Episode #157: Insulin Resistance: The Root Cause Behind Weight Gain, Prediabetes and Diabetes with Guest Dr. Chhaya Makhija

Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Hello everyone, and welcome to this week’s episode where I am bringing on a guest, Dr. Chhaya Makhija. She is an endocrinologist in California. She has two offices out there in her practice. And I am so excited today for us to dive into insulin resistance because certainly as an obesity medicine physician, this is something I’m talking about all the time. She’s talking about this all the time with her patients as well across the spectrum of obesity and prediabetes and type 2 diabetes. So I am so excited for us to dive in today. Dr. Makhija, thank you so much for joining us.

Dr. Chhaya Makhija:
Thank you, Dr. Sarah. I’m excited about this topic too, because it’s very dear and near to my heart. So I appreciate that you selecting this topic, and we will be learning so much more than just the name of this specific condition. Thank you for having me.

Amazing. Yes, thanks for coming. And tell us a little bit about yourself, how you came to choose endocrinology, open your own practice. I’d love to hear a little bit about that for our audience. Absolutely, the million-dollar question.

So I’m triple-boarded internal medicine, diabetes, endocrine, and metabolism and lifestyle medicine, which means I get to integrate all of these aspects of education into clinical practice. Why endocrinology? That is a very personal story, which uh, if you remember, Dr. Sarah, we used to write our personal statements in for applications to medical school. And I had a real story where my grandma was dealing with diabetes. None of us knew if it was type one or type two, but she had a diagnosis early on in her young adulthood. And the only things I remember is she being on insulin and having a four-foot amputation, then above knee amputation, and within a few months her demise because of renal failure. And I was around eight years of age. So that’s all I remember insulin shots, wound dressings, and you know, that smell of wound or dressings that really stayed on with me for the longest time. I knew I wanted to become a physician always, but I had no idea what specialty or what should I practice. And this led me to like really discovering what is this diabetes, like why is someone suffering so much. And we had diabetology at that time. This was you know a long time ago. I graduated med school in 2004. So endocrinology was still new. And um, once I learned about hormones, that this would encompass hormones and diabetes, like this field of endocrinology. So that led me to residency and diabetes research fellowship at Albert Einstein, which piqued my interest even more about this pancreas. It’s just so mesmerizing. And then the application to endocrinology. So thank you. That was a very personal question.

Yeah, well, and it’s amazing, you know. I think so many of us have these connections to the fields that we study, whether it’s personal, whether it’s professional, just even in helping our patients and then seeing that grow over time. And I think too, you know, you and I, one of the things we’re most passionate about is really supporting patients, both our own patients, but then also sharing more broadly of what this message is of how do we understand our bodies, how do we help support them? And so I’m excited for us today to dive into insulin resistance because I think one of the terms that I hear thrown around all of the time on social media is insulin resistance that, insulin resistance this. And let’s talk about it because insulin resistance is a sort of root cause of a couple of health conditions. So tell me for our audience, how do you find define and explain insulin resistance when you’re sharing it with patients or with a broader audience?

Yes, absolutely. So, you know, if you go get an internet search or a ChatGPT search, it’ll outline that definition. But to really understand the concept of what’s actually happening in my body or for us, what’s happening in our patient’s body is knowing the importance of insulin. So one, it’s a hormone. Second, it’s one of the important essential hormones like cortisol and thyroid, without which, so without insulin, we cannot sustain life. So it’s that essential. the third thing, it’s being produced by an organ called pancreas, which is, you know, on your left side of the abdomen, just behind the stomach. Knowing that, how essential it is, what is it doing? It is actually helping your glucose, that is your main fuel. Your every cell in the body, we have trillions of these, is basically an engine. So that engine needs fuel, and the main important fuel is glucose. So insulin is helping this glucose, which is your fuel to be utilized by your cell, which is your engine, more effectively. And that’s the main role of insulin. And then it, of course, is also involved in your lipid metabolism, that is, you know, how our fat cells are being synthesized or manufactured per se, and how are they being processed or metabolized through the body. And then it has many other effects which are called anabolic effects, which we can talk about later.

But now when we know the importance of this hormone this molecule your question about insulin resistance as the term itself explains, that there is some resistance, which is basically in that cell in your engine, where the cell cannot utilize the insulin as effectively. So it’s a defect, it’s a pathology where the insulin-mediated or insulin that was performing an action to tell your fuel, that is glucose, to get into the cell is not happening adequately or not happening effectively or efficiently. What is the problem? The problem is that we have trillions of cells that we talked about, but your skeletal muscle, your liver, and your adipose tissue or the fat cells that we have, they harbor insulin resistance the most. I’m going to give you an example which I usually do that to the students. Imagine if you’re sitting in a small room, it has two doors, and if insulin is standing outside one door and glucose, which is the fuel, standing outside the other door. Door one is insulin, door two is glucose. So for the insulin or for the glucose to enter inside the door, that is through door two, door one has to open and insulin has to get in. So unless that door one is not open and insulin is getting in, there is no way that the door two is going to open up and glucose can enter in. Why do we need glucose inside our cells? Well, because it’s one, I just talked about that it’s a fuel. Second, if there is extra glucose lingering around outside the door, which is our blood circulation, then eventually you may encounter hyperglycemia, that is too much glucose, excess glucose in the body, leading to impaired glucose tolerance, prediabetes, type 2 diabetes, etc., and then other lipid cholesterol issues, and then comes cardiovascular risk issues.
So, where is this resistance coming about? So, why is door one closed? Why is the door one getting some resistance for insulin to get inside? Uh, the most common theory is that there are fat cells which have been accumulated because of multiple reasons. There is ethnicity as one of the main risk factors, there is family history, there is increased caloric intake, westernized diets, processed foods, too much fat. Um, that tends to explain that we tend to harbor more fat cells in our cells, which is your room, that those fat cells are making door one very sticky that, hey, I won’t let you in. They’re telling insulin I won’t let you in. Insulin tells me, okay, let me just generate more superpower. So it tells pancreas release 10 more insulin molecules and let me fight against that door one. And then it’s most of the time successful to enter inside the room and push back the fat cells. So insulin gets in and then comes the glucose. so that’s the resistance. But what are the consequences that those 10 extra molecules which were which were released by pancreas is called as hyperinsulinemia. That is, we have to live with high insulin levels in our body to maintain normal glucose in our blood circulation and to provide fuel to these cells. So that in in you know, I would say fifth grader language is what insulin resistance is. I could pause here if you had any questions or if your audience wanted any questions before we dive into like what are those conditions that are complications related to insulin resistance.

Yeah, no, I think that’s great. And I love, I just want to reflect before we do move on that the importance of insulin peace is so, it’s so significant, right? And I think one of the challenges when we talk about insulin resistance is that I think sometimes we think about insulin as a bad thing, but it’s actually, like you said, it’s essential for life. And without insulin, we have type one diabetes, which until about a hundred years ago was a completely deadly condition. It was a death threat to be, or a death sentence rather, to be given a diagnosis of type one diabetes. And so we know that insulin is incredibly important and this deranged pathology can occur where or deranged physiology can occur such that it starts creating these problems. So, yes, tell me a little bit with understanding what insulin resistance is, how does that manifest in different conditions?

Yes, absolutely. So we had this, it reminds me we have these longitudinal knowledge assessment questions to keep our endocrinology board certifications active. And one of the terms they had asked a question, which was actually this year, that which of these four cells, and they had muscle cells, brain cells, liver cells, you know, fat cells which one of these is helping to utilize glucose without much of an influence of insulin? So that is, how can this particular cell use glucose without much of an impact of the insulin that uh which is every cell that is governed by that is governed by insulin and glucose molecule? And the right answer was skeletal muscle cell, which is not really influenced much with the insulin to help glucose get inside the cell. That is, I don’t need the effect of insulin to let the glucose enter into my muscle engine to work as fuel. And that itself is a great solution as we talk about insulin resistance. So now to get to your question about you know what’s happening, what’s the path of physiology is that one, we talked about you know what are the causes or risk factors for insulin resistance, but the genetic distribution, you know, commonly Southeast Asians, Hispanics, African Americans, insulin resistance is just more prevalent than other ethnicities. So ethnicity becomes a big component when we are assessing someone for insulin resistance. The reason being that these individuals also have a high risk of prediabetes, type 2 diabetes, mellitis cardiovascular disease, heart attacks, metabolic syndrome, which is you know high blood pressure, high cholesterol, high triglycerides, and fatty liver disease. So these are just, you know, in a nutshell, the more common diseases.

But when we break it down, you know, our individuals, women with polycystic ovarian syndrome 50 to 60 percent have insulin resistance as the root cause of polycystic ovarian syndrome, which leads to infertility, which can lead to difficulty in conception, and you know, other metabolic issues as well as mental health disorders. And the rest of it is also explained by other hormonal derangement in hypothalamic pituitary ovarian axis for polycystic ovarian syndrome. So these are not, you know, a couple of conditions or two, three conditions. It’s actually affecting most of our organs. I haven’t even touched based on chronic kidney disease which will also be influenced by insulin resistance.

Okay, I love that you’ve talked about all of these different systems. And a lot of times people will get an end diagnosis of hypertension or hyperlipidemia, you know, high blood pressure, high cholesterol. They’ll have a diagnosis of type 2 diabetes or polycystic ovarian syndrome, PCOS, and recognizing though that a lot of ways are really all the same root condition and it just may be manifesting in different ways, or we haven’t yet seen other manifestations, like maybe it’s not progressed to the point that we’ve seen the end result of it. But I do love as we think about obesity as a disease and understanding it as an insulin resistant condition, thinking, okay, that’s why it makes sense that it’s tied to heart attacks, it’s tied to strokes, it’s tied to dementia, it’s tied to type 2 diabetes, all of these conditions have the same common root of insulin resistance. So thank you. Thank you for sharing that.

Absolutely.

And so tell me when we think about this development of insulin resistance and why it’s a problem, how well what do we do about it? You know, once it’s there, are there things that we can do to prevent it from happening? Once we do have some insulin resistance, how do we work to start treating that?

Yes, absolutely. The key is definitely the muscle. And that’s why I wanted to add that question which we are placed for, you know, as for endocrinology boards, that you can use this skeletal muscle to your benefit to improve your insulin sensitivity or in the other words, reduce insulin resistance. There is nutritional aspect and then comes you know pharmacological aspects to address this condition. But before we get there, you know, insulin resistance is the most common root cause of all the conditions that you and me just mentioned about that we encounter, and these are most of them are the common epidemics that we are going through, including certain malignancies where insulin resistance has been a contributor. It’s first important it’s like, do I have it right? Or my does my patient have it? And how do we identify it? So insulin resistance is a clinical diagnosis for most of us as physicians, and that could be um, you know, I could easily mention tell that based on someone’s ethnicity. In South Asians, they have more hair growth in general. I’m talking about women even though their testosterone levels may not be high. The third thing in all humans that we can notice or look for is acanthosis nigricans, which is darkening of the skin in multiple places, front of the neck, back of the neck, axillary region, and so forth. So not missing those clues and skin tags.

Dermatologists usually will refer a lot of patients to me because they’ve noticed these signs. They haven’t ordered any biochemical evaluation, but they’re suspecting it. And then comes a lot of symptoms that are relevant to polycystic ovarian syndrome. But this is more of a clinical picture.
Weight gain more in the central or the central adiposity, increase in our waist circumference, all will also be more of a clinical suggestion of insulin resistance when a physician is actually going through that clinical examination. Biochemically someone’s glucose may be completely normal, but they may have low HDL, which is the high density like cholesterol or the good cholesterol, triglycerides may be elevated. You know, we commonly see ALT and AST elevations, which are your liver enzymes or you know, someone’s A1C, hemoglobin A1C might be fluctuating or it may be normal. I’m sure you’re looking at other tests like high-sensitive C-reactive protein because this condition can also be a pro-inflammatory condition. So we have a lot of biochemical assessment that can also help to identify along with the clinical findings. So now we end up going, okay, how do we address? How do we get to this solution since we’ve identified insulin resistance? So number one is you know a 24-hour recall with your patient, just a simple 24-hour recall if the patient is meeting the specialist or the physician for the first time and diving into their modifiable factors and non-modifiable. And non-modifiable is very important because we cannot miss out on ethnicity, the race, their family history as a contributor to insulin resistance because there are so many genetic syndromes that we tend to miss. And um, you know, there is this false advice that just lose more weight and eat less to reverse insulin resistance, which is applicable in most of the population. But I’m talking about, you know, once you assess what are the causes of insulin resistance, make sure that we are also looking at non-modifiable risk factors that we talked about.

So, say if we are dealing with individuals who have insulin resistance and you’ve assessed them clinically and biochemically, and now we want to go through preventive measures or preventing complications or reversing this condition. Um, the tools are which you talk to your patients and also on your podcast about nutritional changes. Um, and those are literally universal. We don’t have a specific diet or restrictive diet that is recommended. But in most of the scenarios, it’s always plan forward, lean protein and making sure that there is adequate fiber intake and you know, culturally favorable for that particular individual, is going to be very important and targeting their lifestyle, their routine, their stressors, their sleep, which all plays a role in insulin resistance. So it’s not about just nutrition, but all these factors can improve insulin sensitivity. The main one which we don’t tend to implement as much as humans is physical activity, and it has to be beyond walking. So post-meal walks are a great way for our patients. You know, we use continuous glucose monitors as endocrinologists, and I’m, you know, most of the physicians who are seeing patients with pre-diabetes and type 2 diabetes use continuous glucose monitors. You’ll usually see a dip, a faster dip after a post-meal rise in blood sugar with post-meal walks, post-meal you know stroll, or it could be just doing your home chores or just taking circles around your kitchen, bedroom, whatever you find. But staying active after eating helps with your skeletal muscle, which I’m coming back to utilize glucose without needing much of insulin support. So that’s your skeletal muscle contraction to take on all the glucose that’s come from the food metabolism.

The next step is also understanding that how can you use your muscle? It could be body resistance exercises, it could be using bands, it could be doing you know squats, push-ups at home, it could be modified version but contracting your muscles and making a routine which is going to help utilize your glucose as a fuel. Now, you may not have prediabetes and type 2 diabetes, but you may have insulin resistance, which is very common. Literally, 40 to 45 percent of individuals in the United States of America today have insulin resistance without pre-diabetes and type 2 diabetes. And this I’m talking about patient population between age 18 to 44 years of age, right? So this is our younger generation. And the data is actually from Enhance which was more for 2018 and 2019, the incidence has been higher, the prevalence, I mean to say. So that’s where engaging in physical activity, taking breaks, it’s very easy for us to you know keep on repeating this, right? But also practicing what we are talking about. You know, I make sure that, you know, as I’m recording this podcast, if it’s going to be more than 45 minutes before I get up, 10 squats and then leave the room, right? So it’s also knowing what is the problem. I don’t want to encounter this problem and I know the complications. So the awareness is there. And what can I do while I’m busy in my routine, but still get better outcomes and results. So your skeletal muscle is going to be your biggest wealth that you’re in control of to help improve your insulin sensitivity or decrease your insulin resistance, even when you don’t have pre-diabetes type 2 diabetes, but you’re already at risk of developing these or the other medical conditions that we just talked about.

Okay, that was so, so good because with 40 to 45% of young adults struggling with this, certainly that increases as we age. And we’re really talking about nearly half of the US adult population or young adult population that may have this, I call it pre-pre-diabetes sometimes, but insulin resistance. And so it’s not always, I find a lot of people are not always even talked to about it by their physicians or they’re not even aware of what to look for because some of those biochemical markers are not super obvious. You know, we’ll see glucose levels in the upper 90s, but they’re not flagging as abnormal. You know, traditionally we’ll see a flag as normal in the, you know, 100 or higher, or someone will have triglycerides that are, you know, just below 150, or their HDL will be like just okay, or maybe it’s you know just right on the border, you know, AST and ALT, I frequently see levels that are in the like upper 20s, lower 30s. Again, they’re flagging as normal, but depending on your age and your gender, you know, for women, we want them to be a lot of times less than 25. And so we see these things that are coming up as normal, yet someone struggling with gaining weight or feeling like they can’t lose weight despite everything, or maybe struggling with fertility. And especially then we think about family history, we think about ethnicity, these contributing factors. For a lot of people, it kind of dawns on them, oh, this is, you know, once they realize it, it’s really empowering to see, okay, there’s something here. And while there’s some factors that may be out of my control, there certainly are factors within my control. So thank you for sharing the exercise piece. I love, you know, standing up and doing 10 squats. It’s such a good example of, you know, I try to stay very active, but when you’re recording a podcast, it’s like I’m here, I’m focused on the camera, you know, I’m not going to be doing these sort of walking treadmill or standing desk or anything like that. And so thank you for sharing that example, especially it sounds like for yourself, you’ve got that family history. And so anything you can do to prevent it will be really important.

Yeah, yeah, absolutely. You know, I wanted to touch base on this point that you’re very right about everyone looking at lab ranges for all the labs that your biochemical values that you just mentioned, but it may not normal, not be normal or not signify that, oh, I am dealing with insulin resistance or my patient is dealing with insulin resistance. I commonly make sure that, you know, to get a fasting insulin for most of my patients, and it’s so easy to calculate the home IR, but I don’t even get into the calculations. If my patient’s insulin level is in single digit and I prefer more as you know, four, five, six, and their glucose is normal, that is, you know, less than 90, they’re very insulin sensitive. And then of course you can go online and look at the home IR calculation if you know if you’re a patient or if you’re a physician for I’m taking care of someone. But it’s that easy to understand, you know, where am I at? And now work towards the solutions.

Well, and thank you for saying that because I think there’s whenever somebody posts online, you know, sometimes in these big physician community type Facebook groups, someone will mention insulin, insulin, and a fasting insulin level. And there’s all sorts of upwards. It’s surprising to me that it’s controversial because for someone like you or I, it’s a lab that we order all of the time. And I think there’s many of us who are in this space in medicine that see the value of that either on its own or in that HOMA IR calculation, which is basically just saying for a certain glucose level, for a certain insulin level, is your body appropriately releasing the amount of insulin? Is your body insulin sensitive or not? And so it can give you that ratio. And so I think it’s an important thing to have a conversation with your physician about ordering that fasting insulin test. And it can be really powerful because we see elevations there, as you were implying long before we see elevations in sometimes blood sugar and certainly before A1C.

Oh, yeah, absolutely. The importance is again, don’t look at the lab range because it may say, you know, anywhere between two to 35 is normal, or there’s so many lab ranges. Um, but if your physician is able to interpret or is in that world of science where they know what to make how to make sense of these values, it’ll be very, very useful, clinically meaningful for these patients.

And it’s amazing to see, you know, even just within a couple of months, how quickly some of these numbers can adapt to changes that people are making, even just lifestyle modifications alone. It’s incredibly powerful. You know, I have a patient just the other day that I think it was about four months later, and we saw just every metabolic number quickly come into range with a pretty small intervention, really, lifestyle alone.

Yes, absolutely. You know, that’s what I do in my practice. It’s more preventive endocrinology and all my youngsters. So I do have a lot of young adult population, either PCOS insulin resistance or pre-diabetes with insulin resistance, men and women. And I totally agree with you that, you know, when you’re focused on specific lifestyle interventions, which encompasses everything in lifestyle with all the pillars that are addressed and fixing their vitamin deficiencies or any other concerns that they have, which is very obvious in the labs, you will see an improvement in insulin levels, you will see an improvement in ALT, AST. Oh my gosh, the HDL takes six months to improve, but it is so magical to see that rise. You’re buying great health for the longest time for decades, just by investing in your health for those extra months and then making changes in the future as well.

Well, and I think one of the things that’s really powerful too is that when we’re tracking labs, sometimes we see the labs change before we see the number on the scale change. And so, especially for someone like myself where patients are coming in with a focus on weight loss, we have to really reverse the underlying insulin resistance before we start to see the movement on the scale. And so where you’re seeing that movement on the scale, it can be really frustrating. It’s like, is anything happening here? It can be super powerful to see, oh, look at those labs, look how much they’ve improved. And the number on the scale usually starts moving shortly thereafter.

Yes, yeah. You know, we have to realize, see, even like a woman when she is pregnant, there is pre-conception period, there is this nine-month window of pregnancy, and you know, you don’t see a reversal in her in her body, be it hormonally, metabolically, in the body composition within a month or two months or three months, usually it’ll take a year to one year to two years to get back to a reset point in every aspect, right? Um, so same thing when we are dealing with obesity or weight gain or even other metabolic conditions. Yes, you’re so right that you know, suddenly, you know, my blood sugar was 200, I took all the steps and now it’s down to 100 and it’s consistently 100 in the next say 48, 72 hours, but it doesn’t mean that we’ve reversed insulin resistance. We’ve started improving our insulin sensitivity, but to bring about that cellular change, the adaptation, all the fat cells who have this cross signaling for them to reset or become sensitive in every aspect of our body needs time. So the education that you’re also doing is so important because that helps them to just be in that gain mindset. Absolutely.

Well, and I think too, the lifestyle, it’s so, so important. And sometimes it’s not enough. And this is where sometimes it can be really challenging because you’re like, I’m doing all of the things and I’m not seeing the full improvement that I want to. And we need to think about supporting someone also with medications. And so tell me a little bit, maybe when you’re guiding a patient through that, of let’s layer on some medications, how are you talking to them about it? And how can medications be supportive in insulin resistance?

Absolutely. You know, here I think patient examples would be really great to relate to. So, one example is you know, a young gal she’s 25 years of age. Um, and what was important is the dermatologist referred her to me because she noticed acanthosis on her neck. Um, and ethnicity-wise, she has two backgrounds, a Caucasian and Asian. Right? So father is an Asian and mother is a Caucasian. So the inheritance pattern for me was very important as I was going through her history. And then getting her concerns, which was inability to lose weight or weight gain which has been very difficult and amazing with her nutrition, intensely active, very athletic and you know, going to medical school in the in the next few months. so this is where you know her clinical assessment, knowing that there is a background of ethnicity, you know, that non-modifiable risk factor is very important because that buys a lot of encouragement for the patient that I have something that I can work with and something which was not in my control. I cannot blame myself for it. these are the individuals where we definitely need that support of pharmacological interventions. Um, so you know, A1C was 6%, insulin levels were high, and so on, including ALT, AST. And in those scenarios, what medications do we have? so the oldest medication as an insulin sensitizer that we all know is metformin. And that is, you know, in simple words, is just telling your glucose your liver that hey, don’t produce too much glucose because our liver is one of the largest factories to produce glucose, which is called hepatic gluconeogenesis. And it also has effects on our muscle to help improve some insulin sensitivity while we are incorporating lifestyle interventions. So that’s one pharmacological intervention that will be helpful in these individuals.

The second one that we’ve looked at is pioglitazone or thiazolidinedione, which are also used in type 2 diabetes, but not necessarily for patients who only have insulin resistance but no other glucose abnormalities. The third one, which you are, you know, I call you as a guru of GLP-1 now, knowing how much work you’ve added onto it. But we’ve had a GLP-1 receptor agonist since 2005. Yes, for type 2 diabetes, but with so much evidence as to how it is actually working, what effects does it have beyond um, you know, the gastrointestinal effect as the major one is also improvement in insulin sensitivity. So this patient that I’m talking to you about you know, was on metformin for two and a half months, really diligent. She moved to her med school but there was, you know, three pounds of weight gain or sorry, weight loss, and um, you know, improvement in her glucose levels, but we couldn’t bring her A1C down from pre-diabetes 6% to normal. And I would want her to become normal with her insulin sensitivity because she’s young and she’s got that chance to do so. Now she’s been on GLP1 receptor agonist. In this case, it’s tirzepatide. And within two months, yes, she’s lost six pounds, not much, and we’re not aiming to lose much in her case because her BMI was not skyrocketing, but phenomenally, her CGM and her insulin levels both correspond to normal glycemia and normal insulin numbers, and her HOME IR is back to normal, AST ALT is back to normal. This is almost eight weeks down in her treatment on the lowest dose. Right? So bringing about that importance that of these medications or pharmacological interventions to help our patients and in the near future, I don’t have doubt that I’ll be able to help her wean off the GLP-1 receptor agonist successfully because she’s also honed the preventive measures and following her through the course to make sure that it’s not worsening in the near future, but it has to be with medical expertise and support. So use science and lifestyle as a part of our mission in prevention and treatment rather than you know blaming ourselves as a patient that oh my gosh, I’ve been trying this forever, I’ve failed, or I don’t have any uh, you know, any what’s so-called willpower. and this has led to this condition because of my fault. Or don’t worry about your genes because we have a lot that we can work with to overpower them and also bring about a great health outcome, improving insulin sensitivity and also for sure reversing, I would use a better word, reversing pre-diabetes and bringing about remission for type 2 diabetes.

Amazing. Well, and I think this the treatment of that underlying insulin resistance and thinking of medications as just one of the tools in the toolbox alongside all of the lifestyle, like sometimes lifestyle alone is not enough. And I think that’s where, as a medical community, we see this beautiful opportunity to marry lifestyle support with pharmaco treatments, and it’s amazing. You know, we see these phenomenal results in patients. And as you said, it doesn’t always have to be a long-term treatment. We take it as a very individualized approach. And how is someone doing? What are their weight numbers looking like, what are their other metabolic numbers looking like? And we can see really significant improvement, sometimes with very small doses of medication, but not always, right? It’s just an individual. So we take it as, you know, as an individual’s responding to it, as they’re feeling on the medications, as they’re seeing their numbers improve, and they may need more or less support depending on a lot of different factors. And so we we adjust that as we need to. So thank you for sharing that patient example. That was so powerful.

Dr. Sarah, I wanted to add one specific as you’re echoing the same statement is, you know, in this era, especially in the last two, three years, we have multiple so-called experts who are not medical experts using GLP-1 for patients. and the caveat is that, you know, again, I have this big subset of patients who come in for second opinion where they’ve just tried GLP-1 receptor agonists for these conditions and then abruptly discontinued or thought that, oh yeah, my condition is getting better. Now I could just stop it or wean it off myself. Just a word of caution that you will start seeing the rise in blood glucose levels, or you will start seeing worsening of insulin resistance or other metabolic parameters, because it has to be a structured, educated way of considering weaning down by looking at the entire aspect of your health, your biochemical evaluation, and where you’re at. And I don’t want to miss out on body composition. So looking at your visceral fat is also very important because that is a key component, key component which can give us a prediction of can you eventually wean off or come down to a very low dose of GLP-1 receptor agonist?

Absolutely. Thank you for sharing that. And let me say, as we’re thinking about this, I think we could probably talk just all day long about insulin resistance and how it’s diagnosed, how to treat it, how we support different patients with it. But in light of time, I want to think about wrapping up. And I’d love to hear from you before we do wrap up, is there anything that you haven’t yet had a chance to share with my audience that you really think is important that they should know?

My young adults, this is for you. So, you know, if you are a teenager, you’re a young adult, you think you’re in midlife, you’re all young to me. And I would call young anyone who is less than 70, 75 years of age, but the younger adult population, you know, just to tell you that pre-diabetes, one in three. So anyone you’re meeting through the day, one in three individuals have pre-diabetes either it’s diagnosed or it’s undiagnosed. so that’s why this condition is so important to be aware of and to prevent, because the younger and my youngest is 13-years-old though I’m not an adult, I mean a pediatric endocrinologist, 13 year old with type 2 diabetes, insulin resistance on GLP-1 receptor agonist. My heart aches for these individuals because, you know, we used to see diabetes complications latter part of the life if they if it wasn’t controlled. Now we anticipate to see them earlier. So that’s why I’m speaking to you. That go ahead, move, move, move. And one thing that you could just say no to would be the processed sugar. Like just no to process sugar. Yes, you can go ahead and enjoy your feast and desserts once in a while, which is maybe once or twice in a month. But you know, get into your activity, enjoy it. I’m not asking you to be um, you know, over-obsessive about activity, but that pop piece, and then of course your sugars, just be very, very mindful and maybe just engage in a community and be with each other so that you have accountability partners. So that’s the that’s the mission statement I would want to share with your audience, Dr. Sarah.

I love that. That’s such an important call to action. Just like let’s shout it from the rooftops, you know, stay active, minimize sugar intake. These day-to-day routines are what build up in a really significant way. And I think I love working with young adults and seeing where the insulin resistance a lot of times has only been there for a couple of years and is much more reversible when it’s been there for zero to five years compared to someone who’s had that for many, many decades. And so anything we can do preventative is so important. So true. So true. Yes. Amazing. Well, tell us, Dr. Makhija, if people are interested in learning more about you, following you on social media. Maybe I have some listeners who are in California looking for an endocrinologist, where can they find you and learn more about you and your medical practice?

Oh, absolutely. so my name, Chhaya Makhija, MD, is my handle for LinkedIn, for Instagram, Facebook as well as YouTube. I have a podcast Hormones and Hope with Dr. Chhaya, so available on channels. So you can definitely tune in. And then we have lots of handouts which I create with our medical students, so relevant to your thyroid, your osteoporosis, diabetes as well as GLP-1s or any other medications freely available on our website, unifiedendocrinecare.com, or you can just sign up for our newsletters and receive them through there too.

Okay, wonderful. And we will definitely make sure to put all of those show notes or all of those links into our show notes. So thank you for sharing those resources with my patients. Well, thank you so much for joining us today. This has been a really a treat. I think we dove into some of that root cause, trying to understand the insulin resistance, what it is, how we know if we have it, and then what are some of the steps you can take to reverse it? Thank you for joining me today. I really appreciate it.

Oh, my pleasure, Dr. Sarah. Thank you.

Wonderful. And for everyone who is listening, thank you for joining us for this week’s episode. We are enrolling new patients in Charlottesville, Virginia, as well as by telemedicine throughout the states of Illinois, Tennessee, and Virginia. And if you’re looking for more support, you can visit www.sarastombaughmd.com to learn more and get started in our program or with some of our online support tools. We’ll see you all next week.

SARAH STOMBAUGH, MD

Episode #157: Insulin Resistance: The Root Cause Behind Weight Gain, Prediabetes and Diabetes with Guest Dr. Chhaya Makhija

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