Insulin Resistance: Key To Understanding Diabetes

Jhansi Lakshmi Maradana, MD

Thank you for providing me with this opportunity, Dr. Hsu. Definitely. My name is Jhansi Maradana. I’m a practicing endocrinologist at Wentworth-Douglas Hospital. We have a robust community practice of Endocrinology when the majority of our population has, of course, type 2 diabetes. This is the most challenging and critical condition in the United States. We also take care of other patients with type 1 diabetes and other endocrinology conditions. However, a majority of our population has type 2 diabetes.

William Hsu, MD

Can I call you Jhansi, will that be okay?

Jhansi Lakshmi Maradana, MD

Yes. 

William Hsu, MD

You can call me Will as well. Jhansi, being a fellow Endocrinologist is that we all came into this discipline with a certain degree of passion. Then maybe you can tell us a little bit about what drew you to the practice of endocrinology and specifically to this health condition called diabetes, which now affects up to 15% of US adults.

Jhansi Lakshmi Maradana, MD

That’s a good question. That’s always been a passion because my grandfather was a practicing traditionalist, practicing traditional medicine before. We all grew up eating healthy food and making sure that we followed a good lifestyle. I have seen that one-size-fits-all transition to medical school. Then, when I started my residency in the States, I noticed that there’s a lot of population that is getting affected, mostly because of the lifestyle, and that diabetes’s treatment depends mostly on the changes in your lifestyle. 

I am somebody who wants to maintain a trusting relationship with my patients, just as we used to have family doctors before. That trust helps heal diabetes is what I feel. In the statement in ‘88, it says that a type of diabetes remission is possible, which is not discussed in the majority of cases. I thought I should bring that movement forward. That is my goal with this journey of being an endocrinologist practicing diabetes.

William Hsu, MD

Well, thank you. A lot of people know that. Or, in some way, there’s been criticism of Western medicine for the lack of focus on addressing the root cause of type 2 diabetes. Do you think that’s fair? I think the accusation came from the angle that, we as physicians, just give medicines; we don’t talk about them. How do you reverse it? How do you treat it? A new line, the root cause. Is it a clear statement from a practitioner such as yourself?

Jhansi Lakshmi Maradana, MD

When I was doing my fellowship, the first thing that my mentor addressed to any of his patients, even his type one patient, was that he always used to ask about that occupation. Then he went into the personal details, and the next thing he said was, Always remember, the foundation of treating diabetes is diet and exercise. Anything comes after that. 

That was how I started my training, and I truly believe in that. honestly, everything comes with some side effects from any medicine that we have. Why do we have to take some medication to manage a disease and have the brunt of the side effects, not forgetting the cost of the medications that are involved? When we can choose something more natural to the body and more physiological, we can then use that as a tool to cure diabetes.

William Hsu, MD

Now, one of the root causes, as you said, that arose from maybe inadequate exercise or a poor diet, was the occurrence of insulin resistance, and that’s been the call I don’t want to be. I think the people say it is the mother of all this and many of the cardio medical conditions. But we can also call the father of it, if you will, what is insulin resistance and has been talked about so much to help our listeners understand what it is and why it is so common.

Jhansi Lakshmi Maradana, MD

Insulin resistance is a decrease in the response of your body to insulin.

William Hsu, MD

Okay.

Jhansi Lakshmi Maradana, MD

Usually, whenever we eat any carbs, we need insulin for our bodies to absorb, and the major organs in the body to absorb insulin are our liver and our fat, which are mostly dependent on insulin to absorb the blood sugars. Those are the storage organs. But if it could be genetic or lifestyle, if we have visceral fat mass, which is the deposition of fat around the liver, what happens is that the sensitivity or response to insulin decreases so much that, in general terms, fat is the most insulin-resistant organ in your body. Let’s say, you have the same fat wrapping up around your liver. What happens is your liver, which was sensitive before. Now it is more resistant to the same insulin. 

The way I explain it to my patients is, let’s say you needed two units of insulin to absorb one slice of toast. Before, when you were having assistance, you would require 15 units, maybe, let’s say, to absorb the same amount of sugar by your liver because of the fat around the liver. That’s what we call insulin resistance. Also, now that we are seeing it in patients who are so young, they have this acanthosis nigricans, which is a line around the neck that you see in some of our female patients who are slightly overweight or obese if I would call them. The decrease in response is the driving factor for the burden on your pancreas, which burns out at some point. Then you would end up requiring insulin, and the sugars would start floating in your blood, and you would see all these microvascular complications: heart attacks, strokes, and amputations. The goal for us with diabetes would be to cut back on insulin resistance and dependence on insulin.

William Hsu, MD

Jhansi, it sounds like a terrible cause for many of the conditions. Would you say that one may see insulin resistance even before glucose starts rising or only occurs after glucose starts rising?

Jhansi Lakshmi Maradana, MD

No, we could see it before. That is why we have prediabetes and diabetes. The first thing to form and to start with is instant assistance, and then you progress to prediabetes, and then you progress to diabetes, where you see the sugars are already floating in your blood. When we check your blood, we notice that you’re A1C is higher than 6.4%, your sugars are more than 126, or your 2 hours are greater than 200. That’s when we call it diabetes. But you said that it was progress. 

William Hsu, MD

How do our listeners find out if they have instant resistance? Where are the signs or the other symptoms? Are there blood tests? What can they do to determine if they already have insulin resistance?

Jhansi Lakshmi Maradana, MD

As I said, weight gain and obesity, especially the studies that have been done so far, have shown that people who have abdominal obesity are much more prone to have diabetes in the future than patients who have their obesity centered in their hips and thighs. That’s the first sign of accumulating fat mass. There’s an increase in your waist size. That’s the first time that you might be.

William Hsu, MD

Yes. Let’s go there a little bit. Is it just a measurement of your waist? Are there some other tools to know that there is something inside your body?

Jhansi Lakshmi Maradana, MD

Yes, the visceral fat mass, which is body mass analysis, means you have visceral fat mass, and there’s a separate component called lean body mass. So, yes, definitely, we have this going on.

William Hsu, MD

Just to clarify for our audience, many of the middle-aged men have what we call a love handle. Are those visceral fats? Are they related to insulin resistance, or is that a separate compartment?

Jhansi Lakshmi Maradana, MD

That’s a separate compartment, the visceral fat is mostly about the position of something around your liver. As I said increase, which decreases your insulin response, leading to high blood sugar as the sugars float in your blood.

William Hsu, MD

I see. But it doesn’t seem to be routinely talked about or routinely assessed. That component of that fat. I know, for example, that there are CT scans and ultrasounds that can look into that, but it’s not a routine clinical test.

Jhansi Lakshmi Maradana, MD

Correct. That is never considered to be a screening tool, unlike what we have for cancer. Yes, true.

William Hsu, MD

We should breathe a sigh of relief that it’s not the love handle that’s giving instantaneous.

Jhansi Lakshmi Maradana, MD

Yes, but we don’t want that either. But yes.

William Hsu, MD

Okay. Fantastic. now the relevant part reads: The most relevant part our listener is going to have is: what can we do if there is more fat in the trunk than in the hips? If they are overweight and their BMI is elevated, they know they probably have insulin resistance. What can we do about that?

Jhansi Lakshmi Maradana, MD

Again, we’re going back to the foundation of trying to help them with their diet and exercise before they progress to diabetes. Unfortunately, our health care is not designed in such a way that we deal with these issues in the beginning, but rather make them flow towards the end of diabetes. That’s when we start worrying about bringing the sugar under control rather than preventing its progression or diabetes.

William Hsu, MD

As a clinician who is working the trenches every day, what do you tell your patients when you notice that they have central obesity, or what are some of the treatments you will recommend to your patients?

Jhansi Lakshmi Maradana, MD

That’s a good question. First of all, we need to understand the social barriers as well, because some of the patients, when I bring up diet, let’s say, we want to talk about diet in detail, would get some resistance because of their socioeconomic status sometimes. But then I always offer them a visit with our nutritionist because I feel nutrition is a big part of playing a major role. After all, I feel you could always have the option of choosing good versus bad.

My first counseling with them would be a little explanation of what insulin resistance is and how their insulin resistance would affect them in the future because they might not know how that would affect them in the future. Then what are the ways to decrease the resistance in the first place before it progresses, or diabetes and the foundation, diet, and exercise, and how can they incorporate that into their daily lives without having to pay more or without having to? Sometimes they don’t understand that it is possible. We need to give them that hope and the options that they could include in their lifestyle.

William Hsu, MD

Let’s go there. Exercise. Let’s talk about that. What exercises are helpful? Is it one type? It said, What do you recommend in terms of the intensity or the types of exercise for your patients with insulin resistance?

Jhansi Lakshmi Maradana, MD

Moderate intensity for 45 minutes, at least five days a week.

William Hsu, MD

What does that look like? Moderate intensity? Does it involve running? Does it involve weightlifting, there’s been a lot of discussion around that. Is it more aerobic that’s more important, or is it the stress resistance exercise?

Jhansi Lakshmi Maradana, MD

I would feel that stress resistance is much more important with the time that they have to help with visceral fat mass than aerobics. But honestly, whatever they could have, let’s say they have only some time for them. Then I would say if walking is the only thing they could do, then I would just say, Just start with that and then progress.

William Hsu, MD

Yes.

Jhansi Lakshmi Maradana, MD

But for strength training, I feel it’s much more important to reduce.

William Hsu, MD

That’s a very pragmatic approach. Yes, we could debate about what’s most important and what’s optimal, but the reality is, just get started. That’s a very important point there. You’d mention 45 minutes. Is it in one sitting or is it in multiple sittings, or what they could do pragmatically? 

Jhansi Lakshmi Maradana, MD

Whenever they can do it, I see that some of my patients, while they’re at work, sometimes when they have some time at work where they’re working on the laptop, they use it just as bands for the legs so that they can just do the resistance exercises. somehow they can incorporate to combine to a 45 minutes. But if they could do at least 20 minutes at a stretch, that’s good.

William Hsu, MD

Just a quick poll here of your patients: how many percentages of patients do you think are following these exercise advice?

Jhansi Lakshmi Maradana, MD

To be honest, in general, maybe 20%? I would say yes.

William Hsu, MD

Why is this so difficult, you think? Because everybody knows this knowledge,? Are there are you motivating your patients to do this? Everybody knows diet and exercise are just the everyday implementation that’s challenging. With your experience, what are some of the tips and insights you can use to motivate your patients to do this?

Jhansi Lakshmi Maradana, MD

Unfortunately, we have a health coach program in our practice where the patients have a coach for themselves, and the health coach makes them drive those. Let’s say the patient says, Okay, from now on, I’ll invest 15 minutes of my time into exercise. A health coach follows them for a week and asks them, How did you do with your goals? Some patients do it because they feel they’re more accountable and will schedule frequent visits with the patients, which sometimes is not possible. But we try to stay in touch with them frequently. 

Number three would be: I don’t know if this is a good thing, but sometimes we discuss the bad complications that they would see at the end of the day. The negative motivation, I would say, seeing that, hey, we are not doing this for ourselves at this point. This is what we are looking at. The future. Do you want to be dependent on someone because you have amputations and all of that?

William Hsu, MD

It’s both a push and a pull. You want to draw them to good things, but at the same time, you want to push them and nudge them a little bit towards those lifestyle modifications. Okay. Now let’s move on to a bigger topic, diet edges. much controversy, so many different types, and so difficult to do it daily. What are some of your general big takeaways after seeing so many patients? What do you advise your patients?

Jhansi Lakshmi Maradana, MD

Honestly, most patients do well when it’s more regimented than me discussing, saying, Hey, you have to swap these things with this; you have to stop doing this. Instead, they feel having a regimented routine or following something helps them lose their weight more, for example, Weight Watchers. Some patients do it because they feel they’re more accountable. Some of my patients want to meet the nutritionist because some patients skip things. Let’s say they have soda in their diet for the next three months before I see them. That’s their goal—skipping things. 

Some patients come with such fad diets that sometimes I don’t even have a clue. We discuss options. What would you do? Some patients intermittently fast and then eat whatever they want to eat during the break. Some patients have it. Also, some patients don’t have ketosis, so there are a myriad of options in front of them. But I think I feel it has to be tailored, supervised, and sustainable in the long term.

William Hsu, MD

Do you think that medical supervision is especially important, and why is that?

Jhansi Lakshmi Maradana, MD

Because when you follow a diet and then you lose your electrolytes sometimes. Sometimes you might have low blood sugar. Somebody supervising you to assess because all of this is medical,? You do something, and then you have low blood sugar or a condition requiring you to have ER visits or admissions to the hospital is dangerous—sometimes low sodium, let’s say.

William Hsu, MD

What you should take away is that you should always discuss with your healthcare provider before jumping on a certain type of diet. I was caught up by your mention of intermittent fasting; that is the latest survey that talked about this being one of the most common eating habits of Americans now. More than 10% of Americans are doing some fasting for their health. What’s been your experience with that?

Jhansi Lakshmi Maradana, MD

I said that it is very good that people follow that for a certain amount of time, but they feel that it’s not sustainable long-term. But otherwise, intermittent fasting is great. It has been shown that the results are good; they lose weight on that, and then some resistance comes down. But at the end of the day, how sustainable is it for you to follow a lifelong routine?

William Hsu, MD

Now, before this interview, you mentioned that one of your patients is on a specific type of fasting-mimicking diet. Can you tell us a little bit about that experience?

Jhansi Lakshmi Maradana, MD

This fast-mimicking diet? Honestly, I came to know about it from a patient of mine who wanted to do that, and he wanted my help because it is a medically supervised diet. I got to learn more about it. After meeting some of the experts in the field and learning more about it, I felt that maybe this was the one that might help my patients. One of my patients was a 51-year-old female. She also has a fatty liver disease. She was poorly motivated at that time to maintain her blood sugar. Her A1C was around 8.3% when I saw her, and she’s already on metformin and GLP-1 agonists, which are the treatments now that you would want. But she’s not motivated, and she doesn’t want to be on the medications because of the side effects. She has bad nausea and vomiting, but she’s tolerating them in the hope that they might help her blood sugar. 

I thought she might be the candidate. We discussed this fast-mimicking diet and how your body when you were fasting for five days, would push it into a shock that would help reduce insulin resistance and the benefits of reducing your weight, your blood sugars, and coming off of medications. the goal of diabetes remission. She was very interested, and she started the diet. It’s a five-day diet. Five days for a month, for six months. Then the maintenance was just five days every three months for the next six months. She can choose to do it for the rest of her life. The catch for her is, it’s just five days in a month. That’s what’s left of it. Also, she gets help from a dietician whenever she has any questions. She started it, and thankfully, I just saw her yesterday. She finished four cycles of it. She’s off all her diabetes medications.

William Hsu, MD

All of the diabetes medicine. Wow. For cycles. That’s five days for four months. That’s 20 days of effort there.

Jhansi Lakshmi Maradana, MD

Yes. She lost 26 pounds. Her A1C is 6.2% now. With four cycles, it came down 8.3%, or 6.2%. We are still waiting on her liver numbers. She’s following up with that hepatologist next month. But I’m hopeful that that’s going to get better and better than this. What I know about this is that her husband, who does not have diabetes and is not following this diet, also lost 15 pounds because of the way she changed her lifestyle.

William Hsu, MD

That’s amazing.

Jhansi Lakshmi Maradana, MD

That’s amazing—the way she got motivated. Even her husband, who was with her, got motivated and lost 15 pounds.

William Hsu, MD

As collateral benefits, with the family. That’s fantastic. Yes. this fasting-mimicking diet program, I think you mentioned earlier, is one of these innovative approaches to diabetes remission. But maybe the concept of diabetes remission is still a new one for our audience. Can you speak to that a little bit?

Jhansi Lakshmi Maradana, MD

The ADA guidelines mentioned that if your A1C is less than 6.4% of your diabetes medication for more than three months and you’re off of any diabetes medications, then we can safely call you in diabetes remission. Honestly, I never knew about it throughout my first year of fellowship, and I got to know about it when I was working on this project where the pediatric surgeon who does the sleeve gastrectomy is looking into diabetes remission. Then what is that diabetes remission? It isn’t the 80-foot speed of 80 if you go into that. It is possible, and you don’t have to have surgery. Having options this way means you don’t have to go through surgery, and being free of medications and not having diabetes is a miracle.

William Hsu, MD

Yes, that is news that many of our listeners have not heard before. I think the program, it’s called L-Nutra Health is the name, and you could go to L-NutraHealth.com. 

Dr. Maradana, thank you so much for just giving us an in-depth look at insulin resistance, what it is, and how to treat it. You ended up discussing this case, the patient case. Do you have anything else? Maybe your conclusion is for our patients or our audience looking to second back in insulin resistance. Is there a story or a last-minute summary that you can give them? What would you say to that?

Jhansi Lakshmi Maradana, MD

Start working now. Do not delay.

William Hsu, MD

Don’t wait. 

Jhansi Lakshmi Maradana, MD

Don’t wait. It is now or never. Do it.  

William Hsu, MD

Dr. Maradana, thank you so much for this wonderful interview. I hope to see you again.

Jhansi Lakshmi Maradana, MD

Thank you. Dr. Hsu. It’s a pleasure.