Jan. 12, 2016
If you’d have asked me six months ago what insulin did, I would have answered, “it stuffs energy into cells”. I think most people would say something similar. My answer isn’t wrong, but facilitating the uptake of energy into cells is not the most first or most important thing that insulin does.
Last week I completed the first few modules of an introductory physiology course from Duke University, and I found this in one of the lectures:
The type two diabetic is a situation where we have receptor desensitization and the individual does not respond correctly to insulin. Insulin is present in the system, but the receptor is desensitized. And so, you don't get the movement of glucose from the blood into the skeletal muscle cells correctly.
These statements don’t directly answer my question “what does insulin do?”, but they imply that insulin is required to move glucose (energy) into a cell. This is wrong, and they’re not the first to make the mistake. This quote from “Insulin: understanding its action in health and disease”, explains:
The effects of this ‘black age’ are still with us because these incorrect hypotheses have, with the passage of time, been turned into dogma and become cast into ‘tablets of stone’ in undergraduate textbooks. They are also carried forward into postgraduate teaching. For example, even in well respected texts it is still common to find statements such as ‘The basic action of insulin is to facilitate glucose entry into cells, primarily skeletal muscle and hepatocytes.’
So what does insulin do?
The basic action of insulin is anti-catabolic, that is, it halts breaking down. Insulin works in this order:
So if you're using insulin to stimulate glucose uptake, you're already WAY above the concentrations needed to affect the pancreas and liver, which is going to make those cells insulin resistant first. You've also already shoved a lot of fat into those cells first, which is going to interfere with glucose metabolism.
So what should you do?
Don’t worry about insulin facilitating the uptake of glucose into cells, and instead focus on creating the demand for glucose through movement. Lift weights.
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One of my most frequently asked questions is “How did you learn so much in so little time? How did you build a successful functional medicine practice in less than two years?”. The answer is I had two great teachers: necessity and Dr. Tommy Wood. If it weren’t for Tommy, I’d still be dependant on protocols rather than understanding the principles by which our programmes work.
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0:00:13 What Tommy ate over Christmas.
0:01:02 Tommy is OK with vegetable oils and gluten, so long as it's Christmas!
0:02:20 We love buying our meat from a local farmer.
0:03:01 What is insulin?
0:03:13 Optimising Insulin Facebook group.
0:03:40 Tommy's presentation on insulin resistance.
0:04:01 Most people have been taught that the primary role of insulin is to put glucose into cells.
0:04:26 Insulin isn't very good at pushing insulin into cells.
0:04:40 Insulin is a peptide hormone secreted from the beta cells of the pancreas.
0:04:54 Expecting food can increase insulin.
0:05:26 Insulin decides where nutrients go.
0:05:43 So what is insulin's primary role?
0:06:01 Insulin is anabolic.
0:06:27 The main thing insulin does is anti-catabolic.
0:06:48 Insulin prevents the breakdown of fat.
0:07:27 Insulin first acts on the alpha cells of the pancreas.
0:07:29 The alpha cells secrete glucagon.
0:07:48 Glucose is gone, glucagon.
0:08:00 Insulin turns off glucagon.
0:08:32 Only tiny amounts of insulin are needed to turn off glucagon.
0:08:47 Next insulin goes to the liver.
0:08:57 Turns off gluconeogenesis.
0:09:17 Now at greater concentrations, insulin acts in the periphery to tell cells to stop breaking down fat.
0:09:32 There are some nice experiments showing this in forearm muscles.
0:09:53 10 uIU/mL cells start taking up fatty acids.
0:10:16 Insulin only causes glucose uptake at levels of 40-50 uIU/mL.
0:11:03 How did this mistaken belief become common knowledge?
0:11:06 Partly from work done in type 1 diabetes.
0:11:41 Without the action of insulin, the catabolic hormones act unopposed.
0:12:14 Roger Unger glucagon presentation.
0:12:39 Without insulin, there is uncontrolled glucagon release.
0:13:13 Insulin given as medicine is to act against glucagon.
0:13:31 No one was really thinking about this.
0:13:42 Insulin does increase the uptake of glucose into cells so this was an easy mistake to make.
0:14:15 Your high blood sugar might be coming from the liver.
0:14:56 The problem with injecting insulin into subcutaneous fat.
0:15:57 My carbohydrate experiment.
0:16:17 I did an oral glucose tolerance test at home using a dried blood spot test.
0:16:37 My insulin never got above 7.4 uIU/mL.
0:16:56 Most people eating a standard western diet end up relying on insulin to stuff glucose into cells.
0:17:26 Carbohydrates plus fat is maximally insulinogenic.
0:17:56 This is not something we're necessarily adapted to.
0:18:12 It may have been an advantage to store the excess.
0:18:45 75% of glucose should go into muscles.
0:19:08 I did exercise during my test.
0:19:46 We know that I'm very insulin sensitive.
0:20:01 My muscles are primed to take the extra glucose.
0:20:20 So the carbs go straight into muscles without the insulin.
0:21:07 Most glucose uptake into muscle does not require insulin.
0:21:32 This pattern is common in people eating a high-fat diet.
0:21:56 High insulin smashes the pancreas and liver over the head.
0:22:25 The problems come when the muscles don't need the glucose.
0:22:52 My blood glucose peaked at 200 mg/dL.
0:23:08 The peak was in part due to a stress response.
0:23:31 Insulin is not for putting glucose into cells, exercise should create the demand.
0:23:48 If all your cells are overloaded already, then you create a problem.
0:24:09 Cortisol and adrenaline are there to drive up glucose.
0:24:55 We will repeat the experiment without the carbs.
0:25:18 I'm going to do an experiment to see how much cortisol I produce during a race.
0:25:56 Elevated fasted blood glucose, aka the dawn effect.
0:26:24 This questions comes up a lot.
0:26:38 A low-carb diet can cause physiological insulin resistance.
0:26:58 We're not sure if this is anything to do with insulin resistance at all.
0:27:17 Cortisol waking response.
0:27:58 Cortisol should come up before you wake.
0:28:15 People may have heart attacks more often at that time for this reason.
0:28:28 A lot of potential things could be going on here.
0:28:44 Anything which is interfering metabolic health could be causing this.
0:29:10 Are people looking at food quality?
0:29:40 Ketogenic diets can increase cortisol.
0:29:59 Insulin resistance leads to fast cortisol metabolism.
0:30:21 Previously we would have seen this as low cortisol on a saliva test.
0:30:44 It's not that the ketogenic diet is stressful per se, but that the cortisol is no longer being metabolised so quickly.
0:31:28 People that haven't addressed other health issues may find a ketogenic diet stressful.
0:32:03 The dawn effect is likely multifactorial and complicated but not normal.
0:32:35 My fasted blood glucose was creeping up into the 90s.
0:32:49 Now it's down in the low 80s and even high 70s.
0:33:09 Could nicotinamide riboside (NR) be lowering my fasting blood glucose?
0:33:21 NR is a precursor for NAD.
0:33:35 NAD is an electron acceptor.
0:33:46 The ratio of NAD to NADH is important.
0:34:00 In type 2 diabetes there's lots of extra NADH compared to NAD.
0:34:18 Nutritional deficiencies can cause problems.
0:34:38 You can end up with not enough NAD to accept the electrons from all the calories you're taking in.
0:35:00 If NAD goes up with respect to NADH it could signal more glucose to enter the cell.
0:35:29 As always, there are confounders.
0:35:41 Beta-alanine.
0:35:46 Eating more carbs and sleeping better.
0:35:57 Not much data on NR in humans.
0:36:20 I've been racing but not training.
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