longer excursions. Have a dog? Great. They need exercise too :-) Take them for a long walk. Find some friends at work who want to walk outside at lunchtime. I see this quite often, most people will not turn this request down. They are looking for someone to motivate them too.
D. Sleep !!
Next… sleep. 😞 Yes, sleep. Sleep is so important to our overall health and well being. Below is a list of diseases that are not caused by or worsened by a lack of proper sleep.
It’s true… sleep is very important for our bodies and our minds. We are a chronically underslept society. Sleep for many is a passive process. You go to bed only after you are utterly exhausted and can’t binge-watch another episode of your favorite shows. You need to address that by prioritizing sleep. You need to treat sleep like you treat other important goals. You set a time to get to sleep and you stick with it. We will all have nights when we toss and turn… but there are many hacks available to improve our chances to get a full 8 hours sleep. Again, this will be a post that we cover here in far more detail in the future.
Sleep improves how our body manages sugar by different mechanisms. Our brain has an influence on our liver via the vagus nerve. The better slept and rested your brain is, the better your chances are at achieving metabolic health. The more relaxed and well slept, the better our baseline glucose levels are. The better we sleep, the lower our internal stress. Bottom line, sleep matters. Make it a priority in your life.
Understanding how our bodies work to influence our health is empowering Hopefully this deep dive helped you understand how your food intake, exercise and sleep patterns can influence your risk of developing insulin resistance and type 2 diabetes. You have the power to change this.
Don’t forget to keep your doctor in the loop. Especially those of you with cardiac issues, or chronic disease. Speak with your doctor about changing your diet, and exercise to determine your risk profile.
Disclaimer: this information is for your education and should not be considered medical advice regarding diagnosis or treatment recommendations. Some links on this page may be affiliate links. Read the full disclaimer.