Insulin Resistance: Why Your Labs Are Normal and You Still Feel Like This
Medicine is glucose centric. The disease is insulin centric.
Karen is forty eight, tired by two in the afternoon and eighteen pounds up in three years, eating the way she always ate. Fasting glucose ninety four, A1c five point four, and she was told to watch her carbs. Dave is fifty four, A1c five point nine, on a statin and blood pressure pills, told they will keep an eye on it. Sophie is twenty six, thin, a runner, with irregular periods and hair on her chin, offered the pill.
One disease.
What insulin resistance actually is
Insulin is a hormone your pancreas makes every hour of your life. Moving sugar into cells is one job. It also tells fat cells to store, the liver to make fat, the kidneys to hold salt, and the ovaries what to make.
When cells stop responding to a normal amount of insulin, the pancreas does not shrug. It shouts. It makes more insulin until the cells answer, and the glucose stays normal. Karen's glucose is normal because her insulin is not. Insulin resistance and high insulin are the same condition seen from two sides, and each feeds the other.
Fat cells overfill and leak, the liver fills, the muscle jams, and only then does glucose drift. Fatty liver is usually silent: on routine CT scans of adults with no symptoms, more than half had at least mild fat in the liver. In more than six thousand British civil servants, those headed for diabetes ran about a third lower insulin sensitivity for a decade before their glucose moved, and were different at the first blood draw, thirteen years before diagnosis.
It is not how much fat you carry but how big each fat cell gets before it spills. Sophie hit her limit at a size four.
The two tests everyone gets move last
Normal on the report runs to ninety nine. I want seventy five to eighty six. Karen's ninety four is in range and not optimal, and that gap is where the disease lives.
The A1c is a red blood cell test. Anemia, iron, thyroid and kidney function all move it without the sugar moving. In more than twelve thousand people, an A1c at the diabetic cutoff caught forty seven percent of those diabetic by fasting glucose. In thirteen hundred young adults in India, among those with a normal A1c, fasting insulin flagged about one in ten, and insulin measured two hours after a sugar drink flagged four in ten.
What I read instead
A pattern, not one test. Fasting insulin, optimally under five: a high one rules insulin resistance in, a low one does not rule it out. Triglycerides divided by HDL under one point five, and better still, HDL higher than triglycerides. SHBG, a liver protein insulin turns down: women in the highest quarter had about a tenth the odds of diabetes of those in the lowest. That is an association, and a low SHBG is a smoke alarm. Waist times two should be less than your height. An A1c already creeping past five point two.
Then what no lab measures: facial hair and acne, night sweats, waking up to eat, sugar cravings, trouble going a few hours without food. Any one alone is a question. Several together is the answer.
The ovary is the one organ that keeps listening when the rest goes deaf, so it answers the shouting with more testosterone. That is PMOS, formerly PCOS, a metabolic disease wearing a gynecological name. The pill regulates Sophie's bleeding and does nothing about the disease.
The drugs lower a number
The standard of care aims at the glucose: a sulfonylurea whips the pancreas for more insulin, and when it tires, the patient gets insulin itself, for a disease of too much insulin. The number comes down, the weight goes up, and the chart says chronic progressive. Statins raise the odds of new diabetes about nine percent in pooled randomized trials, and their authors, who judged the heart benefit worth it at higher cardiovascular risk, wrote to weigh the diabetes risk at low risk. Nobody stops a medicine because of an article; ask the prescriber what happens to it when the insulin resistance improves.
Hormones are the treatment
Estrogen here means the horse drug the big trials used, and estradiol means the human hormone.
Thyroid is the floor in my practice. Among people already prediabetic, progression ran about thirty five percent at the low end of normal free T4 and about fifteen percent at the high end, in an observational study. In more than a thousand men with prediabetes or new diabetes and low normal testosterone, all in a lifestyle program, adding testosterone cut the share who were diabetic at two years from twenty one percent to twelve. Their A1c did not differ, about one in five needed their red cell count managed, and industry paid for the trial. Pooled across over a hundred trials, mostly of estrogen, hormone therapy cut new diabetes in women by about thirty percent, and the smaller estradiol trials point the same way, by pill and by patch.
Diabetes is reversible
Forty nine family practices were randomized. People with type two diabetes of under six years, not on insulin, came off their diabetes drugs on day one and went through a structured weight loss program. At one year forty six percent were in remission against four percent with usual care, and eighty six percent of those who lost more than fifteen kilos. That was a trial, with clinicians: medicines come off with the prescriber, as the numbers earn it. Remission stays in the people who keep the weight off, and in my practice holding it is the hormones' job. No trial has tested that; the pieces around it point that way. I prescribe GLP-1 drugs only on top of optimized hormones: a year after stopping, trial participants regained half to two thirds of their loss, the top figure from a study where coaching stopped too, while those who stayed on held it.
Monday morning
Not eat less and move more. Lower the insulin first. Control the carbohydrates that come in bags, boxes and bottles. Prioritize protein. Do not fear fat. Leave time between meals, and break a fast with protein and fat, not a bagel. Lift at least twice a week and keep walking. Protect sleep: six nights of four hours cut glucose tolerance by forty percent in healthy young men.
And change the kitchen. In a British cohort, children's insulin tracks had already separated at nine. That is not a talk with a child about a child's body. It is a decision adults make about what comes into the house.
Karen gets the whole panel. Dave gets his insulin measured and his hormones checked before the first drug. Sophie gets the truth: her ovaries are not the problem, and her disease is reversible.
The whole argument:
⚠️ Educational content, not individual medical advice or a treatment recommendation. Nobody should start, stop or change a prescription because of an article. Your labs and history belong in a one on one.
🩺 DNP led telehealth hormone optimization. Book a consultation and find everything: withinyou.health/links
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