0:00 hi there folks this is dr. Robert service the Cobb addiction doc and today we're going to try to explain something that most doctors out there don't understand and that is the difference between pre-diabetes and insulin resistance and and this is such a fundamental fundamentally important concept to understand when it comes to modern diseases and and chronic non-communicable diseases in other words the most likely reason why you are going to die and get sick okay so the way this works is that the human body is designed to use insulin to perform a variety of different tasks in the body and when the
0:46 body is sensitive to tiny fluctuations in insulin insulins primary role is to control the production and release of sugar from the liver and the hormone that is directly responsible for that is a woman called glucagon so insulin when it becomes micro elevated and it insulin becomes micro elevated to a micro increase in your blood sugar when your insulin sensitive insulin then in in a fluctuating way it's not on or off it's not a switch it's not binary it's a continuous fluctuation kind of a vibration of insulin insulin modifies glucagon is release of sugar from the bloodstream when your blood sugar dips a little bit low insulin levels go down gluto and produce a little bit more and
1:32 then insulin gets produced and glucagon goes down okay it's not the direct effect the second effect that insulin does have is it has a longer standing effect on steroid hormone production and the steered woman's we talking about here are the Adrenaline's the quote the catecholamines and in particular cortisol and cortisol starts out as a cholesterol precursor so it starts out as this molecule called cholesterol cholesterol the thing that everybody tells you is gonna kill you is actually vitally important to being human so stop with the damn cholesterol is bad for you that's anyway that's a tangent cholesterol is a precursor for steroid hormones so cholesterol will become cortisol but
2:18 insulin modifies the enzymes that convert cholesterol downstream so influence Allah not only has a direct effect on glucagon it also effects all of the catecholamine production and when you sensitive there's these slight fluctuations so that's how you can modify the door effect for example when you wake up in the morning you get a little cortisol rush it affects glucagon your blood sugar goes up well if insulin is blocking the glucagon and insulin is affecting cortisol production you've got all these fluctuations that are controlling each other and managing your fluctuations in a very healthy way and and that's insulin sensitivity insulin also affects the rate at which cells take sugar up from the bloodstream insulin affects every cell in the body
3:03 pretty much is some like the red blood cells where it doesn't really affect them but almost every cell with a nucleus has an insulin receptor and those receptors allow sugar to into the bloodstream there are some cells like endothelial cells that will allow also sugar to enter the cell without insulin and by the way insulin doesn't really have an effect on fructose as much as it does on glucose and galactose so fructose tends to be one of your most dangerous sugars because it doesn't trigger insulin release that's very sophisticated so sugar insulin allows sugar to enter all the cells and the reason it should be a sugar should be entering the cells is to be used as energy not to beat and convert to fat but to be used as directly as energy or stored in some cells a little bit of
3:49 glycogen and then insulin also effects fat uptake in fact release from the fat cells by regulating a whole an enzyme called lipoprotein lipase amongst a few other effects so that as your blood sugar Rises your your ketone production goes down and it should balance those two and remember glucagon not only converts amino acids to sugar as gluconeogenesis it also it's ketogenic when you fat adapted producing ketones so it's an incredibly intricate system and it's so beautiful it's so beautiful sucking little dance it's like the vibrating wire is the way I look at this with little dampeners that's the way the human body should work and it's like little it's all about nuance feedback and the most sensitive you are the
4:36 tighter that control the less fluctuation there is now along comes modern America you have to eat carbohydrates you have to snack so we sit there stuffing our face with all the sugar and starch and even if you following the standard American diet perfectly it's 60% carbohydrates even if you're on a ketogenic diet with a carbohydrate allowance you still putting sugar in your face sugar the human body actually doesn't need and what does that do it's like if you look at a pond a pond with with no breeze on it looks perfectly fat obviously if you look at it on the microscope the wood is slightly vibrating it's called a Brownian effect but the vibrations are
5:21 tiny that's a healthy hormonal environment now you come along and you drop a grain of sand on that pond and there's a slight little ripple you might be able to see it you might not and that's maybe eating a carnival or an ultra low carbohydrate diet but then you come along and throw it on rock a brick into the pond and the plan just explodes and you get the tsunami effect of the ripples that's like eating carbohydrates folks and if you throwing rocks into that pond all the time think about what that water's done it doing it's doing this all the time how the hell can your body cope and eventually all that water spills over the edges of the container and you lose water that's
6:09 damage and disease happening that's my easiest example of insulin resistance so what happens is when you're consuming carbohydrates in a chronic excessive weight as big meals as little snacks and it doesn't matter how those carbohydrates into your face I don't care if it's a baked potato french fries I don't care if it's brown pasta white pasta I don't care if it's ice cream or an apple sugary sugar by the time it enters your bloodstream folks sugar is sugar and those rocks of sugar that bounce into your bloodstream cause these wild fluctuations in insulin wild fluctuations your blood sugar and the but the body's so cool to to adapt to that I'm insulin sensitive okay I'm fat adaptive insulin sensitive my blood sugar the total amount of sugar in my
6:55 bloodstream is about 4 to 5 grams if I went and ate an apple that's about 25 to 30 grams that immediately rushes into my bloodstream and yet because my body's insulin sensitive it can tolerate it can cope with that one rock falling into my pond but if I'm eating apples and ice cream and everything all the time is just plunging those rocks in the next step the next way in which my body protects itself is to become resistant to the influence of those hormones so you become insulin resistant well that means that sugar is now building up in your bloodstream your body doesn't want that because that's causing damage so if you are a high producer of insulin if
7:40 your pancreas genetically has the capacity to produce massive amounts of insulin no matter how resistant your tissues become to insulin the pancreas says screw you boys here's more insulin do your down job and it overwhelms the system so your liver split is converting sugar to fat your tissues are still taking them up even though it's harming the tissues it's protecting your blood stream from cardiovascular effects from endothelial effects so you can have a relatively normal blood sugar a normal hemoglobin a1c because that's damage to red blood cells which are floating and floating around in your bloodstream you protect them but you become enormous so the first way in which the human body protects itself from this massive overload of sugar is to rapidly convert the sugar to fat and you've gained
8:27 weight that's weight gain doesn't come from eating too much steak Oprah or or or fat because your body won't allow you to so you begin to gain weight but then eventually the insulin resistance overwhelms your ability to produce insulin and you can no longer convert that sugar to fat and then what happens is that sugar starts to build up and it's that sugar that builds up that slowly damages your red blood cells now red blood cells are tuning over body 310 220 days so what we measure in those red blood cells is something called hemoglobin a1c which is where the hemoglobin becomes permanently attached to glucose and it damages the mclovin and that's the percentage of cells that are damaged which is your percent a1c so what happens is slowly as you become
9:14 insulin resistant your a1c rises but it only rises because insulin is not that effective at clearing sugar from the bloodstream so when you test somebody somebody walks into my office there may be fat there may not be the first number I test is insulin and c-peptide because I want to know if their insulin resistant or their instance sensitive if there are insulin sensitive the insulin number should be I like to see 400 below I'll tolerate between four and six but typically 4 or lower that means that it's just Brownian motion that's happening in their bodies if their insulin is enormous lehigh let's say it's above 10 which is /e in the normal range of insulin which is ludicrous I've seen insulin as high as 78 80 but let's
10:01 say your insulin is elevated above 10 the next number I want to look at is your hemoglobin a1c and if your hemoglobin a1c is normal I know that that person is insulin resistant and they're gonna have some of the steroid hormone effects of the insulin resistance but their likelihood of developing type 2 diabetes is extremely low as long as they can manage that a 1c in their blood sugar because that's what it's reflective of on the other hand and that's called insulin resistance type 1 where your insulin level is high but your a 1c and your blood sugars are in the normal range maybe upper end of the normal range but their normal range but then you reach a peak of insulin resistance and now you're a 1 C starts
10:46 to rise it's still below six point five that's insulin resistance type 2 which is where your blood sugar starts rising out of the normal range is capped at about a hundred and you're a 1 C is rising because your insulin resistant but you can't produce enough insulin to maintain a normal blood sugar and that folks is what I call type 2 diabetes because for me type - diabetes is where that chronically elevated blood sugar starts to affect all of your organs supplied by blood and I care about the damage being done by the disease not a number at which you treat because that's when people should start a ketogenic diet to eliminate that rise in blood sugar so then what happens is that situation continues for a longer period of time and now you're a 1 C
11:33 slowly creeps up and you get to six point five and that's where most endocrinologist would start treatment for diabetes and they call you diabetic but the paradox is for early type-2 diabetes your insulin is elevated but not may not be that high it might be 9 10 14 okay it's elevated above the fall but not massively elevated but your pancreas can no longer produce sugar above that level and your insulin resistance is greater than insulin you can produce so now you die be so genic and that is pre diabetes diabetes on the other hand if you can continue to produce more and more insulin and keep a normal blood sugar ir1 you are insulin resistance but your insulin resistant
12:19 but your likelihood of type beat type 2 diabetes is pretty close to 0 thank your parents for good genes obviously it ain't at some stage the whole system is collecting to collapse and die but the important thing is that the disease spectrum is different so for example people with women with polycystic ovarian syndrome are insulin resistant they're not pre-diabetic women that have gestational diabetes were pre-diabetic they they weren't necessarily insulin resistant and it's important to understand those nuances because it's a different disease spectrum that occurs with both but your fattest people are often cardiovascularly the healthiest people so I can see someone who's been 300 pounds and as a normal CAC score the coronary artery calcium score I can see
13:04 people who weigh 200 pounds but their diet type 2 diabetic and the CAC scores are in the thousands that's the difference between cardiovascular damage and not based upon the way insulin resistance over pre-diabetes works so those are important metrics and there are very very few people out there that understand the difference the treatment algorithm still remains removing carbohydrates from your life and the pattern of eating which is snacking but the tracking the monitoring is different so an insulin resistant person with high insulin should never require a statin well nobody really should require a statin but to put those people on statins is ludicrous okay what you want
13:50 to do there is lower their triglycerides because typically they triglycerides are high because they're tuning will that sugar - - soluble fat the shorter chain triglycerides on the other hand the diabetic people you want to worry about cardiovascular disease and you want to control their cardiovascular risk much more closely those are probably the people that might benefit from an aspirin or even a blood thinner although I'm not a big fan of those really the treatment is to come off carbohydrates but as doctors we need to understand those two because otherwise we're gonna mistreat people we're gonna assume that the person with a normal a 1c a normal blood sugar has no risk and we can assume that the person with an elevated blood sugar and an elevated a1c is at high risk so we've got to understand
14:37 that distinction and as you if you're as a patient are going to see your doctor demand demand that they check your C peptide that they check your insulin that they check your a1c and your fasting blood sugar as well as a lipid panel because you need all of those numbers to be able to understand what your genetics are I hope this helps now one of the comment athletes athletes all look wonderfully fit but the question every athlete has to ask is what is happening inside my bloodstream based upon what I'm putting in my face because you can look absolutely strong huge very fit you couldn't run a marathon in half
15:23 an hour not really that's coming but you can be extremely athletic and yet be very very sick inside your body if you're a Cobb loader and that's what athletes don't understand right now when I'm in my 20s and I'm fit and I'm doing great I'm fine but where am I my thirties my 40s my 50s am I going to join that dead runner society because my internal health is terrible and it's only measurable when you measure those numbers so I would urge every athlete to get an insulin c-peptide measured because your doctor will not understand that you come in looking like it like an Adonis you come in looking like Hercules but inside
16:08 you're rotting because of the damage you're doing by what you put on your face diabetes happens as soon as those carbohydrates into your bloodstream you cannot burn them off through exercise so if your if your insulin number is above 46 and you're an athlete you have a problem busy happening modify your diet modify what you're eating and drinking to see if you can bring that insulin down I promise you long term it will not harm it will actually improve your performance but for a lot of our athletes their diet is a performance reducing drug a PRD understand that
