“Why do you think that?” I responded.
“Well, our entire family has type 2 except for you,” he said. “So I’m pretty much doomed to get type 2.”
“Yep. you’re probably right,” I agreed.
“And I’ve been slowly gaining weight since I became an adult, which could be due to my lifestyle, but it could also be due to the fact that I’m becoming more insulin resistant as I get older.”
“That’s usually how it works,” I confirmed.
“And as a response to my insulin resistance that’s been getting worse over time, my pancreas has been producing more and more insulin. Which causes extra weight gain,” he said.
“All true. Where are you going with this?” I asked
“Well, my fasting glucose and glucose tolerance tests and my A1C are all normal. So according to the docs, there’s no sign of diabetes.”
“Right,” I said. “No one actually tests positive for diabetes or pre-diabetes until they’ve become so insulin resistant that their pancreas can no longer keep up. Basically, the only time you’ll get an interesting test result is when it’s already too late.”
“So,” said my brother, “I could be very insulin resistant, but I wouldn’t necessarily see anything interesting on a test, because my pancreas could be chugging along like the little engine that could, squirting out an ass ton of insulin into my body to keep my blood sugar normal, all the while secretly petering out and basically dying a slow pancreatic death.
“Well, it's more complicated than that, but as a summary, it's close enough,” I said.
“So at some point, my pancreas won’t be able to keep up with the demand for insulin, and then my blood sugar will finally start going high, and then I’ll be pre-diabetic, and eventually I’ll become diabetic.”
“Yes. All of this is true.”
Then he said, “Well, wouldn’t it be better for me to know that I’m insulin resistant NOW, when I’m 34, instead of in 20 or 30 years when it’ll be too late?”
And this stopped me in my tracks, and my heart sank.
I started to think.
He was so, totally, absolutely, 100% right. If my little brother is doomed to become diabetic, wouldn’t it be better to know NOW instead of in 20 or 30 years? Yes. Yes, it totally would.
I started to think even harder. Here’s what I thought:
Fact 1: Type 2 diabetes starts with insulin resistance, which is, at least partially, genetic. Quite simply, your body stops being efficient about its use of insulin, and so your pancreas has to start squirting more insulin (a fat storage hormone) into your body, which makes you hyperinsulinemic (too much insulin in your body), which, in many cases, causes you to get chubbier and chubbier.
Fact 2: Over time (years and years), your pancreas gets so exhausted from all the extra work that it just can’t keep up.
Fact 3: Your pancreas becomes even weaker as your cells continue to become more insulin resistant, and finally your pancreas just can’t squirt out enough insulin anymore, and your pancreas starts to peter out, and at some point during this process, your blood sugar starts to go up and you become pre-diabetic or diabetic.
The next logical question in my thought process was this: Why isn’t everyone in the entire world getting tested for hyperinsulinemia on a regular basis? Because wouldn’t the presence of hyperinsulinemia be a pretty damned clear indicator that you have insulin resistance?
Yes. Yes it would.
As it turns out, there are a couple of pretty cheap blood tests that can diagnose hyperinsulinemia in a person who otherwise appears healthy.
I immediately got on the phone and called my good friend Ed, who is a family medicine practitioner in Phoenix, and is also a type 1 diabetic.
I asked him, “Why wouldn’t doctors just test everyone for hyperinsulinemia, which, in many cases would indicate early-on insulin resistance and then we could better predict and ultimately prevent type 2 diabetes?”
Ed said, “That’s an interesting idea, but I’m not sure we can guarantee positive outcomes by telling people they’re insulin resistant. We already have tests for pre-diabetes and metabolic syndrome, which are known precursors to diabetes. And, there’s no real compelling evidence that a metabolic syndrome or pre-diabetes diagnosis is going to cause someone to implement the life changes they need to implement to avoid becoming diabetic.”
[interjection: Ed agreed that the diagnoses of these diabetes precursors typically occur when a diabetes onset is imminently likely, or, in other words, these diagnoses typically occur at the tail end of the insulin resistance duration. You know. Once you’re already old and set in your ways].
Then Ed asked, “If an actual diagnosis of metabolic syndrome or pre-diabetes doesn’t result in a lower eventual diabetes diagnosis rate, then what good will come of an even earlier insulin resistance diagnosis?”
My friend Dr. Ed has a good point. In fact, a recent study confirms how good his point is.
But I still wanted to believe that a early absolute predictor of type 2 diabetes would cause a younger person to take steps to prevent the eventual diabetes diagnosis. Wouldn’t it?
Ed said, “We don’t actually know the answer to that, because there’s not enough data. That would have to be a really long and expensive study, spanning many decades.”
And then, I started doing more random thinking. And here’s what I randomly thought.
Fact 4: People get diagnosed with metabolic syndrome or prediabetes only after their pancreas has had years to slowly peter out from exhaustion.
Fact 5: Most medical professionals will tell you that your goals in preventing diabetes are to eat right and exercise while ensuring that your blood sugar stays in target range.
I’d like to pick apart these facts. First, I think, “eat right and exercise” is a fine thing to say, but I have two problems with this advice.
The first problem I have with this advice is the TIME at which we’re giving it. Once you have a prediabetes or metabolic syndrome diagnosis, it’s almost too late. You’ve probably already gained a bunch of weight over the years as a result of your insulin resistance, you probably feel like crap, you’ve probably spent years developing habits to compensate for how your body feels as a result of the insulin resistance and, essentially, the barriers to “eat right and exercise” are unbelievably high. If you say “eat right and exercise, because you are going to get diabetes” to a 65 year old with insulin resistance, this advice is likely going to be far less catalytic than if you were to tell a 35 year old the same thing.
The second problem I have with the common “diabetes prevention” advice is that it isn’t focusing on outcomes more specific than “not getting diabetes.” The outcomes that a hyperinsulinemic normoglycemic at-risk person should instead focus on are, in my opinion, these:
- Reducing insulin resistance
- Preserving pancreatic endocrine function
[Note: If you are type 1 and at risk of insulin resistance, don’t bother getting these tests and don't bother preserving pancreatic function. Just work on reducing insulin resistance.]
And certainly, “eating right and exercising” can contribute to both of these goals. But the “eat right and exercise” advice is nowhere near specific enough to actually help someone who wants to reduce insulin resistance and preserve pancreatic function! There’s also a whole bunch of other stuff (besides “eating right and exercising”) that you can do to reduce insulin resistance and preserve pancreatic function. And, there’s a bunch of stuff you can do to ruin your progress toward these goals. As a diabetic community, we aren’t giving at-risk people the tools they need to reduce insulin resistance and preserve pancreatic function (But I will! I promise! That’ll be another blog post!).
So, if you have a family member who is at risk of diabetes, telling them to “eat right and exercise” just isn’t likely to work. Here’s what to do instead:
- Encourage your family member to get tested (every year or two) forfasting insulin levels to see if the pancreas is overproducing insulin (hyperinsulinemia) or under producing insulin (hypoinsulinemia). This should start at age 35 or anytime they become overweight. [Note: hyperinsulinemia, in rare cases, is an indicator of a handful of other health conditions. So check with your doctor about these.]
- Encourage your family member to also get their fasting glucoselevel or their A1C tested every year or two.
- Have your family member track the results of their fasting insulin levels from year to year. Does the fasting insulin level increase from year to year? If so, insulin resistance could be getting worse.
- Does your family member notice lower fasting insulin levels from year to year and higher fasting or average glucose readings? This could indicate depressed pancreatic function and could turn into pre-diabetes or metabolic syndrome.
- If your family member has/had gestational diabetes or PCOS, they are automatically at risk.
- If your family member is at risk of diabetes, help them take steps to reduce insulin resistance and preserve pancreatic function. I’ll write another article about how to do this soon. I’ll send it to my email list as soon as I publish it.
What’s my point, here? I have several.
- I don’t think the medical community is diagnosing pre-diabetes early enough. We’re diagnosing pre-diabetes when, for most people, it’s too late. We have the capability to pre-diagnose pre-diabetes YEARS earlier, and we’re not doing it.
- People at risk of type 2 diabetes need to get the right information at the right time about how to delay or prevent type 2 diabetes.
- There’s a ton of stuff you can do to delay or prevent diabetes, and the earlier you start, the better.
- Diabetes is extremely expensive for an individual. Preventing diabetes is, by comparison, dirt cheap, as long as you do it in a way that is actually effective.
As it turns out, my brother is indeed hyperinsulinemic. But he’s also 34, so there are steps he can take NOW to reduce insulin resistance and preserve pancreatic function and potentially delay or even prevent a diabetes diagnosis. My next article will be for him and for everyone else who needs to do the same.
I’m sure he’s really excited to have his big sister boss him around and tell him what to do. It’ll be just like old times.