Dr. Boz [Annette Bosworth, MD] - Insulin Resistance: 3 Signs You’re Running Out of Time

Is it ever too late to reverse insulin resistance? Yes, unfortunately it is. But I've also seen people walk back from the metabolic edge when nobody believed they could. Let me introduce you to Patrick V. Patrick is a brilliant engineer. He's the kind who counts everything. On keto, he would have eating habits that were meticulous: an eating window that was very narrow, and food that was very nutrient-dense, like bone marrow and sardines. He would even weigh his food to be compliant, exact down to the ounce. But as the years went by, his labs made me nervous.

I met Patrick when he was in an ICU when his kidneys stopped working. His surgeon went in to try to remove the stone that was obstructing his urine, but his tissue was so swollen he couldn't complete it. He placed a tiny little stent to drain the fluid. And then everybody prayed that he would not die. The best part of that whole hospital stay is when his urologist whispered to him about keto on his way out the door. He learned that the ketogenic diet could lower blood sugars and reverse several of these other problems, like his blood pressure or metabolic syndrome. Patrick applied his methodical rules, and over the next year he went from obese to a normal weight. He took his hemoglobin A1C from 10.1 down to 6.4, and then went on to hit 5.3. He followed the plan perfectly. But still, as the years went on, his blood sugars crept up. With somebody this methodical, I was not expecting to see that. And by the end of the story, he's going to be injecting insulin to stay alive. Why did this happen? And most importantly, if it's happening in you, can you prevent it? Yes, but only if you recognize the signs early. Here were the signs.

Sign one: your fasting blood sugar and your A1C start to drift up. I don't mean that your morning fasting blood sugar is up because you sabotaged it with ice cream last night. I mean that, despite this regular, perfect behavior, morning fasting blood sugars are rising, and those hemoglobin A1C numbers drift north despite consistent behavior. The best time to look at blood sugar is first thing in the morning, immediately after you wake up. That baseline blood sugar tells me what your rate of metabolism is before you stir things up in your body. Blood sugars rumble up and down due to cortisol, exercise, stress, and even a bowel movement will change your blood sugars. All that noise complicates things, so I tell patients to test on the toilet before all those other things get in the way. Check your A1C: how glycated are your red blood cells, or how gummed up with sugar are they? This test will show you how your body has responded to the way you've been eating for the past three months. When that number is stable, great. But if it starts to drift north, that's what happened with Patrick, which gave me the clue that something was happening that we were unaware of. Maybe he was underestimating what he ate. For another patient, that might be true. But this was Patrick V. That's not an option. So I needed more data to understand what was really happening.

This brings me to sign two: rise in sleeping blood sugar. You've probably heard of the dawn phenomenon. This is a small blip in blood sugar that is normal and happens when cortisol is waking you up. In healthy people, you can hardly see that rise in blood sugar. But in insulin-resistant patients, it can be a 30 to 50 point bump, all happening before you wake up. You will need a continuous glucose monitor (CGM) to see this. This monitor checks your blood sugar while you're sleeping every five minutes and allows us to see what your blood sugar was doing while you slept. Your metabolism should shift to a resting metabolism while you sleep, and this should correlate to a low and stable blood sugar. The more metabolically healthy people get, the less dramatic that dawn phenomenon becomes, and their resting blood sugars drift down into the 70s and 80s. Your body naturally shifts into low gear when you're sleeping, and I'm most interested in that blood sugar right before you wake up. This teaches me the most, and I don't have to worry about all those other factors mucking up my data. Notice how stable that line is while I'm sleeping. That's the goal. When insulin resistance lurks in the body, those blood sugars don't sink into the two-digit numbers; they stay north of 100. Even worse is when I see blood sugars do this on a CGM. This wasn't Patrick. This is a patient with obstructive sleep apnea, and the blood sugars rise when he's holding his breath. As soon as he wakes up enough to breathe, the blood sugars go down again, and his body is doing this over and over while he sleeps. This is a metabolic nightmare. When Patrick's sleeping blood sugars drifted up gently, I knew something was wrong, and his labs confirmed it. His A1C went up, his triglycerides went up, and his HDL went down, all while his fasting insulin stayed fairly normal.

Sign three is to check these two labs. Maybe his adiponectin stopped working. Adiponectin is a hormone made by your fat cells, and it is an antidote to insulin resistance. It helps insulin work better, reduces inflammation, and improves lipid metabolism by decreasing triglycerides and increasing HDL, the opposite of what Patrick was experiencing. Without adiponectin, inflammation wreaks havoc throughout the body. Low levels of adiponectin are a bad thing, but Patrick's were normal. The second lab is GAD antibodies. When these antibodies are found in your circulation, it means your immune system is attacking the cells that make insulin, the beta cells found in the pancreas. It means your immune system has turned on you and is destroying the cells that keep you alive, an autoimmune disorder eating those beta cells. Unfortunately, Patrick had this problem, and his pancreas lost the battle. He can hardly make any insulin. The good news is that, because of the way he eats and lives, he only needs a very small dose of injectable insulin to stay alive. Even better, because of his persistent state of ketosis, we don't see any other autoimmune disorders brewing in his body.

If this lesson in health freaked you out, you're welcome for the wake-up call. People hear this and they fast for 10 days, go OMAD, or eat sardines for a whole month, and I call that "ass over apricot." Although those aren't bad options if your metabolism is ready, jumping in too fast can burn out more than your beta cells. It can burn out your motivation. The best first step is a stable rhythm of eating, and once that is constant, slowly take it to the next level. So what should you do? Track with a CGM, keep your total carbohydrates per day under 20, and fast strategically. For folks this far along the edge of a broken metabolism, different rules apply. Click on the next video to see how to eat for a broken metabolism.