What You Didn’t Know About Insulin Resistance & Blood Sugar

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Today I spoke with Dr. Ron Sinha about glucose monitoring, how to balance blood sugar levels, and the interplay between sleep and blood glucose. This was actually quite an insightful interview. There may be some misreadings on my part regarding the validity and accuracy of glucose monitors because of my habit of eating too late at night, and how that has caused me to be a C-minus grade sleeper, so to speak. And you’ll hear some elaboration on those insights there, and hopefully it’ll provide you with some cues and targets for when you’re exercising during the day, i.e. not doing it too late, and when you’re eating, i.e. not making your last meal too late at night, because of the implications for your sleep and how those impact your blood sugar. So a few great insights there. We also discuss how important blood glucose stabilization is, and how both overindulgence on carbs and unhealthy fats can be problematic.

DrMR:

We had some reinforcement of the concept that exercise shouldn’t always be high intensity, and this lower intensity albeit, in my opinion, kind of boring exercise can be helpful for this cardiovascular base. Dr. Ron ties in the mitochondrial implications of that same target. We also revisit what happens in insulin resistance and what is happening when people are insulin sensitive. So this was a great interview with Dr. Ron. I hope you will give it a listen. And remember if you’re in need of help, not only with your gut health, but also how these other pieces fit together, namely lifestyle, meal timing, blood glucose, exercise, these are things that we’re building into the clinic model and are being integrated into the wellness and optimization facet of what we’re currently offering at the clinic.

DrMR:

So what’s really exciting about the growing offering at the clinic is it’s not just gut health and the gut thyroid connection and the myriad of symptoms that can be an offshoot of an aberrancy in gut health. But as I’ve learned more, and my personal health has evolved beyond food reactive brain fog and gut inflammation-driven insomnia and fatigue, I’ve attempted to have the best performance and sleep and energy that I can. And thankfully this podcast gives me a platform on which to interview bright minds and to fine tune some of these things even further. These things are all then quantified into what we’re doing over at the Austin Center for Functional Medicine. So just a reminder, that resource is available to you if you are in need of assistance there. Okay, now we will go to the interview with Dr. Ron.

DrMR:

Hey everyone, welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio, today with Dr. Ron Sinha, and we’re going to be discussing amongst other things, what we can do to monitor and balance our blood sugar and our insulin levels. I caught an interview with Ron and Dr. Z. I’m not going to attempt pronouncing his name because it’s a pretty challenging one to pronounce, but you did a great interview on some of the metabolic implications of COVID, and it really showcased how this is something that’s front and center for your practice at large. So I thought it’d be fun to have you come on and help walk us through what are some of the mainstays that you’re using in your practice to help people regulate their blood sugar. One of which might be CGM or continuous blood glucose monitoring. So Ron, a lot for us to unpack, and welcome to the show.

DrRonSinha:

Thanks for having me, it’s a pleasure to be here. Insulin resistance has been the heart of my practice for over a decade now. Initially Michael, I really nerded out on this topic because I just loved it so much, and I dig deep into the molecular mechanisms of what really is a root cause of this. But now, over the last several years, I think I’ve shifted my attention to teaching this concept to laypeople so they understand the science of it. And you won’t be surprised, Michael, but even a lot of our physicians who are trained don’t understand insulin resistance to great depth. So I hope we have a conversation around what is the underlying operating system; I’m using that word because I work here in Silicon Valley, but I think once people are able understand insulin resistance at its most basic level, the lifestyle changes are much more motivating and easy to make as well. So I’m looking forward to our conversation.

DrMR:

Awesome. Before we launch, in case people haven’t come across your work, give us the short backstory on you, your background, and how you found your way into this facet of integrative medicine.

DrRS:

Sure. The majority of my practice has actually been here in Silicon Valley. Over a decade ago, as I was seeing patients up in the heart of Silicon Valley near all of these high-tech companies, I was giving sort of standard generic advice to many of my patients who were coming through the door. I realized that they were actually presenting with very high levels of insulin resistance at a very young age. As I gave them the standard dietary advice, I was shocked at the fact that they weren’t getting better, but also that adhering to these standard dietary guidelines, I actually developed metabolic syndrome, which as you know, is a major manifestation of insulin resistance. So that really made me look outside of the box to what else can we do to really help these individuals. And again, in the Bay Area here in the U.S., it’s a very diverse population. So I also noticed a lot of different ethnic nuances to how certain ethnic groups present in much more aggressive states of insulin resistance than others.

DrRS:

I was practicing internal medicine at the time, but I really became passionate about going out to communities and corporations to teach people about insulin resistance. Really, I was probably in the early stage of biohacking back over a decade ago, where I was trying different things on my body and then trying that on my patients too, and gradually learning so much about insulin resistance that continues to this day. I wrote a book on the topic, I’m doing a lot of corporate lectures and programs on it, and really developing a lot more of a fine expertise in that area. So now what I do today is I have a consult practice that’s focused specifically on insulin resistance and how to prevent and reverse it through lifestyle changes.

DrRS:

It’s actually got a focus on culturally diverse groups, particularly those of Asian background who can present with this very early on, but that’s only part of my job. My actual day job is actually to run health education and corporate wellness programs for Silicon Valley companies. So really going into the big tech companies and designing lifestyle strategies to help their employees lead better, healthier lives. As you can imagine, in our current pandemic environment where we’re recording, this has become even more of a concern for companies, because now employees aren’t visiting the onsite fitness centers and all these wonderful resources that high-tech companies offer. All of a sudden employees are basically working from home, so we’re having to be very innovative around how to get employees healthy around that.

DrRS:

And also tied into that too, Michael, I’ve been doing a lot of work with local schools like high schools and even colleges, because I joke that a lot of our youth now have become high-tech workers because they’re in front of screens all day. So how can we implement lifestyle strategies throughout the day to get the whole family healthier? So that’s been the passion and forefront of my work currently.

Insulin Sensitivity Explained

DrMR:

And let’s redefine insulin sensitivity for people, because I’m sure people have heard that term. I’m assuming, much of our audience probably understands that, but let’s redefine that and help people better understand the mechanism of what’s going on in insulin sensitivity.

DrRS:

I’m a real visual person, so when I explain this to my patients or in lectures, I tell people to use what I call the traffic paradigm. I tell people to think of the carbohydrates you consume as being a car in your body, and think of three major parking lots in the body: your muscle, your liver, and your fat parking lots. Ideally Michael, whenever we consume carbohydrates, we want 80 plus percent of that carbohydrate traffic to go to our muscle lots, where muscle can burn that for energy. The way that carbs get inside the muscle is by using the insulin parking path to get the carbs through the door. In most cases of insulin resistance, our bodies are producing plenty of insulin, but the muscle is not responding to the signal. So as a result of that, we’ve got this overflow glucose traffic. Depending on your lifestyle, your genetic tendencies, and even your ethnicity and your sex, often that overflow traffic might go overwhelmingly to fat.

DrRS:

And I tell people that fat parking lot is open 24/7. It’s got unlimited parking space, unlike the muscle. It can also go to the liver, and the liver can convert those extra carbohydrates into triglyceride cholesterol particles, and then the liver can also accumulate that excess carbohydrate as fat. Over time, as the liver accumulates more fat, that seems to be one of the central root causes for why the liver can overproduce sugar and develop Type 2 diabetes. One of the big shockers when I first started my practice was seeing rampant amounts of this condition, particularly in my Asian Indian vegetarians, because they were eating such a starch-centric diet. They were shocked at why they were developing heart disease so early on. We realized that despite being named vegetarian, their diet was so grain and carbohydrate based that it was literally overwhelming the muscle parking lot and being rerouted to these other sites where it was causing more damage and all the manifestations of insulin resistance.

DrRS:

So really at a high level, when I try to motivate patients, I tell them our number one goal is to teach those carbs to go back towards the muscle parking lot. If we can drive them back towards the muscle, you decompress the fat cells, meaning your waistline and body fat goes down. You offload the liver, meaning those triglyceride particles go down, and your healthy cholesterol goes up. And then all of a sudden we see blood sugar improvements as well. Now, how do you do that? There’s various strategies, but I think it’s truly important for people to sort of understand that paradigm as we go forward.

Carb-Centric Diets

DrMR:

You make an interesting point and probably an important point, which is that these grain and starch centered diets can be a problem. I think much of our audience is somewhat paleo and/or ancestral diet and lifestyle practice friendly, so they’ve probably heard the concept of reducing carbs as the paleo diet advocates. The paleo community seems to have a lot of tie-ins with this lower carb community, but that didn’t seem to serve everyone very well. This was brought forward by Paul Jaminet and some of his work around The Perfect Health Diet. I think that brought to the forefront that not everyone does well on a lower carb diet, and that’s something we’ve tried to embody here on the podcast. It’s not about the perfect diet, but there’s a spectrum of diets on offer and we should help the individual navigate to what’s going to work best for them.

DrMR:

One of the things that I think opened the door for this carb renaissance was this concept of metabolic typing, that perhaps some people due to their genetics will do better on a moderate or even higher carb diet. And you’d think of Asian and Indian populations being two of those higher carb friendly metabolisms. But it sounds like there’s an upper limit, perhaps. So I’m curious as to how you’re finding the carb allocation maps out to different genetics or what other indicators people can look for to help them know where they may want to go with their macronutrient ratios.

DrRS:

Yeah, you nailed it. I love the way you framed it. So you’re right, there’s not really a perfect diet, but really more what I call a personal diet. Because you’ve got to personalize that diet towards your individual risks. Without doing complex genetic testing, which only tells part of the story, you can first start off with a family history. Many of my patients come in and they’ve got several first degree family members, maybe parents, siblings, et cetera, that have Type 2 diabetes or other signs of insulin resistance. So then we know that they have a genetic tendency. We talked about the second thing, which is ethnicity. So if you’re South Asian, we’re seeing a lot of East Asians, Filipinos, et cetera, that have a higher predilection towards these conditions.

DrRS:

Now, aside from those, even without measuring any labs, I can often tell by looking at patients walking into my clinic whether they’re going to be more or less carbohydrate tolerant. What I mean by that is, if I already see that they’ve got some extra abdominal obesity, if they’re not very physically active, that’s not part of their lifestyle, I see that they’ve got very slender limbs, then going back to my paradigm, I picture that they have limited parking space. So even though they’re consuming carbohydrates, and good quality carbohydrates, they’re really outstripping their muscular ability to actually metabolize those carbs. And initially I have to tell you, Michael, when I started this practice over a decade ago and I was experimenting with low-carb and ketogenic diets, my jaw dropped at how incredibly well these patients responded. But now that it’s been eight to 10 years later in some of these patients that I’ve been following up with, they’re eating probably the same diet that we started with 10 years ago, but they’re starting to have a recurrence of insulin resistance.

DrRS:

And part of the reason is, I think they’ve overemphasized the fact that they think diet is a silver bullet for the rest of their life to beat insulin resistance. But what they haven’t realized is because they’re not doing adequate level exercise, it’s caught up to them. Their muscles are still not metabolizing carbs appropriately. As we age, we lose some of that muscle metabolic efficiency, especially if we’re not exercising. So you’ve really got to understand each individual body and how much their carb tolerance is. And you’re right, in certain ethnic groups, especially if they’re inactive, their body phenotype is really less muscular. We have to understand that right now at this point, they’re very carb sensitive. Before I was probably a little too predominantly emphasizing the diet, and now I’m really pairing the diet with exercise, especially after age 35 or 40, you’ve got to do both together, or it’s just not going to last very long.

DrRS:

So we start off with that metric, and then of course we do the standard labs, looking at the lipids in particular, the triglycerides, and the healthy cholesterol. The blood sugar markers are important as well. But if you put all those little puzzle pieces together, you can get a good sense of how insulin sensitive or resistant somebody actually is.

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DrMR:

What about on the other side of the spectrum? I’ll see in the clinic, prominently an IBS cohort. That cohort of patients has more anxiety around food. They tend to be more prone to under eat, or end up on overly restrictive diets of which sometimes they’re inadvertently going too low-carb. Are you ever seeing people who are going too far in the other direction?

DrRS:

Oh my goodness, yes. As much as I’m a fan of some of these restrictive diets when they’re done properly, I’ve been writing a lot about how we’re seeing now the other side of the keto diet or the other side of fasting where people become way too restrictive and now they’re so nutrient deficient. And Michael, I know you’re a major expert on gut health, we’re seeing their gut health getting disrupted quite a bit because they’re not getting healthy fiber, soluble fiber, gut diversity promoting type foods in their diet, and I’m seeing the other side of that. One thing that really hits the point home, and I know you alluded this early on, is when you look at continuous glucose monitors. When I put these patients on sensors, they’re shocked by the fact that they have tremendous glucose variability, despite the fact that they’re eating so few carbohydrates.

DrRS:

That’s when I tell them our body is not just a simply equation that low carb means low glucose means better health. Sometimes when you’re too restrictive, you completely throw off the body’s metabolism, and you’ll see glucose spikes even though you didn’t have carbs for, let’s say, eight to 12 hours. I mean, the body’s much more complex, and you’ve got to look at inflammatory markers, gut health, all these things. But you nailed it. I think the pendulum for a lot of people has swung the other way, where they’re overfasting, overdoing the ketogenic diets, and now we’re seeing other types of abnormalities arising from that. So I think for both of us, if there’s one message we can take out of this discussion, it’s that we need to really optimize and put people more towards the center where they’re really getting a good balance of nutrients, while reducing some of those extra carbohydrates and calories at the same time.

DrMR:

When you say that, it reminds me of a point made by Mike Nelson, which is his concept of metabolic flexibility. Meaning a health metabolism should be able to buffer carbohydrates because you’re giving it some fasting pressure, some higher carb pressure, some lower carb pressure, some exercise pressure. It’s that adaptation that seems to be important. So yeah, that’s a good point. And I guess to tie this in for our audience, if you’re maybe in that position of being a bit restrictive, this is almost a license for you to have some breaks from being overly restrictive, hopefully get some enjoyment from food, and maybe even socialization at the same time. That’s a good opportunity to exercise the flexibility of your metabolism by doing so.

DrRS:

I totally agree, well said.

Continuous Glucose Monitoring

DrMR:

Let’s talk about, CGM, because this is something that I have to admit I’m a little bit confused by. I’ve put on three monitors now, and I’ve had a vastly different experience with one of the monitors as compared to the other two. That may have been due to the positioning on the tricep. I want to credit Dr. Mark Burhenne with giving me the advice of not having it too high up on the arm. I think by just bringing it down by maybe an inch, the reading seemed to make much more sense than the first two applications. I guess maybe starting there, is that something that you’re seeing?

DrRS:

Yeah, with application, the devil’s in the details. And you’re right, I actually wear mine a little bit lower down. The downside to it is everyone can see it when you’re wearing a short sleeve shirt. So you get a lot of questions about, “What is that you wearing?” It’s a conversation starter, but for me, lower down on the tricep does tend to register better numbers. It also doesn’t interfere as much when turning over in bed if you’re a sensitive sleeper. If you’re a side sleeper, when you’re wearing it high up, sometimes you can really feel it over the muscle there. So I tell people, just be aware of what type of sleeper you are and which sensor you’re using. Freestyle has gotten very popular for those of us that are sort of more into biohacking. If insurance doesn’t cover it, it’s also much more affordable. But that is typically recommended to wear on the arm.

DrRS:

Even though this is not what they recommend on the package label, I’ve talked to some folks that have worn it on the upper chest area and have gotten really good numbers. I did try it on my chest once and I did get very accurate numbers, but for now, if you’re starting off, I think wearing it on the arm over a nice flat area where you’ve got some fat there, because you want to avoid the muscle, that’s probably the best spot for you. But having said that, in doing this for years, as much as I love these sensors there can be a lot of variability in terms of the numbers that you get back. So sometimes it is not a bad idea to just get an over-the-counter finger stick glucose device to just sort of see where the numbers fall. But often what it is, Michael, it’s more learning about the trends than the absolute number. Just like with a body fat scale, they’re not very accurate, but if you’re seeing upward arrows and you’re seeing improvements when you’re eating certain foods or doing certain physical activities, it gives you tremendous information in terms of how your body responds to different lifestyle factors. But in most cases, if you wear it properly and you’re following the instructions properly, you should get fairly accurate numbers back. But yeah, wearing it lower on the arm has worked really well for me.

DrMR:

One of the things that I found interesting was when I calibrated this to a finger stick, or attempted to, so to speak, I saw some variance between the two, and then I looked up the acceptable level of variance. I don’t actually recall it off the top of my head, but it was a larger variance than I thought would have been acceptable. It made me think, “Okay, we can’t be looking at this data literally. Like you’re saying, we have to really look at the relative movement, rather than the absolute value of a given food. Can you maybe unpack that a little bit more for people? I know, especially in this crowd, and I want to praise people for being so interested in their health, but that can cut both ways, especially if we take certain lab data too literally. So I’m trying to help them find that balance point.

DrRS:

So the first big point to make about these sensors is that they’re not measuring blood glucose. The sensor basically sits just over the skin in a compartment called the interstitial fluid. The interstitial fluid is a fluid layer that sits above the blood, and it’s a fairly good surrogate marker for what’s happening in the blood. But for some people that delta between the interstitial fluid and the glucose can be quite great, for various different reasons. It could be your own body temperature, your own metabolism, there can be certain things about the capillaries that cause some difference between those two sites. In some of my patients and in myself, it’s fairly precise. In other, you’re right, you can get quite a bit of variance that’s still allowable and acceptable. So it is important to sort of be aware of that, but then it does get very consistent in terms of the delta and the changes that you see as a result of your lifestyle changes.

DrRS:

So that is a little bit of a disclaimer. Some people will get more different numbers than they’d expect, but again, the changes and shifts that you’ll see are really the more powerful numbers. The interesting thing is, Michael, even though I’ve seen that when people wear this for, let’s say a month, month and a half, I would expect based on the delta’s that their estimated A1C would be much more different. When you actually look at the data points over a longer period of time, they line up pretty well. I’ve rarely seen big variations in the estimated A1C from what you’re getting from the CGM versus when they go into their labs to get their blood glucose checked. So I’ve been pretty impressed, and it seems like the newer generation sensors keep getting more and more accurate. So it’s really an exciting piece of technology. It’s still in the early to mid phases, but we’ll keep seeing better iterations of it going down the line.

Insulin Spikes

DrMR:

I have another question, and I’m just borrowing from my own experience here and trying to see how that would map on to various patient populations. Being fairly low body fat, fairly athletic, a decent amount of muscle mass, I’ve typically eaten moderate to lower carb, but I will practice a post-workout shake of some sort or have that be the meal where I eat more carbs. After a vigorous workout, I’d have maybe four ounces of coconut water, four ounces of somewhat fresh-squeezed vegetable juice, a beet or carrot sort of thing from Whole Foods with whey protein. And I would see a fairly substantial spike, even more than if I went out to eat on like a Friday night and had a couple glasses of wine and some French fries and fruit, and I was saying, “Wow, my post-workout shake is far worse than this indulgent meal on a Friday night, with alcohol.”

DrMR:

But then it got me thinking, “Well, I’m trying to make a sugar spike right now to get the insulin reaction, to drive more of this into the muscle.” And perhaps that’s not a bad idea if done in the right context, meaning a person with a fairly low body fat who is trying to optimize for body composition and muscle gain or maintenance. And it made me think, “Okay, maybe a spike isn’t always a bad thing, but we want to be discerning about how we’re interpreting that.” But on the other hand, I was thinking, “Well, maybe this is too much of a spike and I’m doing some harm.” So it’s still kind of a question mark for me, but how do you look at that?

DrRS:

So this is a really important point. I have plenty of patients in the same boat as yours. I’ve got some elite athletes that come see me, and they’re seeing pretty significant spikes. The key word you said is context. So with somebody who’s very physically and metabolically active, you’re going to see a lot of nutrient flux in the blood. And the way I describe it to my patients is, if you’ve got extra nutrients sitting in your fat cells, it’s like cleaning out your closet. The hallway is going to be a mess temporarily, but you’ve got to get the hallway messy to get the closet clean. So when you’re actually doing a workout, and especially if you’re in a moderate to low carb state, what you’re basically triggering is a process called lipolysis, where your fat cells are going to release free fatty acids into the blood.

DrRS:

Well, where are those free fatty acids going to go? They’re going to go to the liver to be converted to glucose. Your liver is going to take the fats away from the fat cells and turn it into glucose. As a result, the liver is going to actually cause a spike in glucose. Now on top of that, if your workouts are pretty intense and you’re in the anaerobic zone where your body’s producing lactic acid, that lactic acid is also a precursor for glucose production in the liver. Back in the days when I didn’t know this stuff and I was doing high intensity workouts, I would be very frustrated. Why am I seeing such intense glucose spikes? But even without eating a single bite, if I’m doing an intense workout, now I expect that my glucose is going to spike.

DrRS:

And on top of it, if I’m going to have a whey protein shake, et cetera, I’m trying to drive insulin and nutrient storage towards the muscle, for that transient time you are going to see some of those glucose spikes, but I wouldn’t panic. It’s just like if we were to panic about our heart rate or our blood pressure after a high intensity workout. It’s not all about the actual workout there, it’s about the after effects, and that’s what you’re looking for. Now, having said that, if you’re seeing a persistent elevation that’s actually lasting more than, let’s say, 45 to 60 minutes after that workout, and it’s really persisting much longer than you’d expect, or you’re post-meal and you’re seeing other patterns in average sugars that are high, I’d be a little bit worried about that. But the other thing too, is fasting blood sugars are very commonly elevated. I actually did a dedicated blog post on the fallacy of fasting blood sugar. Some people just get a slightly elevated cortisol release in the morning, and they’re just so ketogenic that they tend to get these glucose spikes. They’re really not a sign of pre-diabetes as it is for somebody who’s got a metabolic abnormality. So the context really matters. I wouldn’t be concerned about those glucose spikes, just to reassure you. I’m not worried about those.

DrMR:

That’s good to know. I also monitor myself with what would a patient be thinking as they’re going through this and I try to list those things here, so we don’t take too much away from any one number and forget context.

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DrMR:

I believe what you described for people who are eating lower carb and might see a somewhat elevated fasting blood glucose, maybe in the low hundreds, which I’ve had a few times, is known as the dawn effect, correct?

DrRS:

It is, you’re right. Part of that’s the dawn effect. And just keep in mind when you’re keto too, your muscles are so good at using fat for energy, that often they’re just not going to pull sugar in. We call that physiological insulin resistance, where you might get those glucose elevations already throughout the day, but you’re right, you might see a spike from that dawn effect in the morning too. One other quick thing, before I forget Michael, a key point I make to many of my patients on the exercise end is many of them are actually exercising too hard. They’re constantly anaerobic.

DrRS:

So if I keep seeing consistent glucose spikes with their workouts, I really try to tailor their workouts down. Not down as in meaning less effective, but really they’re doing too much high intensity. And when they track their heart rates and I watch them while they’re running and cycling, they’re constantly anaerobic. And really that should be dosed, maybe one or two workouts a week, especially for those that are just not physically active or elite athletes, because that over time can have effects on the mitochondria and can lead to more persistent glucose elevation. So do be aware of the fact that if you’re seeing that more persistently, you might have to tone down your workout intensity into more of a Zone 2 type workout.

Proper Exercise Intensity

DrMR:

Oh, interesting. Because that’s something that I was noticing on most workouts, but most of my workouts are fairly vigorous. That being said, we recently had a podcast with Mike Nelson, and he made this point that there is such a thing as doing too much high intensity exercise. I mean, that probably doesn’t sound too groundbreaking, but I typically think of the person who’s doing like an hour and a half, six days a week and they’re just really beating themselves into the ground. Whereas, at least in my mind up until now, and I’m kind of reappraising this, if you’re doing 45 minutes, four days per week of those higher intensity exercises, you can probably get away with that.

DrMR:

One of the points that Mike Nelson had made is that needs to be done against, and while maintaining a cardiovascular base. People can drift into what he described as this heart chamber hypertrophy imbalance, where you’re over optimizing this intense left ventricular output against a lot of resistance. That can lead to fatigue actually, so it’s something to maybe motivate people, myself included, to balance out the programming. So you’re saying some of these exercise sessions during the week, they shouldn’t cause any blood sugar spike, or should they cause some?

DrRS:

I mean, if you want to be quantitative about this, Michael, it really comes down to the mitochondria. It’s all about the mitochondria. When your workouts exceed a certain limit, now you are stretching the mitochondria to some degree, but now most of your metabolism is anaerobic. You’re going to end up hitting some sort of wall. So I don’t have a podcast myself, but I had to do an interview with one of my endurance fitness heroes. His name is Phil Maffetone, and he’s done groundbreaking work behind this. A simple rule of thumb he uses is 180 minus your age. We’ll make the math simple, so if you’re 40, 80% of your workouts should not exceed 180 minus 40, which is 140. Now, if you’re diabetic or you have insulin resistance or other chronic health conditions, you subtract five points from that.

DrRS:

So that means most of your runs in cycling, et cetera, should be at about a 125 to 130 zone. Now for most people, that’s going to seem way too easy. But even with his elite endurance athletes, world-class triathletes, they are basically restricted to that zone because that’s where you’re going to get the maximum mitochondrial benefit. You’re going to have the least amount of lactic acid production, less reactive oxygen species. And it took a lot of discipline, because I’ve been a Type A workout person for a long time, but I’ve seen game-changing improvements in glucose control, metabolism, and even fitness just by disciplining myself.

DrRS:

The good news is, as you do this more and more, you become faster and stronger at a lower heart rate. So I tell people when you watch a soccer match, if you’re watching the NCAA tournament right now, the fittest people in the fourth quarter are barely breathing heavy. They can do an interview without getting out of breath because they have trained themselves to be fitter at a lower heart rate. And we mortals here, our amateur athletes, we have to do the exact same thing. So when I hit a wall with my patients with diabetes control, they’ve been doing low carb keto forever, I zone in on the exercise and I am so disciplined. I’m like, “You have to measure heart rate, you cannot go above 180 minus your age for the first two to three months.” And they hate me for it, because they’re not getting the adrenaline spike from the workouts that they love so much, but it leads to incredible improvements in their metabolism and their overall health. So definitely a key takeaway.

DrMR:

No, thank you for that. When Nelson made me aware of this, it’s something that we’re integrating into our clinical model now for when we hit a similar wall with fatigue and recovery. There’s a couple tasks you can have people do, like a Cooper’s 12 minute run test and get their time, and that will give you their VO2max score. And you can look at that with a few other benchmarks to get a sense for if they are not in possession of this base of cardiovascular conditioning, and if you have to revisit that lower level. And regarding your disdain for doing that exercise, I feel the same way when I strap on the heart monitor. It’ll beep at you every time you go above your target heart rate and it’s like, “Geez, I’ve been running at a snail’s pace.”

DrMR:

I do remember back to when I started doing some training with Nelson, I started with that two month period where three days per week, my cardio was at that snail’s crawl. But it did actually get me to a point later where I hit some pretty high benchmarks for output. So as someone who likes to work hard and associates hard work with with better outcomes, it’s hard for me to wrap my head around. But I guess a parallel that we’ve harped on the podcast is that more testing doesn’t equal better results. So, in this case, maybe more effort doesn’t always equal better results.

DrRS:

That’s so true. And a couple of things just to tell your listeners is, if you did a high intensity workout and you see that glucose spike, let’s say you’re wearing that continuous glucose monitor, I’ve made it a rule of thumb that no matter high intensity my workout becomes, I’m going to finish off with that low intensity zone. If you can finish off for at least 15 to 20 minutes in that Zone 1, Zone Two, which should actually be a natural cool down process already, you’ll see that your glucose spikes won’t be nearly as bad. So that’s something to integrate. Coming back to our central topic of insulin resistance, your aerobic performance, your VO2max, it is a central root cause for mitochondrial function, which is a root cause for instant resistance. So I tell a lot of my patients that as much as they’re obsessing over their lipid and glucose numbers, actually to me, what’s more important is how fast can they walk a mile or do the Cooper’s test.

DrRS:

Like I tell them, “Once a month, once every six weeks, you’re going to come in with your flow sheet, with your labs. I want a column for your physical exercise output.” Even my seniors that do a two or three mile walk, I tell them, “Time that walk. How fast can you walk that three mile neighborhood circuit?” Now, if you do this right, you should be getting a little bit faster. If you’re getting a little bit faster, your mitochondria is getting stronger, and you are combating insulin resistance. So I tell people you’ve got to treat that like a vital sign that’s even more essential than all these other labs that we obsess over and day and night.

Insulin, Fasting & Diet

DrMR:

Love it. What about fasting? You alluded to people over fasting, which I would agree with. Like many things, there’s this Goldilocks sweet spot that we want to be aiming for, but how are you integrating fasting if at all?

DrRS:

This is personalized too, but it depends on the level of insulin resistance people have. Some of my patients, especially if they’re overweight and their time windows are extended, are eating over a 12 to 14 hour period. It’s very difficult to all of a sudden put them on a 16/8 or an 18/6 fast. So I might just gently shave off two hours, and they do fine. But the biggest problem I find in my patients, I’d say in half of my patients, even before they’ve seen me, they are so-called fasting because they’ve read a book about it, or they’ve heard a podcast. But my biggest concern is during their feeding window. I think most fasting regimens are broken by the feeding window, because my patients are still not eating very well during that feeding period. They’re still eating very nutrient deficient foods, they’re not getting enough fiber, protein, and healthy fats. And if you’re really not doing well during that feeding period, the fast is going to break down. You’re going to be in a chronic state of starvation or nutrient deprivation. In women, we see all types of hormonal abnormalities, thyroid, sex hormones, thrown all over the place.

DrRS:

So the first thing I really do with fasting is, I want to see what types of foods you are actually eating. What’s in your cupboard or pantry? What are you eating on a regular basis? What’s your physical activity like? I tell people, “You have to be in shape to fast. You can’t just come in with a broken metabolism, poor eating habits, and started doing 16/8 fasting. That’s not going to do you any favors. It’s just going to be an additional stressor on the body.”

DrRS:

Once we’ve got the diet cleaned up, we’re doing some physical activity, stress and sleep are managed better, that’s when fasting really blossoms if you do it the right way. But I think for your listeners, you have to understand that fasting is medication, and like any other medication, if you don’t do it right, you can overdose or get significant side effects from it. So with many of my patients, I’ve had to take them off fasting and just focus on eating good foods. Don’t worry about fasting right now. Let’s get the physical activity up, and then maybe we can gently transition into fasting to make it more tolerable.

DrMR:

Great point. The analogy I often use in the clinic of fasting being like running. You can’t just go out and run five miles if you haven’t run in a few years.

DrRS:

Exactly, well said.

DrMR:

So maybe this is one of the questions I should’ve asked first, and this is probably a lot to unpack. I know there’s a lot there that might be nuance with diet, but what are some of the keystone guiding principles you’re providing people with to try to find the diet that works best for them?

DrRS:

First of all, the key question I ask my patients, or the interaction I have with patients in the clinic is what are the types of foods that they really prefer to eat? And I don’t think we often ask that enough. Oftentimes as practitioners, we’re just looking to cut things out of the diet and the plate. But again, I see diverse patients from different backgrounds. Telling an Indian vegetarian to cut back significantly on carbs is a big challenge, because that’s such a staple part of their diet, but there are certain foods that they can enjoy that are healthy and are part of their ancestral traditions. So can we hold on to that? I find that in patients that really do lack a lot of willpower about letting go of foods, that’s where time-restricted eating or doing even gentle fasting to start off with is a great approach.

DrRS:

So if you’re really struggling with stress, you really can’t be too disciplined in the beginning, can we at least shave off two hours from your eating window? I start with that. And then I really focus on nutrient dense foods. And for many of my patients, I find that especially as a result of fasting in these regimens, many of them are severely protein deficient. So just getting them to eat high-quality healthy proteins, and getting in more fibers and nutrient dense foods are really key, because they’re struggling with hunger. And as you know firsthand, getting enough protein and healthy fiber into the diet can at least be a natural appetite suppressant. Also, giving them a window of time to eat during is really helpful there.

DrRS:

Now, one other thing I want to throw in there also is regarding the keto. I’ve put patients on ketogenic diets and they’ve done really well. I’ve been intermittently on keto for many years as well, but we do have to acknowledge the fact that patients that are not physically active and have insulin resistance, many of them can be fat resistant as well too. As much as we love saturated fat, it’s still a high energy fuel. I tell many of my patients, “You’re putting jet fuel into a minivan.” If you’re not physically active and your metabolism is disturbed, we can’t just throw unlimited amounts of coconut oil and saturated fat into the diet. So when you modify the fats, you’ve still got to be aware of the quantity that you’re putting in. In some of my patients, I’m shocked because even though their carbs are low, until I fix their dietary fat intake, we don’t reverse their diabetes completely.

DrRS:

And a lot of people listening might be like, “Oh my God, what do you mean? Fat has nothing to do with diabetes,” but fat actually is one of the central mechanisms for causing receptor dysfunction in the muscle and the liver that can actually drive that. So we need to be aware of the fact that just like you personalize the carb intake, you’ve got to be very careful with the fat intake as well, because it can really cause more significant lipid abnormalities. It can actually drive higher glucose, too. So we just can’t put our blinders on when we’re giving dietary advice, because there’s so much variability in each individual.

DrMR:

Are you finding that some people, and I’ll include myself in this, will overeat certain types of healthy fats? In my case, I was eating half a block of organic grass-fed cheese at dinner. And when I actually started punching it in the chronometer, I said, “Holy smokes, this is a ton of calories.” And so I learned, I have very poor breaking mechanisms when it comes to eating cheese. So I had to bridle that. That was one of the insights I had regarding how to get my body composition from good to better, by just trimming back some of that overindulgence on healthy fats that I thought I could eat indiscriminately, because I hadn’t pieced this together yet.

DrRS:

Oh man, we have the same kryptonite. Cheese is my big weakness too. I can go nuts on that stuff, but that’s exactly right. And again, I’m pretty flexible about the approach used, but you have to look at the output. The output is going to be body weight, body composition, lipid results, glucose homeostasis, all these things are important. Many of my patients feel like based on what they’ve read, they can just have unlimited amounts of this. And then really the variability you’ll see as you do follow-up labs. In the beginning, I might err on the side of my insulin resistant patients consuming a little bit more fat, hopefully a diverse array of fat, just to get the glucose numbers down. But then we might have to fine tune the fats further.

DrRS:

Now the one thing I will say just as a high-level marker point, in the community often people are saying “Sat fat’s the best thing ever.” I do tell people that if you’re eating high quality sat fat, the good news about it is, for most people, it’s pretty lipid neutral. It doesn’t tend to drive up cholesterol levels much except in some of my patients. But the one thing that hasn’t been shown with sat fat, it is not a proven heart-healthy fat, like we’ve proven with the Mediterranean, the monounsaturated fats. Maybe that’ll dish out later on in future research, but right now I would rather bet on more of the monounsaturated fats with some sat fat. But right now, I’m not confident enough to say that sat fat is a replacement for olive oil, that it’s heart-healthy just like that. We just don’t have nearly enough studies to really say that.

DrRS:

So if you’re somebody that’s been low carb for a while, but you’ve hit a wall, really play around with your fat composition, because that might be a central culprit. You’d be surprised at how incredibly your glucose and other numbers might improve.

Stress and Insulin Levels

DrMR:

I love how you made the point that we shouldn’t just be chasing lab values, but we should be looking at outcome data whenever possible. That’s a fantastic point. Well, we’ve stopped at a few different important pieces here, but is there anything else that you feel is important for people as they’re trying to optimize their blood sugar, their diet, their exercise? Obviously there’s a lot there to unpack, we could probably do a podcast on any one of those, but anything that you’re maybe seeing as common stumbling blocks for people?

DrRS:

Well, I’ll tell you, of all the benefits I’ve seen with the continuous glucose monitor, I think probably the greatest benefit has been quantifying the impact of stress and sleep on blood sugar. People have always heard that stress is bad, cortisol is going to raise blood sugar. You might know the mechanism, you might’ve heard of it, but until you see what it does to your blood sugar, you will not believe it. And sometimes that’s the only thing that I’ve been able to use to get people to start meditating or going to bed earlier. So again, I know a monitor is not going to be accessible for everyone, but please believe me when I tell you that I am just shocked at what an impact they have.

DrRS:

I just saw a patient a few days ago who has had incredibly great blood sugar control, no signs of insulin resistance. And then she basically showed me that she sat at dinner with her in-laws, and her in-laws are anti-vaxxers and refuse to get the COVID vaccine. There was a heated exchange that happened at the dinner table, and she showed me a blood glucose spike up into the 170s, which was so far from any glucose that she’d seen. And I’ve seen those anecdotes and stories, and so have many of my metabolically healthy patients, that it just makes the point that the stuff we talk about regarding the theoretical connection between cortisol and glucose, it is so real.

DrMR:

And right now in our COVID-19 environment, with all the stresses we have, we all have to give ourselves enough space to rest, to breathe, to relax, to have fun. All topics I’m sure you’ve covered in prior podcasts. But I can tell you, our body, our glucose is paying attention to those stress levels. So do everything you can to manage that.

DrMR:

Great point.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health-supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

DrMR:

Are there certain levels that you’re advising people to look for as a good meal as compared to a bad meal, with maybe, 60, 90, or 120 minutes post? I’m sure this is something that people who use the monitors are trying to suss out. There’s also this contracting piece, which is, we’re not necessarily looking at absolute levels, we’re looking at relative changes. But what are some of the barometers that you advise people on to help find that balance between those two?

DrRS:

First of all, for those of you out there that are diabetic or have glucose that has been out of control, the numbers I’m going to say right now might sound very aggressive. So you want to just gently move in the right direction. So you’re looking for 10 to 15% improvement in what you’re looking for. But let’s start with completely metabolically healthy people. Really data on this is limited, because CGMs are fairly recent, but often we find that in metabolically healthy people that have very little risk of going on to develop diabetes, their glucose levels rarely go above 120, even post-meal. 140 is like an anomaly.

DrRS:

So first thing is, their G-max, as I call it, their glucose max, is rarely ever above 120. They just stay within that zone. Their average sugars are usually in the 100s. When it comes to when their glucose comes back down postprandial, typically it happens within 30 to 60 minutes. The minute it lingers beyond that, that’s already a sign that insulin resistance is probably somewhere in the background. So I know that’s going to sound very aggressive for people that already have insulin resistance, but I think it’s important for us to know. And those of us that maybe have a strong family history, and you want to be proactive, those are the numbers you want to aim towards.

DrRS:

Really, our postprandial glucoses, except for those occasional cheat days, et cetera, should rarely go above 120 or exceed 140. But when you get those monitors, it’s going to give you a default level of 180. So that’s way too high. But as you know, standard guidelines tend to be a little bit different when it comes to managing Type 2 diabetics versus those that are trying to prevent these diseases. So I think those are numbers to pay attention to.

DrRS:

One of the things we need to be aware of that’s just starting to come out in studies is the role of glucose variability. So what I mean by that is, typically in my experience with patients, you should not see the swings in glucose being more than 15 to 20%. When I see highs and lows that go much more beyond that, that’s when people really feel not so good. They’re having a lot of hypo events, their glucose is varying, their hunger fatigue levels are really in bad shape. So when you get one of these sensors, you will see the graphs and the trends, and they’ll often give you a percent value of what your glucose variability looks like. And I literally tell people one of our goals is we don’t want to flatten the curve, because glucose variability is normal, but you want to minimize those fluctuations. So paying attention to those key markers are ways not just to prevent disease, but to make you feel better. It helps people rest and sleep better. Everything gets much better when we can get that glucose variation under control.

Insulin Levels and Sleep Quality

DrMR:

This is really interesting because one of the things that was frustrating me was finding it somewhat challenging to stay postprandial below that 120 cutoff. I think one of those was because of a mispositioning of the device, but when I had the positioning correct, I was still struggling. But I think I’ve shared with the audience that I have only recently finally given into the advice of not eating late at night. It took me years to fully wrap my head around this, and it wasn’t until Mark Burhenne gave me a very harsh, paternalistic talking to. I’d go to the gym at 6:00 or 6:30, and by the time I’m done working out and I get home, I pop in the sauna and then I’m done in the sauna and I finally eat, I wouldn’t be eating in a lot of cases until 8:00 or 8:30. I wouldn’t be done until 8:30 or 9:00, and I’m going to bed at 10:30 or 11:00. I was always seeing my Oura Ring sleep scores come back as a C-minus sleeper, maybe C-plus. It bothered me, but I felt okay, so I didn’t read too much into it. Well, now that I’m working out midday and I’m usually eating by 6:00 or 6:30, and done eating by 6:30 or 7:00, I’m seeing that I’m a B-plus sleeper.

DrRS:

Oh yeah, key point. I’m sorry to interrupt you. I love the fact that you brought that up because often in my Silicon Valley talks, I show the CGM data with the Oura Ring data. I often say that when your daytime glucose is under control, it reflects into nighttime. So when you have a lot of glucose variability during the day, often at night you’ll have deviations that actually erode your sleep score. So I love the fact that you brought up this anecdote because once you really regulated your nutrient intake and you sort of minimized the late night eating, your sleep scores got better. And we see that over and over again. So it’s such a key point.

DrMR:

I’m going to get myself another FreeStyle Libre and run the test again. I’m curious to see if I can keep within the margins of under 120 now that my sleep is better.

DrRS:

Yeah, let’s see if that’s the case. In some of your cases, I know that you’re doing pretty high intensity workouts followed by that. So I wouldn’t panic too much, because you might have some of those values. That’s the nice thing about these apps and devices that you can mark that. So I’ll sometimes write down, “Okay, today’s high intensity. I’m going to be doing hill runs.” I know my glucose is probably going to go above, but in the long run I know that’s going to help me. So aside from those sort of outliers, you want to make sure on other days that most of your glucoses are within that range. That’d be ideal.

Episode Wrap-Up

DrMR:

Great. That’s a terrific insight. Well Ron, this has been an awesome conversation. I feel like I could pick your brain here for another couple of hours, but I’ll respect your time and leave it there. Any closing thoughts that you want to leave people with? And then please also let our audience know your website and anywhere else that they can find you on the interwebs.

DrRS:

The closing thoughts are that I think a lot of us get very depressed by chronic disease, and we sort of become a little bit imprisoned by our family histories, but I want to tell everyone that this is a very exciting time in medicine and health and wellness. I mean, we’ve got podcasts, like what you’re delivering, it’s such tremendous information, but really the cutting edge is these sensors becoming more affordable. Companies are actually competing in this space, so these will be over the counter before we know it. You know, the FreeStyle Libre in Europe is over-the-counter. You can walk into your local drug store or whatever store and pick one of these devices up and put it on your arm and exercise and see what happens. And we’re not too far away from that happening. So I think learning about this is just so empowering, so feel encourage by that.

DrRS:

The other thing I want to throw out there that I mentioned in the beginning is really keeping track of our kids and teens, because I actually see adult patients, but I’ve just started seeing teenagers. And Michael, I’m just shocked by how much insulin resistance I’m seeing in middle schoolers and young teenagers. So it’s that fitness vital sign that I talked about. We’ve got to make sure we’re doing that in our kids too. Especially after a year of just being homeschooled, are they able to get out there and jog a mile? Can they walk a mile? I tell people, instead of hovering over your kids’ report cards, you need to hover over their fitness scores too. That’s probably even more important in the long run. So that’d be one key point to make.

DrRS:

To learn more about my work, I am at culturalhealthsolutions.com. I blog a lot on these topics. I’m not always very good about my social media, but I am trying to be much more active on Instagram. So I put a lot of posts on recent studies, my glucose data, sometimes I’ll share some patient glucose data, and my handle is @RoneshSinhaMD. So you can find me there.

DrMR:

Awesome. Well, thank you sir, for the enlightening perspective here. You’ve given me a few personal action items to move on and I’m sure our audience the same. So I just really appreciate all the work you’re doing and thanks so much for taking the time to speak with us.

DrRS:

Hey, thanks for the opportunity. Take care of yourself.

Outro:

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Defining Insulin sensitivities 

• Muscle, liver and fat
• 80 muscle, fat, liver – triglycerides

Ethnic groups

• Asian – Indian vegetarian 

• Predictors of CHO intolerance 

• Family history/genetics
• Ethnicity 
• Body composition 
• Smaller limbs (less muscle)

• What about under eaters of carbs 

• yes

 

Interventions 

• Diet: 

• What do you they like to eat
• Nutrient dense foods
• Often need more proteins 
  • Vegetarian 
• Too much fat can be a problem, fat resistant 
  • Too much can increase cholesterols 
  • Monounsaturated better outcome data for heart health 

• Exercise:

• Finish workouts with zone 1 exercise to lower blood sugar 

• Fasting

 

CGM (continuous glucose monitor)

• Can spike if too low carb…..
• Wear lower down on the triceps 
• Trends more important than numbers 
• Monitors interstitial fluid glucose 
• Exercise
  • Sugar spikes 
• Fasting blood sugar
  • Dawn effect 
• Target post meal, met healthy
  • Rarely above 120, at any point
  • Average sugar 100
  • Post prandial drop within 30-60 minutes 
• What are some people changing from CGM
  •  Variation should not be more than 15-20%

• Organic Pharmer
• Elemental Heal
• Dr. Ruscio Resources