Harmonize Your Hormones with Insulin Control

Morgan Nolte, PT, DPT, GCS

I’m excited to be here. Thanks for the invitation.

Mindy Pelz, DC

Of course. Here’s the problem I’m trying to solve for women: It’s different in different decades. And the root cause: Here’s the challenge: the root cause of so many hormonal issues, whether it’s PCOS or a woman going through menopause, the root cause there is metabolic health. You’ve got all these women that are, like, debating HRT or bioidentical hormones, or they’re struggling with PCOS without any answer or even fertility. And nobody is coming to this root conversation about how we need to address insulin resistance. Help us understand that when glucose gets out of control, insulin gets out of control. How do all our sex hormones get out of control? How do they affect us at different ages? because it’s the same root cause with different symptoms that show up at different ages.

Morgan Nolte, PT, DPT, GCS

You’re right.

Mindy Pelz, DC

That’s a loaded word.

Morgan Nolte, PT, DPT, GCS

I could take it away. I’ll start to unpack it. And then I’m sure you can kind of guide us through the conversation in a way that you think is most valuable and productive for the listeners. Insulin resistance is such a passion of mine as a geriatric physical therapist because I saw firsthand what happens if you don’t take care of it, and that is end-stage diabetes. So we’re talking neuropathy, amputation, kidney dysfunction, loss of vision, all those things. Heart disease. I like to say heart disease is not the number one killer in America. It is insulin resistance that causes certain types of cancer. And Alzheimer’s, dementia, and vascular dementia. That’s what’s waiting for you. If you don’t take care of this problem. Now, earlier in life, as you mentioned, women may experience PCOS, or polycystic ovarian syndrome. And I had a really interesting doctor on OB-GYN on my podcast, and we talked about this, and she said, You know, often with PCOS, people go to their gynecologist because it causes reproductive issues. They’re having irregular cycles, heavy bleeding, painful periods, pain with sex, or infertility issues. But really, it’s a metabolic problem. We need to be talking to metabolic specialists, not necessarily reproductive specialists, because they’re not always one and the same. Insulin resistance, we used to think of type 2 diabetes. I think that’s the best example because it’s the most direct, like insulin resistance, which most directly causes type 2 diabetes, right? So that is such a great example.

It used to be called adult-onset diabetes, and it is no longer, so type one used to be child-onset, and type two used to be adult. And it’s not like that anymore because we are seeing high blood insulin levels in children. It precedes any other metabolic dysfunction marker. So we need to be checking for insulin levels no matter what hormone abnormality you feel like you’re experiencing, whether you were in that earlier age division with some PCOS and fertility issues or maybe in your 40s or 50s experiencing perimenopause, or maybe you’re after menopause struggling to lose weight. Test your insulin. That is one of the biggest key takeaways that I hope people get from this because fasting, insulin, and specifically what’s called a Kraft test, which is almost like the oral glucose tolerance test but is called a Kraft test, measure insulin and glucose and fast for 30 minutes, one, two, and maybe three hours after. It’s a post-meal insulin assay that can predict type 2 diabetes up to two decades before fasting glucose. So these conditions, Isn’t it crazy?

Mindy Pelz, DC

It’s so easy to test.

Morgan Nolte, PT, DPT, GCS

Easy. Yes, and we are missing decades of potential interventions for people, and what happens is that things compound, right? We might start with just high insulin levels, but if you don’t get it under control, it’s going to mess up your sex hormones and your stress hormones, and you’re going to end up with more health problems than you otherwise would have. So I wanted to just emphasize that this problem is very, very overlooked by primary care physicians. If they are not, if they’re just Western trained, if they have no integrative or functional background,

Mindy Pelz, DC

Why do you think that is? Before we go into that, I want to go where the numbers should be, but from the place that you and I set, it seems so easy to just go there. You’re already getting a yearly blood test. Why can’t the doctors say, Hey, you’re 20 years old; your hemoglobin A1C or your fasting insulin are too high. If you’re not careful, PCOS infertility is coming down the road. Why are doctors not saying that?

Morgan Nolte, PT, DPT, GCS

I think one of the reasons is because they’re not trained to, number one. And one of the reasons they’re not trained is because the pharmaceutical companies are so heavily influenced by their education. That there’s not a, I mean, you can give metformin any drug that lowers blood sugar, in theory, lowers blood insulin. But this is not the way in which they’re trained to communicate. And so they don’t see the value in testing for insulin because they are not the ones providing the lifestyle interventions, such as what we have always talked about all time: stress, sleep, diet, fasting, and movement. You’re not talking about those things with your doctor in the 5 to 10 minutes that you’re with them; they have time to prescribe you medication. And unfortunately, a lot of people want a quick fix. They want the bandage. They don’t want to deal with the root cause. If you don’t deal with it, well, that’s going to be the solution that you’re offered. I think one of the reasons that they’re ignoring it is because how big medicine is set up, is not to incentivize preventative health care. Testing for insulin is a preventative measure. I just went through this with my dad in PA; he’s type 2 diabetic, and I said, Ask for your insulin test, because you’re going in for your A1C again anyway, and back and forth. And he never got it because they were like, We can get all the information we need with an A1C test. And I’m like.

Mindy Pelz, DC

Walk us through the tests, because the other thing I want everybody to know is that what’s really cool about this day and age is that you can run your own tests and actually don’t need a prescription from a doctor, so you can go. There are a lot of online programs where you can get your own prescription and go to your own lab. They’ll draw the lab and send it back to you. With that in mind, talk about if and when your doctor did a CBC on you. Let’s pull that out and tell me what hemoglobin A1c should be. What should fasting insulin be, what should fasting glucose be, and any other markers we would look at on our blood?

Morgan Nolte, PT, DPT, GCS

Okay. We look at a few for insulin resistance, and the first that we look at is a fasting insulin test. So this is at least 12 hours of fasting. Ideally, that’s going to be between two and six. Now, normal lab results might come back a little bit different. But we’re looking at the ideal. I like to give ideal numbers because if you’re looking at “normal”, in my opinion, you’re too close to the borderline levels. So I like to keep it a little tighter. 2 to 6 on fasting insulin; now hemoglobin A1C we like to see at about 5.5 or less. Again, well below that pre-diabetic range. And for fasting glucose, we like to see it at 90 or less. Normal is going to be up to 99. So we’d like to see it a little bit tighter. Those are the three ways. We do offer a fasting insulin test through our website. You do not need a doctor’s order unless you live in California or Maryland. Not available in New York. Those three states kind of have their own regulations. So those are three. We like to look at hs-CRP, which is a marker of low-grade chronic inflammation, because insulin resistance and inflammation really drive each other. And so, ideally, that’s less than one triglyceride. We like to be less than 100; HDL is 60 or greater. And that triglyceride to HDL ratio, in an ideal world, is like 1 to 1, but healthy people will take it if it’s 2 to 1. So if your triglycerides are 100 and your HDL is 50, we’re going to give you a thumbs up on that. And those are the main ones that we like to look at. Another one is called the Homa IRR score, and that’s another measure of insulin resistance that uses insulin and glucose. And we have a YouTube video on that. So if they want more information, they

Mindy Pelz, DC

Amazing. So helpful. What’s your website? So everybody listening can make sure they get that.

Morgan Nolte, PT, DPT, GCS

Totally. Zivli.com is our website, and we have a really great playlist on YouTube for free about insulin resistance. We have an insulin resistance diet starter course that gives all of those numbers plus more if they’re looking at their blood panel. Because this happens, we had a client once who said that her doctor wrote excellent on her blood report for years, even though she was in the pre-diabetic range. Until you learn to look at your own numbers and do your own fasting, it’s not that hard. But that diabetic is not excellent. So we’ve got to watch out for that.

Mindy Pelz, DC

I love that you guys offer this as a resource. Walk through with me, like, just because I think the common person is not grabbing this and it’s really, really important. One of my takeaways from Fast Like a Girl launching into the world has been how many 20- and 30-year-olds are either missing a period or struggling to get pregnant, and nobody’s teaching them how to look at glucose and insulin. So let’s start with infertility. What’s the tie between insulin resistance and infertility? How did those two pair up?

Morgan Nolte, PT, DPT, GCS

That’s a really good question, and I’m probably not the best person to answer it, just because I’m not an OBGYN. But I did have someone on her podcast, and I asked her that direct question, and she said, It really has to do with how elevated levels of insulin, obviously hyperinsulinemia, will precede insulin resistance. So if you have high elevated insulin levels for a high period of time, you will develop insulin resistance. But even just having high levels of insulin can be stressful for your body. This is one way. There’s, of course, more that I am probably not even aware of. But if Hyperinsulinemia is a stress on your body, your body doesn’t want to get pregnant; your body wants a nice, healthy, low-stress environment in which to conceive and carry a child. So that’s one of the ways that high levels of insulin can contribute to infertility, just because it puts stress on your body due to the level of inflammation. The other way is that high levels of insulin can cut. It’s a fat creation and storage hormone, so it drives excessive development of body fat if you’re giving it too much of the wrong nutrients. We know that excess body fat directly releases inflammatory substances. Again, driving more inflammation and stress in the body. Now, as it relates to estrogen, I’m a little bit more familiar with the postmenopausal phase because estrogen is actually an insulin-sensitizing hormone. The fact that, like a lot of women after menopause, they will gain belly fat because they lose that protection from estrogen. Are you aware of any specific links between, I kind of spoke on a couple between how high levels of insulin can raise inflammation and cortisol, which will create a less hospitable environment for a baby. Are you aware of any other direct links between estrogen and insulin and women, maybe in their 20s and 30s?

Mindy Pelz, DC

But this is the way I look at it. I think everything you said is spot on. Then I would add that if a cell is resistant to insulin, it’s also resistant to vitamin D, and it’s going to be resistant to sex hormones getting into the cell. It’s going to be resistant to nutrients getting into the cell. Once a receptor site is blocked, it can be blocked with a chemical. It can be blocked, by too much of a hormone, like insulin. Nothing can get into the cell. Once we see a sign of insulin resistance, it’s almost like you have estrogen resistance as well, although we don’t really use that as a term. So that’s one piece of it. The second piece that I think to add is that, again, I agree with the stress going up. I feel like that’s spot-on. When your body’s in a crisis, there’s no desire to, you know, create a baby. That makes absolute sense to me. But when we start to see that the estrogen can’t get into the cell, that extra estrogen is going to go into your fat cells. So all the fat is just storage for the things that couldn’t get into the cell. So when you walk into your doctor’s office and they’re like, Hey, you have a BMI that’s too high and you’re not going to be able to get pregnant. Where my brain goes is actually all that’s seen as nothing getting into you getting into your cells, and it’s all being stored in fat. A lot of systems are going to break down, and fertility is one of them.

Morgan Nolte, PT, DPT, GCS

Yes. The OBGYN that I spoke to said, You know, estrogen is kind of finicky, especially for fertility. We don’t want it too low, and we don’t want it too high. So a lot of times, that will happen. If you have excess body fat, you’re going to have estrogen dominance, which is what it’s called, and you’ll have excess amounts of estrogen. I think it’s sad. I mean, we were able, thankfully, thank God, to conceive our two children naturally without much effort. But we know so many people who have gone through rounds and rounds of IVF and not been successful in conceiving. And so how many thousands of dollars, tears, and relationships that have been ruined because of infertility issues? And if we’re talking about basic mental and physical health, a lot of those would be resolved. And I think that’s really sad. And it’s hard to talk about because it’s such a sensitive topic for so many people who are trying to conceive. But if you’re trying to conceive and you’re not taking insulin resistance very seriously, that’s a missed opportunity for you and your health. I think another thing I wanted to point out, Dr. Pelz, was that we have to focus on maternal health if we want to focus on the health of the baby. Because research makes it clear that if the mom’s insulin and glucose are high, then the baby’s insulin and glucose will be higher. And so we need to be addressing maternal health as soon as possible, ideally before conception. 

Mindy Pelz, DC

Yeah. Agreed. And I would say that we’re not giving moms enough information on how to get their bodies prepared for the pregnancy process. And we are seeing in our community that when just going through what I’m teaching in Fast Like A Girl, when women start to fast like a girl, all of a sudden they’re getting pregnant if it’s the woman who’s the challenge. So I bet it’s been really fun to watch people’s cycles get synced back up when you know to go in and bring your glucose up and when to bring it down according to what hormones are there. So that’s a whole other discussion, but that’s been a byproduct.

Morgan Nolte, PT, DPT, GCS

And it’s been helpful to me. Dr. Pelz, I think you were on my podcast a while ago, maybe a year and a half ago, and it’s one of my most popular episodes, and I’ve adopted that. I’ve really done what you’ve taught in that book and in that podcast. What I notice is a tremendous increase in my energy levels. When I’m fasting correctly, I’m not just dredging through the day, and my workouts are a lot more effective too. So if you have an hour, here’s my pitch for your book: When you’re at it, go get it..

Mindy Pelz, DC

Thank you. It’s been fun, because we can see on our Amazon reviews. I’m watching women go there and post, Oh my God, I did the infertility protocol, and I was pregnant within 30 days. So really, it’s a really interesting concept. Now I want to go back to something you said because your specialty, how you got into this, was through geriatrics, and what I’m seeing and what I saw in my own life is that as I went through perimenopause and menopause, the old tricks that I used to keep my weight where I wanted it to be didn’t work anymore. Because I became more insulin-resistant. So talk about estrogen’s connection, and you kind of brought it up, like when estrogen goes down, we become more insulin resistant. Why is that?

Morgan Nolte, PT, DPT, GCS

Well, that’s a really good question. And again, maybe a little bit more biochemistry than what I’m familiar with. But I think it’s important to recognize that estrogen is an insulin-sensitizing hormone. So what that means is that you need less insulin to get the job done. You’re more sensitive to what insulin is being produced. So when you lose that insulin sensitivity, when you become less sensitive to it, you need more of it. And when you need more of it, we start to see hyperinsulinemia and increased levels of body fat. And it’s also important to note that, for women, it’s not just about body fat. This is about your bone health, this is about your muscle health, and this is about your brain health, as well as your heart health. So estrogen is not just a sex hormone. It’s kind of our power hormone—a powerhouse for women. And we have to really be mindful that after menopause, you’re at an increased risk of all of those things: diabetes, heart disease, dementia, osteoporosis, and sarcopenia. We talk a lot about obesity because it’s often linked with insulin resistance. But I wanted to point out that it’s not just about obesity; it’s mainly about that insulin-sensitizing effect.

Mindy Pelz, DC

Yes. I love the way you phrased that estrogen is an insulin-sensitizing hormone. I think that’s really important because when you lose estrogen, what I’m finding is that so many women are trying to apply the same lifestyle they did at 35. They’re trying to maintain the same lifestyle at 45. And they don’t realize that they have to do it differently because they don’t have that insulin-sensitizing hormone. So it’s just the carbs they ate at 35 that are now causing them to gain weight at 45.

Morgan Nolte, PT, DPT, GCS

I think the best example is your own cycle. If you’re a younger woman, look at your weight fluctuation during your cycle. You’re going to notice that you’re probably feeling a little bit thinner, maybe a little bit sexier, when your estrogen levels are highest. That just kind of proves the point that your weight will probably be at its lowest when the estrogen is at its highest because your insulin sensitivity is at its greatest. Now, what happens that week before your period when you might start to get kind of bloated and gain some weight while your estrogen is going down? So your insulin level and insulin sensitivity fluctuate throughout your cycle. It fluctuates throughout the nine months that you’re pregnant. It’s not just at perimenopause and menopause. When we see this, it’s every single month for a woman. 

Mindy Pelz, DC

Yes. Super well said. Part of the hormonal conversation that just isn’t being had is how, again, something as critical as insulin resistance ties into all these other sex hormone situations. Talk a little bit about the brain changes that happen as we go over 40. So this is kind of my new obsession. My next book is going to be on what happens to the female brain after 40. And one of the things that I stumbled upon was a research article that showed that estrogen, when it goes down, is a precursor for dopamine and serotonin. So if you don’t have enough dopamine or estrogen, you’re not going to have enough for dopamine and serotonin, which are compounds that cause this depressive, anxious state that so many women find themselves in. Do we have any research on what causes insulin resistance? And now I don’t have an answer. I only have a question about this. Do we have any research on what insulin resistance does to our neurotransmitter system?

Morgan Nolte, PT, DPT, GCS

That’s really interesting. I’ve done just a smidge of research. I’ve been trying to find interesting research. There’s interesting research, not like if you’re doing research for central insulin resistance, which is what I would look up, If people are interested in this. Every single cell in your body has an insulin receptor. What’s fascinating to me is that in geriatric PT and dementia, we used to think that those were caused by; plaques and tangles. Well, what we’re learning is that your brain cells can also become resistant to insulin, and your brain is used to using glucose for fuel. So what happens then? Your brain cells are not getting the glucose that they used to. That’s why the ketogenic diet and the ketogenic approach allow ketones to be used for fuel in the majority of your body and many areas of the brain. Some do require glucose, but your body can make it. That’s another conversation, but that’s why people notice things like clearer memory and clearer mental focus. That’s why it’s sometimes used with people with neurological conditions to give the brain an alternative fuel source that doesn’t require insulin because the glucose isn’t getting in sufficiently. So that’s one reason, and if the cells don’t get energy, they’re going to slowly die.

So, yes, that’s one way that insulin resistance is definitely being known as a control contributor to dementia. But the other is vascular dementia. So there are different types of dementia. There’s Alzheimer’s dementia, there’s vascular dementia, and there’s Lewy body dementia. And insulin resistance, again, will lead to a reduction in the cells ability to take in and use glucose for energy, and your blood vessels, you know, those are made of cells. If you’re insulin-resistant, then your blood vessels will not be as efficient at delivering blood to the cells of your brain. And so that can contribute to vascular dementia when the vascular system of your brain is insulin-resistant. So it’s a fascinating topic. I’m excited to learn more about it. The book, The XX Brain, is really interesting.

Mindy Pelz, DC

Did it get you to read that one? 

Morgan Nolte, PT, DPT, GCS

Yes, I love that stuff.

Mindy Pelz, DC

I love that explanation because of what we ate, and it reminds me that just so the listener is fully up to speed on what insulin is, Talk a little bit about: What’s the purpose of insulin? When we say insulin resistance, it’s kind of become this phrase that everybody’s like, Yeah, I’m insulin resistant, but what does that mean, If you are insulin-resistant for the cell?

Morgan Nolte, PT, DPT, GCS

Now, it means your cell can’t take up energy as well, period. 

Mindy Pelz, DC

Specifically glucose.

Morgan Nolte, PT, DPT, GCS

But it’s really an anabolic hormone too. So it’s important for building muscle. But we want the right nutrient substrates and the right resistance training for that. But we speak of it mostly for glucose. So if you think of the cell membrane as kind of like the top of a ball, there’s an insulin receptor. And when insulin goes into that receptor, almost like a lock, what happens inside the cell? Something called a Glut4 transporter, which I think of as a tube slide, it goes from inside the cell to the cell membrane so that glucose can move from the bloodstream down that tube site into the cell to be used for energy or stored for later use, or the body can repackage it and ship it off to fat cells. So that’s what happens when insulin binds the glut4 transporter and moves to some membrane, where glucose can come in. That’s really what reduces blood sugar. So that’s what we’re talking about when we’re talking about insulin resistance: it takes more and more insulin to keep your blood sugar stable.

Mindy Pelz, DC

I love the visuals of the slide. I was like, That’s really good. I would have to use that. You can use it. But then I want to take it one step further. So if I can’t get glucose into the cell, then where does the body go and store it?

Morgan Nolte, PT, DPT, GCS

Well, I mean, fat is that you can’t, and that’s the main thing if you. But the problem is that even fat cells can become insulin-resistant. It’s got to go somewhere. But if you have to really think of it in terms of, well, what happens when you eat something? It’s going to go through your whole digestive tract, right through your intestine, through your liver, and through your intestines, and then it’s going to get stored. It’s going to end up somewhere. But the problem is, just how much insulin will be required to store or use that? Does it answer the question?

Mindy Pelz, DC

Yes. Also, where my brain goes is that when we look at storage places for glucose, we have actual fat that it will put on your body. This has been a big cry that I have to my research academy members: Fat is just your body’s brilliant way of taking and storing something that it doesn’t know what to do with. It’s just storing that excess. When we’re looking at the explanation that you just gave, glucose because insulin can’t get it into the little slice and ends up storing it in fat around your belly, your glutes, your arms, and all the other places you don’t want it. But the other major organ that is fat is the brain. Part of what we’re seeing with Alzheimer’s and dementia is that it stores fat in the brain.

Morgan Nolte, PT, DPT, GCS

Really interesting.

Mindy Pelz, DC

Yes. Is that the best way to look at it? Because it’s going to push it wherever it can put fat. And one of those places is the brain, or, I don’t know, another organ that has that much fat in it outside of the brain.

Morgan Nolte, PT, DPT, GCS

That I don’t know. I honestly don’t know. I’d be really interested to look at the fat content of some brains with Alzheimer’s or vascular dementia. But I haven’t; I can’t speak to that because I don’t know. 

Mindy Pelz, DC

It puts its fat around the liver. But then my brain goes, Well, why does fat accumulate around the liver? We’ve heard of fatty and nonalcoholic fatty liver disease as a huge issue for people who eat a high-sugar diet. It’s just sucking them away, and all of these different areas are contributing to poor health as you go down the line of aging.

Morgan Nolte, PT, DPT, GCS

Yes. It’s a little bit more complex because, the level of stress that you have and the level of cortisol that you have, your body might take 100 grams of sugar, which we’ll just call glucose for now. And it might store more of that in your belly area versus on your hips, your thighs, or your subcutaneous tissue. If you have high levels of cortisol or stress, you’re going to be more likely to store that as belly fat. The same goes for high levels of insulin. Another thing that I think is important is that sugar is not sugar. So if you’re having 160 grams of, say, glucose compared to 60 grams of fructose, only about 20% of the glucose is going to be pushed through the liver. Otherwise, other cells in your body can use that glucose; every cell in your body can use the glucose. But for fructose, nearly 100% is metabolized in the liver. So when we’re talking about nonalcoholic fatty liver disease, that’s why we add sugar, high fructose corn syrup, or really any form of sugar, because even honey and agave are usually higher in fructose than regular table sugar, which most people don’t know, and that is going to contribute to fatty liver disease if you’re having it in excess. And the book Nature Wants Us to Be Fat by Dr. Richard Johnson is the best book that I’ve read on fructose. If people want to take a deep dive down that, that’s really fascinating. So sugar is not sugar. We’re kind of speaking in broad terms. But I wanted to point that out. That it matters what you eat, and it matters what type of food you’re eating.

Mindy Pelz, DC

Do you feel like it matters the combination of food that you put together. So I’m starting to see a lot of glucose hacks.

Morgan Nolte, PT, DPT, GCS

Yes.

Mindy Pelz, DC

Where we’ve got this, and I see this in the women that I’ve been coaching, is that you can take somebody who’s got a vegetarian diet, which, as from a glucose standpoint, I’m not such a fan of the vegetarian diet because it spikes too much of your glucose. But if I can get vegetarians to pair their apple with some nut butter or to add extra olive oil onto their salad that might have some legumes, what we’re seeing is that the insulin spike is not as high. So talk a little bit about what happens if I am going to have nature’s carbs, which I’m a huge fan of for a lot of different reasons. What happens? Do you believe we should pair it with fat? Should we pair it with a protein? Do we have any control over minimizing that glucose spike?

Morgan Nolte, PT, DPT, GCS

Yeah, there are a lot of things, so I’ll just kind of run through a list of them. I think the best thing you can do is wear a continuous glucose monitor. We don’t have continuous insulin monitors yet, but if you get a continuous glucose monitor for a couple of weeks, you can do this experimentation on yourself and see what works for you. So I’m going to start with the fact that a starch is not a starch, number one. So if you’re getting 50 grams of glucose from things like lentils, beans, and maybe some sweet potatoes or barley, like those darker starches, that is going to be digested slower than 50 grams of glucose from white pasta, white bread, and white rice. And the reason is because the white stuff is higher in something called amylopectin starch, which, if you look at my hand, has a lot of branches on the amylopectin, which means the enzymes that chew up those individual molecules of glucose can go really fast. And so that glucose is then released into the bloodstream much faster compared with the darker types of starches, which is amylose starch, is a straight-chain polymer. There are two ends for the glucose-digesting enzymes to chew up the glucose. Independent fiber content, so food manufacturers are actually trying to now manufacture grains that are higher in amylase content for that reason

Mindy Pelz, DC

The thing is to manipulate the food even more; like, why don’t we throw the original weight of the food chain? Had to put a bunch of chemicals in. So now let me put something good in to make sure that you can be insulin-sensitive anyway. Go ahead. That’s what I heard in that statement.

Morgan Nolte, PT, DPT, GCS

That’s right. So, sugar is not sugar. A starch is not a starch. That’s a big, big piece that people want to understand. And the second thing is to eat fiber with your meals. So fiber, especially from whole foods, We’re not talking about metamucil supplements. We’re not talking about the low-carb bars that are stuffed with fiber. We’re talking about structurally intact fiber from whole foods because that will help line the first part of your small intestine and reduce the absorption rate and digestion rate of anything else you eat. It’s almost like you’re rolling out the red carpet on your small intestine for the other nutrients to kind of slowly walk in fashionably late.

Mindy Pelz, DC

I like the way you say that. 

Morgan Nolte, PT, DPT, GCS

Yes, so when you say fiber, first eat non-starchy vegetables and salad before your meal, then have some protein and fat. So if you’re having salmon, chicken, beef, eggs, maybe Greek yogurt, whatever your protein of choice is, if you’re going to choose to have starches or sugars, have them at the end of the meal. Don’t have them in isolation; like you said, some nut butter with an apple or peanut butter bananas are great. If you’re going to choose to have those. Now, that’s another hack; another one is, of course, apple cider vinegar. So 1 to 2 tablespoons once or twice a day. I love it hot, with some lemon juice and hot water. It’s almost like tea instead of herbal tea. You can do that in the morning or at night. It’s fantastic. A great way to reduce the morning blood sugar response. And it’s really, really good, I think.

Mindy Pelz, DC

Post meal? Do you think it’s a post meal or pre meal?

Morgan Nolte, PT, DPT, GCS

Yes, for the blood glucose response one to have it.

Mindy Pelz, DC

When to have it?

Morgan Nolte, PT, DPT, GCS

Before. 

Mindy Pelz, DC

Okay. And how much. Because everybody is going to ask how.

Morgan Nolte, PT, DPT, GCS

I know, you can do 1 to 2 tablespoons. It really just depends on your tolerance for it. You can shoot it. You can plug your nose and just shoot it. You can dilute it in water and drink it through a straw if you’re worried about the acid damaging your tooth enamel. And I love using that for my exception meal, as they call it. I Don’t Eat Perfect 100% of the Time.” When we go out to dinner. When I go out, I still try to make healthy choices. But if I’m going to have more carbohydrates, I’m probably going to have some apple cider vinegar before that meal. And again, do your own testing, get a continuous glucose monitor, have some ice cream, or whatever. I’m not going to listen.

Mindy Pelz, DC

To organic ice cream. Yeah, I eat ice cream. I am dessert. But I do know. But the hacks that you’re talking about. So go ahead. So I guess it’s organic or chemical free ice cream.

Morgan Nolte, PT, DPT, GCS

Yes. So, have some of that, and then the next time you have it, have some apple cider vinegar beforehand? There’s this guy, @insulinresistant1, his name is Justin Richard, maybe. And that’s all his Instagram account is: him with a CGM. He does 16 hours of fasting a day, then eats for eight, and he’ll eat some pizza. Then I’ll check his glucose, and then the next day he’ll have a salad, and then he’ll eat the pizza, and they’ll compare the glucose. And the next thing I’ll do is make apple cider vinegar, then pizza, and compare. That’s a great account if you don’t want to get your own one to just see what it does for someone else. Those are some interesting little hacks. And another one of my favorites is walking after a meal. So a ten-minute walk after you eat is great. We did one of our exception meals on Friday. Ironically, my husband’s a farmer, so he got done planting. We went out for a family dinner, went off to our favorite ice cream place in downtown Omaha, came back, and went for a family walk. It felt so good to not just come home and let all of that sit, and the reason that’s so important going back to that tube slide that goes to the cell membrane is that the only way that glucose can get into your cell is from insulin, or like the glut4 transport for muscle demand. So if you’re exercising, if you’re walking, you can get that glut4 transporter to the cell membrane, independent of insulin. So that’s one of the reasons that it’s important. Now that dovetails into this next recommendation, which is my personal favorite, which is, if you’re going to have carbohydrates, have them within 30 minutes of exercise. Again, the exercise will get those glut4 transporters to the cell membrane so that the glucose can get into your muscle cells to be used because you’re using that energy during exercise. Well, those glut4 transporters stay there for 30 to 40 minutes after you’re done exercising. You can eat some more carbohydrates, and they’ll just get soaked into your muscle cells to replenish muscle glycogen stores so that you can use them the next time that you want to exercise. One of the big misconceptions about fasting, I think, is that you have to go through all of your muscle glycogen before your body will start to burn body fat. And that’s not true. Your body stores that muscle glycogen for exercise to fight or flee stressful circumstances. And I kind of happened on that one because I love high-intensity interval training and I was wiped out like when I was a fully low-carb lifestyle, which I still do, but I do now incorporate some more carbohydrates if I know that I want to do high-intensity or interval training, or I’ll just go longer periods of time between those types of training sessions. I’ve learned a lot about nutrients and exercise and what types of nutrients are used for which types of exercise. And that’s helped me a lot. And then another great little tip is to have your carbs within 30 minutes of exercising. Those are some of the top ones on my mind. 

Mindy Pelz, DC

I just want to point out that watching the trajectory that we’ve made as a society in this conversation, I feel like ten years ago, 15 years ago, the conversation was just starting to be had that, hey, certain foods are going to make you more insulin resistant. If this is a new part of the conversation for you, welcome. You know, we’ve been having this conversation in the health world for 15 years. The quality of food really matters. So go back to nature’s food. Get out of the man-made foods, because typically that’s where insulin resistance is. You’re heading more toward an instant-resistant state. When man has manipulated food. Now, what you just said was gold. And I would even encourage people to go back and relisten to that, because what I’m seeing now is that we’re changing the conversation and asking, Okay, well, I want to be insulin-sensitive, but I don’t want to be in deprivation. So what can I do? And this is where apple cider vinegar comes in—where you place your carbs within your meal. All of that is the new version of this conversation that is so important because health should be fun. It should feel easy. It does. You don’t have to be deprived to be healthy. Do you feel like that’s what you’re seeing as well in this conversation of insulin resistance?

Morgan Nolte, PT, DPT, GCS

I think so, yes. I’m with you in that I think it’s going to progress into more disease conversations. I think there’s going to be more evidence; nonalcoholic fatty liver disease is an excellent example. But I think we’re going to start to see that type of conversation around Alzheimer’s and other forms of dementia. That’s my opinion, as I do believe that brain health is going to become central, especially as our baby boomers age and we’re going to see higher incidences of dementia. And people are going to say, Oh, what’s happening? Like, Wait, we told you what’s happening; it’s insulin resistance; it’s an unhealthy lifestyle. It’s important to recognize that these are lifestyle diseases that are fixed by lifestyle. They’re not medications. They’re fixed.

Mindy Pelz, DC

Tell me where you think muscle comes into insulin resistance because one of the plates that the menopausal woman has is that after 40 hours, our ovaries aren’t making sex hormones as much anymore, and so our adrenals are working triple time. In my experience, in my own body and watching a lot of women go through this is that the adrenals will start to break down muscle to get the nutrients they need to be able to make sex hormones. And it gets harder and harder to build muscle. But, shoot, muscle plays a part in insulin resistance. I’m already losing estrogen; now I’m losing muscle. Like, give me a freaking break. Like, where do I get to the door? Talk about what I’ve done; really, my workouts are muscle-centric. I am massively focused on building muscle at 53, a lot more than I was at 43. So share with the group: where does muscle come from, and what is the amount of muscle specifically in a female body? How does that relate to keeping us insulin-sensitive?

Morgan Nolte, PT, DPT, GCS

I think there are a couple of things on my mind. The first is the space in which we have to deposit glucose after a meal that is not fat tissue. So if you think about, let’s say, a tennis ball and a volleyball, let’s use those analogies. Someone with low muscle mass might have the muscle mass of a tennis ball. That’s not very much room to put the glucose after a meal; muscle is a really important place for glucose to go after a meal that’s not fat tissue. And the bigger you are, the more muscle mass you have. It’s almost like a garage. A garage. You can put more cars in a bigger garage. If you have a one-car garage, you’ve got a one-glucose garage. You’re going to have a lot of stuff—a lot of glucose—being stored in fat tissue around your liver and around your organs, not where you want it. If you have more muscle mass, maybe you have volleyball-sized muscle mass in your body. Well, guess what? You get to tolerate a higher amount of carbohydrates without them being diverted into your fat stores right away because you have more muscle. Now, the second piece of the conversation is to look at the surface area. 

If the surface area of the tennis ball is larger, you can fit more insulin receptors around a larger surface area. You’re going to have maybe ten insulin receptors around a tennis ball and a hundred around a volleyball. The more insulin receptors you have, the more insulin-sensitive you are. So glucose is more efficiently stored, and we are again elevating our insulin and creating that hyperinsulinemia situation. So it’s about how much space we have to store glucose and how many insulin receptors we do have to create that insulin-sensitive environment. Those are a couple of things, but when we’re talking about muscle, I think it’s really important: resistance training protein. Anabolic resistance is not talked about enough, and anabolic resistance is resistant in nature. That we can develop as we age to build muscle, that can happen. Think of these as risk factors: obesity, physical inactivity, kidney failure, and low protein intake. They stack on top of each other. A lot of people are talking about 30 grams of protein per meal. Fantastic. I’m all about it. We need that leucine threshold that we talk about a lot; three grams of leucine are found in about 30 grams of complete protein. But if you have antibiotic resistance, that amount goes up to closer to 40. That’s really what we talk about from an aging adult standpoint as postmenopausal women. If you’re getting eight grams right now in your oatmeal with special K, going to 30 grams a meal is a big jump. But ideally, we want you closer to 40 so that you can build muscle because anabolic resistance is probably something you might be experiencing if you are interiorly obese or have some kidney dysfunction.

Mindy Pelz, DC

I love that, because the research that I’ve seen shows that it’s somewhere between 30 and 90 grams that will trigger that amino acid receptor site, building the muscle stronger and creating more openings for insulin to drive glucose in. After 90 grams, it turns more into glucose, and now that it’s going to be more, it’s like a detriment to you. Now whenever I quote the study, people always say, Well, what about if I’m a hundred, you know, a 200-pound male? Is that the same as a 130-pound woman? I don’t have the answer to that, but I will say that the amount of protein really, really matters for building muscle. I also want to point out that I don’t think this is talked about enough: you don’t just have to do resistance training to build muscle. You’ve got to eat protein to build muscle. And would you agree on that?

Morgan Nolte, PT, DPT, GCS

100%, and the reason is because your body doesn’t have a way to store extra amino acids. So if you think about what happens when we eat extra glucose, well, it’s stored as fat. What happens when we eat extra protein? It’s converted to glucose and then stored as fat. Your body likes your muscles and stuff, and yes, there are amino acids in your muscles, but your muscles are not a storage form of amino acids. Your body’s not going to break down your muscle tissue so that it can use the amino acids to build more; that’s totally counterproductive. People have to understand that you need doses of protein. You don’t build muscle without doses of protein, and you can’t store it. It’s almost like sleep; you can’t store up your sleep. You use it for it day to day that we are going to buy that. Yes, you can’t. Your body fat is just fat. It’s just energy. It’s glucose. There’s no protein stored in your body fat. We have to get it from our diet.

Mindy Pelz, DC

Well said. Again, I think that we don’t give protein and muscle enough credit. What I’ve seen in a lot of menopausal women is that they’re really struggling with muscle and then that plays out to your overall health as you age on many levels. I think that’s amazing. But let’s talk a little bit about the monitors that are out there. Like you, I’m a huge fan of the glucose monitor, but it’s not always financially accessible for people. Are there signs and symptoms we could see? Talk about a glucose monitor. What’s the difference between pricking your finger and using a glucose monitor? And if you don’t have the financial resources to measure, is there another way for us to know if we’re moving towards insulin resistance or not? If a meal worked for us, or if it didn’t work for us?

Morgan Nolte, PT, DPT, GCS

That’s a good question. First of all, I like the ketone motor device, which is a finger-prick device. And that also measures ketones. I find that very motivating to do, like towards the end of a longer fast, to see where my ketones are and where my glucose level is, and that’s only a point in time, though. So you’ve got to be kind of careful because a lot of people will get really obsessive over the numbers, and your glucose is going to be higher in the morning because you have a morning cortisol response. Check it out at 11 a.m. It’ll probably be lower. You get to see that data with a continuous glucose monitor, but it is a little bit more of a financial investment for people. So if you’re thinking about just a general rule of thumb, how did my body respond to that meal? How was that load of carbohydrates? The first thing I think about is energy levels. If you’re eating a meal and you’re like, I’ve got to go take a nap; I am so tired, your body is just overloaded—overloaded with blood sugar and insulin. That’s one of the first things: it’s just that—fatigue after meals and fatigue throughout the day.

Another one is frequent hunger. If you’re having frequent hunger or frequent carbohydrate or sugar cravings, that’s one of the signs of insulin resistance because, again, the glucose isn’t getting into your cells. Even though your body has plenty of energy, it’s not getting into the cells. And that’s the best example of that as a type one diabetic, so they are hungry all the time, they’re thirsty all the time, and they can’t gain weight because of that. They don’t make insulin, but they’re hungry; their cells are starving. There’s plenty of energy, but it can’t get into the cells. If you’re insulin resistant, you’re going to have high blood sugar levels even if you’re not. You’re going to have high insulin levels because you’re not a type 1 diabetic. But the point is that the cell is starving. The cell wants energy and they want energy now. 

Mindy Pelz, DC

Which is crazy because it’s starving, but you’re eating, eating, eating, and your cells aren’t getting what they need. So it tells you to eat more and more and more. I mean, this is the interesting part about dopamine. When you look at why we eat certain sugary foods, we’re going for that dopamine response. But the research has shown that people who are more obese have less access to these dopamine receptor sites, so they have to eat more and more of the chocolate cake to get more and more of the dopamine response. 

It all comes back to that cell. It’s like it’s crazy when you go and think about that. Let’s finish up this conversation. If you had a 55-year-old woman who had just gone through menopause, had gained a bunch of belly weight, was losing some memory, still had hot flashes, and had a hemoglobin A1C of like 5.8, What would you do? What would be the top three things she can do immediately to start moving her insulin sensitivity in the right direction?

Morgan Nolte, PT, DPT, GCS

Fabulous question. Aside from bringing in a mindset, which is a different conversation altogether, right? Skip over that.

Mindy Pelz, DC

That another podcast or interview at another time..

Morgan Nolte, PT, DPT, GCS

Another type of mindset is having the right mindset, which is huge. So at the top, we have some clutter and an overly habitual hierarchy, and the first two things are related to mindset. Right after that, there is water. Drink half of your body weight in ounces of water every day, or at least until your urine is clear or very light yellow. We’re not talking Diet Coke. We’re not talking; coffee and tea count up to about 400 milligrams of caffeine, which we really recommend reducing anyways; she’s dealing with hot flashes, and she’s probably having some sleep issues. I think if she can really reduce that caffeine intake and increase her water intake, number one, that will help with satiety between meals and weight loss. The second thing is to focus on protein again, getting 30 to 40 grams of protein per meal. We have an ultimate food guide. There are all sorts of resources out there on how to increase our protein intake. And then the third thing that I would say is that I think next might be like added sugars because I think fasting is so powerful. But if you’re trying to do what I consider more moderate fasting without first dialing in your water, then sleep is the next one. It’s hard. It’s going to be harder because your satiety is not going to be long. So I’m going to give them a bonus. I would say sleep 7 to 8 hours a night. We’re going to really dial in the sleep because that makes everything else easier to implement if you’re well-rested, and for that, you can wear amber-colored blue light blockers, I like to say, like 2 hours before bed again, reducing that caffeine, and there are certain adaptogens or supplements that may help with screen time. What are your screen habits before bed? What are you doing to wind down before bed? All important things. Then the last is to fast for 12 to 14 hours a day. So she’s used to snacking after dinner. I would say, Stop that. That’s like one habit right away to stop her from eating 2 to 3 solid meals a day and eliminate snacking, especially after dinner. That’s where I like people to start. We want you to build the foundation. We’re not doing crash diets. We’re not getting like a two-week meal plan because it’s a lifestyle change, a water mindset, a different conversation mindset, which is kind of like stress management, water, sleep, and intermittent fasting. Start with soup, you know, 12 to 14 hours. Everyone can do that. You can work around your medications. It will help with your sleep if you don’t eat right before bed. Those would be the top three things that I would say.

Mindy Pelz, DC

Oh, I think that was brilliant because part of my passion is, How do we make this simple? And what happened is that the health care system—our conventional health care system—made things very, very complicated. All of a sudden, those of us who are trying to teach lifestyle medicine started off with simplicity. But man, now it’s gotten very, very complicated. And I am trying to bring people back to their roots, so that was brilliant. That was such a good explanation. And they’re like things you’re adding in.

Morgan Nolte, PT, DPT, GCS

Yes, exactly.

Mindy Pelz, DC

You’re not depriving yourself. You didn’t say to take your soda away. I didn’t say take your sugar away. You were like, Drink more water, prioritize sleep, and eat some more protein. And yes, really.

Morgan Nolte, PT, DPT, GCS

Cool because I think that’s important. The order of implementation is important because if you’re just trying to cut sugar without having adequate hydration and protein, your sugar cravings will be off the charts. If you’re sleep deprived, if you can implement certain things in a certain order, it’s almost like dominoes. One domino falls, making the next one easier and easier. Well, by the time we get to the top, you’re really implementing those higher-level habits so much easier and more consistently. So, that’s what I wrote.

Mindy Pelz, DC

Brilliant. Now, okay, Morgan, do people find you? I love you, and what I always think of about you is that you have such a sensible approach to insulin management. When I hear you speak, I’m like, That’s clear. You give us great steps; you’ve got great resources. You and I are both out there trying to get the world metabolically healthy because we know the impact it has on everything else. So I want our listeners to find you. So where can they find your information?

Morgan Nolte, PT, DPT, GCS

Yes, in a few places. Our website is Zivli.com. Z I V L I dot com, and I’m on Instagram, Zivli. We have a YouTube channel, Dr. Morgan Nolte Zivli, And then our podcast is Reshape Your Health with Dr. Morgan Nolte. All of those are great places. I would recommend people start with our ultimate food guide that they can grab on our website. It’s free, and it has over 80 foods that help control your hormones

Mindy Pelz, DC

Morgan, perfect. Well, I appreciate this conversation. I appreciate all the education you’re giving. And I always say we’re more powerful together when we’re having conversations like this. The way you phrase things makes me think about them differently. The people who may have heard this concept before the language used, like the slide for the glucose, were brilliant. It just gives more context to this. The art of staying insulin-sensitive, which has now really become an art, so just grateful for you though. 

Morgan Nolte, PT, DPT, GCS

Thank you. I’m so grateful for you and all the wonderful work that you’re putting out there too. So thanks. Thank you.

Mindy Pelz, DC

Thank you.