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Insulin can be elevated for years while your blood sugar still reads normal, and insulin is not on a standard annual panel. Dr. Sasha Rose, ND, LAc explains what insulin resistance actually is, the early signs that get dismissed as ordinary life, why the weight will not move, why the fat lands around the middle, and what a workup looks like when someone goes looking. Functional medicine for adults in Maine and New Hampshire.
In this episode of the Med Matrix Method Podcast, Dr. Sasha Rose, ND, LAc explains why insulin resistance is not a diabetes story, why it builds for years or decades before blood sugar ever looks abnormal, and why the one marker that would show it is not on a standard annual panel.
Insulin is the key, the cell is the lock. Turn that key often enough and the lock wears out. Dr. Rose walks through what that means in practice: why the weight will not move, why the afternoon crash happens, why the fat lands around the middle, and what a workup looks like when someone actually goes looking.
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This episode is for educational purposes only and is not medical advice, nor is it a substitute for medical advice. Individual results vary and are not typical. Nothing here is intended to diagnose, treat, cure or prevent any disease. Always consult a qualified healthcare provider before starting, stopping or changing any treatment, supplement or medication.
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Hello everybody. Thank you for joining us today. Thank you for joining the MedMatrix Method podcast. I'm Dr. Sasha Rose and I will soon be joined by Brian Ligotti. He is one of the owners here at MedMatrix. We are super excited to have him host the show today. He's going to be on in a minute. But if you are new to this podcast, I'll tell you a little bit about what we do. One to two times per week, we talk about all things functional medicine and how to take a more personalized preventive approach to your health. So we talk about all sorts of things. Today, I am super excited to talk about insulin resistance and to talk about the fact that it is more than just diabetes. So we're going to kind of dive into that. We're going to let a couple more people kind of stream in here, but I will mention a few housekeeping details and just kind of introduce myself a little bit as well. So everything that we talk about today is really for educational purposes only. We're not giving medical advice. The other thing that I will do as we wait for Brian, my name is Dr. Sasha Rose. I am a naturopathic doctor. I'm a licensed acupuncturist, and I am one of the lead providers here at MedMatrix. I've been practicing functional medicine for over 20 years, going on 21 years, and a lot of what I have done over those 20 years is metabolic health. Insulin resistance is obviously included in that. So yeah, we're going to, again, kind of give people a few more minutes to stream in, and then we will start. So just to give a little bit of, again, if you are new to the podcast, what we usually do is we focus on one topic. Today, again, it's insulin resistance, and then we will answer questions. So we really encourage you to put questions in the chat, and again, we're not providing medical advice, but a lot of questions we really can answer, and we really do appreciate your engagement and just simply letting us know that you're here. I'm going to start kind of talking about insulin resistance because I think that term is thrown around a lot, but many people don't actually kind of understand what it is. So I'm just going to start kind of with the basics. That is that insulin resistance is when cells are less responsive to insulin. So the pancreas, which is one of the what we call visceral organs, the pancreas is the organ responsible for producing insulin. When insulin is elevated, and those insulin levels can be elevated for a long time before your blood sugar actually becomes high or abnormal. So what can happen is that a lot of things can kind of contribute to insulin resistance, and when there's this higher level of insulin in the body, and that can be going on for a while, it's going to be affecting everything from your energy level to your weight, even to your hormonal balance, to inflammation, cardiovascular health. So this is kind of why we're tackling this topic today. We're tackling it because, again, it goes beyond diabetes. It goes beyond blood sugar. It's overall metabolism. It's overall inflammation. So that's kind of just an introduction to why insulin resistance is important. Now that I think Brian's audio is on, can we hear you? Can you hear me okay now? I think so. Can you have Leah check that everything is good? Okay. Yeah, I think good. Okay, great. So let's swap a little bit here, Brian. I kind of introduced you, but can you introduce yourself and your role at MedMatrix? Sure. So I don't know if you said this, but I'm the guy that signs the bottoms of your emails with all the webinar updates and whatnot, so I figured it'd be a good time to put a face with the name. Great. All the emails you're getting, that is me. You're welcome. And we're super happy to have you. Yeah, and just to follow up on what I said earlier, that, again, this is educational purposes only. It is not meant to replace medical advice, but if you are interested in us giving you medical advice, you are more than welcome to book a discovery call on our website. Anything that you feel that you want to mention before? As you came in, Brian, I was just kind of giving an introduction of why insulin resistance is more than just diabetes, but is there anything else that you want to add before we kind of dive a little bit deeper? No. Sorry. I think a good place to start, I think you already did this, it doesn't sound like we covered this, what even is insulin resistance? Yeah. Yeah. So I started to talk about how the pancreas is the organ that produces insulin, and after time, the cells throughout the body, we have insulin receptors throughout the body, and over time, when the pancreas is compensating for high blood sugar, it's compensating for inflammation, all these metabolic things are going on, and the pancreas just keeps putting out more insulin, the cells over time become less receptive, less sensitive, less responsive to the insulin. So one analogy is the role of insulin is to shuttle glucose into the cells. It's a little bit like a lock and a key, so it's a little bit like we need that insulin, which is the key to open the lock, open the door so the glucose can pour into the cell. Every cell in the body runs on glucose. That's fuel for the cells. That's food for each cell. So when that goes on and on and on, and there's so much insulin, and there's so much over and over, that key is going into that lock, it gets a little worn out. The lock gets a little rusty, a little bit, it's not working so well anymore. And so that's one way to think of that increased insulin production kind of over time creating metabolic stress throughout the body. I think one important key is that we have these set, we have these basically insulin receptors, we have these locks on like every cell in the body. Every cell needs glucose, so every cell has to be responsive to insulin. Got it. So with all that said, I mean, for the average person listening, that sounds, I mean, I can gather that that's pretty important. And why should anybody actually care about insulin resistance specifically? Yeah, so what, right, why? We hear this term insulin resistance, why does it matter? And as I said at the beginning, it is more than diabetes. You know, a lot of people do not have diabetes, but insulin resistance still may apply to them. So again, as insulin is helping move glucose from the bloodstream into cells, in that way, it's playing such a crucial role in metabolism, fat storage, hormone regulation, cellular communication, we basically need insulin for just normal body function. And so when there's issues, like when that lock key relationship is not optimal, that's when problems start to arise. Got it. So with that said, what are some of the problems and or health issues that people may, might not realize are connected with insulin resistance specifically? Yeah, it's a really good question. Because again, I think we've all heard the term insulin resistance, what, what other what are some of you know, I've used kind of broad terms in terms of like metabolism, but to get a little bit more specific, other than diabetes, type two diabetes, we are looking at what used to be called PCOS, or polycystic ovarian syndrome, it has recently been renamed, which I think is a great thing. It is now PMOS, which is poly endocrine metabolic ovarian syndrome. So PMOS, fertility, so oftentimes a woman will deal with like some infertility if there's an insulin resistance. And that as well as often linked with PMOS, sometimes fatty liver disease, and fatty liver disease is not, it's usually non alcoholic. So usually there's not necessarily alcohol as the culprit, but insulin resistance and fatty liver disease often go hand in hand. cardiovascular disease, sometimes more, this is not like a condition or a disease, but symptoms such as brain fog, cognitive decline, chronic inflammation, difficulty losing weight, a lot of our patients are struggling with this. A lot of times there is an insulin resistance component to that. And then overall metabolic syndrome, another super common group of signs and symptoms. So that will include high cholesterol, high blood sugar, fatty liver disease, sometimes high blood pressure, oftentimes, you know, person being overweight or obese. So the insulin, you know, kind of having that lack of sensitivity on the cellular level to insulin is going to impact all of that. And it's kind of like, I guess I think of it this way, like insulin resistance is a part of all of those things. I don't think of it as that insulin resistance causes all of the things I just listed, but that all of those conditions are very complex. And insulin resistance is often a pretty crucial component of them. Got it. And you've listed almost every single like comorbidity that yeah, it's currently struggle with. So I mean, it sounds fairly important just based on the litany of things that it's tied to. Am I hearing that correct? You are hearing that correctly. Yes. Okay. Got it. And it's not just, I mean, we've been over this and over this, but it's not just the end result is diabetes. No, it's off. It's right. It's sometimes diabetes, like type two diabetes is often kind of the end result. But these it's been developing over years or decades, right? So insulin is not, we have it on our initial comprehensive panel of blood work, but it's not insulin is not tested with your annual blood work. It's just not commonly done. So there's no way to really know if you are insulin resistant. So, but it's most likely it kind of, you know, happens over years, decades, and your blood sugar might be normal that whole time, but there's all these other underlying issues kind of starting to progress again, the inflammation, some of those other kind of comorbidities, difficulty losing weight, blah, blah, blah. Everything I just said is takes, it does not happen overnight. And then in the end, somebody is, you know, kind of handed this diagnosis of type two diabetes and oh, and oh, yeah, you're insulin resistant as well. Hmm. So, I mean, for some of those things, it's, it's really tough to know, like what's happening, as it's happening to you, until almost it gets to be like, you know, critical event or something. So, like, what are some, if any, early warning signs that a person might be experiencing as like, that letting them know they may or may not be insulin resistant? I think you're absolutely right. I think one of the most difficult things about insulin resistance is that someone is most likely going to be kind of asymptomatic. So, maybe they're feeling a little, their cravings have gone up, maybe they're feeling an increase in hunger, you know, there's that energy crash or that fatigue, kind of we call it postprandial or after meals, maybe especially in the afternoon. A lot of these things that I'm listing are not unique to insulin resistance, difficulty concentrating, again, midsection weight gain, mood changes. I mean, this sounds like a lot of things we talked about on this podcast. We've talked about inflammaging, we've talked that we talk about hormone imbalances a lot. A lot, you know, we talk about the importance of sleep. So, all of these things can all contribute to weight gain, cognitive issues, and mood changes. And insulin resistance, I would add to that list of it can cause slash contribute to these kind of vague, often somewhat debilitating symptoms that somebody might be going through, but because they can be relatively subtle, it's easy for either the individual themselves and especially a physician who has a five-minute visit to dismiss them. Got it. So, I mean, insulin resistance is rarely the thing that's caught right off the bat. Is what I'm hearing. Correct. It's always a bunch of other things. And then the hypothesis you're working backwards from is like, oh, this person might be insulin resistant because of X, Y, and Z. Is that? That is correct. I mean, sometimes again, there's like more intense sugar cravings. We talked about the difficulty with weight. Sometimes you might see like some skin tags or some darkening of the skin around the neck or the underarms. I wouldn't say that that's, we use this term kind of pathognomonic, like if you have that, you automatically have insulin resistance. Likewise, you don't have to. Yeah, it's a possibility, but it's not like an absolute. So, I think some of these kind of symptoms that are common and difficult to pinpoint will maybe more often than not include at least the beginnings of insulin resistance. So, the energy fluctuations and kind of overall metabolic issues going on. But unfortunately, insulin resistance is not usually included when we're kind of assessing all of that. Got it. And so, I guess given everything you said, when, if at all, do symptoms typically become serious enough to where people are actually seeking help? It's usually not until something else develops. Is that basically the gist of it? Yeah, I would say it's usually that people are really frustrated with their weight is probably the first thing. Possibly, the fatigue gets to the point where they're finally seeking help. And then eventually, we do start to see lab values change. So, if we are going to test the insulin, you start to see that that insulin is creeping up to the higher end. If somebody is getting their hemoglobin A1c tested, that's an average blood sugar over the last three months. And so, that's going to be, again, you're going to get into that pre-diabetic range for a while, eventually into the diabetic range. But it's not like, oh, you know what, I've been eating poorly for three months and that's kind of, this has, again, been going on for years, if not decades. All these more subtle metabolic changes. Got it. And you mentioned, you actually mentioned weight loss a few times. And I know that is something that not just our patients, but like, I mean, everybody, I mean, all you have to do is go to the grocery store and you'll kind of see where everyone's at. So, why does insulin resistance make it so difficult for weight loss? Yeah. I mean, back in medical school, when they were first describing insulin, you know, it's basically a fat building hormone. It's a storage hormone. So, it basically, if you have an elevated level of insulin, that is promoting fat storage. It's not really going to promote fat loss. It limits fat burning. And, you know, part of when, just I think our, how we're wired just in terms of how to survive, when the body has these higher levels of insulin, it's almost like we are in, the body's prepping for like a famine. So, holding on to fat, right? And then cravings can increase and hunger can increase because we're wired to basically, in case the food supply is not here tomorrow, hold on to what you have. It's based on our biology. It's not based on our current reality. And so, that kind of, the longer that that goes on, there's less what we call metabolic flexibility. And it just kind of, the body gets stuck, the insulin level kind of gets stuck. And it's, that's just, it's not like, that's the new normal, I guess is the way to say it. Metabolically, I see a lot of people who are just kind of in this stagnant place. And they are maybe doing the things, they are doing the exercise, or at least to some extent, they're trying to eat well. And yet, it's just like, really hard to move because metabolism has been at this level. And it, the old, unfortunately, the older you get, the easier it is for metabolism to kind of get stuck. And so, they might be restricting calories, and it seems like nothing's happening. I heard. And then, so, I'm just curious, how, because you mentioned, you know, if there's too much insulin in a person's bloodstream, it makes fat metabolism nearly impossible. So, I mean, how does body composition affect this? Is it, does it just become this reinforcing kind of feedback loop? Where, you know, there's more insulin in my blood, which means it's more, you know, it's more difficult for me to metabolize my fat, onto my fat. Right. And then, my body composition starts changing, because I've got all this muscle mass that's not getting the appropriate glucose it needs. And then, it just becomes this, basically, a downward spiral that just keeps self-reinforcing. Is that, just so I understand, is that effectively what happens, or how does body composition fit into this, if at all? Yeah, good question. How, you know, what's the relationship, or how does body composition relate or impact to, impact insulin levels or insulin resistance? I think it's really kind of, like you said, maybe a vicious cycle, maybe a kind of a feedback loop, where higher the insulin, the more kind of fat storage. The higher the fat storage, the higher the inflammation, the higher the insulin levels. And what we're going for with most people is, as you mentioned, increasing lean muscle mass, decreasing percent body fat. And so, there's, and we'll get into this in a little bit, but that's kind of the goal, right? The goal is to maybe shift what the body composition has been, and to start to now trigger this process where we're burning fat, we're maintaining, or even better, building skeletal muscle mass, lean mass, and then kind of sending the message pretty loudly to the body that it doesn't need to keep producing the pancreas, you know, doesn't need to keep producing insulin, kind of all these things that we can do to regain that sensitivity in terms of the insulin receptors. So, it's not this, I wouldn't think, I don't think of it as a linear thing, but I think that, yes, there is an imbalance of less than optimal body composition that's contributing. And so, when we do different things to shift that, hopefully everything will line up. Got it. And so, another question that I was curious about is, why does the fat kind of concentrate around the midsection specifically? Like, why not, is there something about this that makes it predominantly visceral fat? Why is it not kind of spread across the body, et cetera? Yeah. Insulin resistance is strongly linked with, associated with, visceral fat accumulation. So, visceral fat, it's not necessarily what you see on the outside. It's that visceral means internal. So, the visceral organs, when there's fat kind of around and in between those visceral organs, that's visceral fat. And then sometimes we will also see it on the outside. Oftentimes, we see it kind of in that midsection. So, with insulin resistance being associated with that accumulation of visceral fat, we have that excess abdominal fat. It's metabolically active and it's, again, vicious cycle. It's kind of contributing to inflammation. Other components that will contribute to that, specifically that midsection weight gain, is dysregulated cortisol and chronic stress. So, basically, kind of coming back to that, you know, how we are wired as humans to survive and when we are chronically stressed, part of that is survival and part of that stress response is I might not have my next meal or there might be a famine around the corner. And so, I am going to hold on to the fat that I have so that I have something to burn in case I don't have any food. You know, that kind of reptilian brain doesn't know the difference between the daily stress of can't pay the bills and got to take care of my aging mother from and that jerk at work. I don't know the difference between that and that I might be starving tomorrow. And so, there's that accumulation of fat in the midsection. And then, we do, you know, part of, like, the way that we look at health is that we have an in-body scan in the office, as you know, and that is monitoring waist circumference and that is one tool that we have to kind of look at metabolic health. So, I'm, you know, when I'm working with somebody, at least every three months, I have this tool where I can see what's happening with their waist circumference. So, in addition to how they're feeling, in addition to their blood work, in addition to their actual weight, I have this other metric of waist circumference and my goal is for that to slowly go down. And that's going to tell me that a lot of things are most likely improving, maybe including insulin resistance, including these other comorbidities because of that association. Got it. So, you mentioned, and you've been mentioning stress quite a bit here. And when I think of stress, I mean, oftentimes I think of it as, like, a lifestyle factor, for lack of a better term. So, I mean, are there any other lifestyle factors that are common contributors to insulin resistance? And if so, like, what should we be on the lookout for? Yeah, I would say that there's a number of lifestyle factors that are going to contribute to insulin resistance. I think we all probably can guess that what you eat is going to play a role. So, ultra processed foods are, you know, going to definitely contribute. But there's other ones that people don't always associate with insulin resistance. But those include poor sleep quality, and that's both, like, duration and quality. Chronic stress, as mentioned, just overall being sedentary, pretty easy to do in this day and age with desk jobs, with driving a lot, etc. Blood sugar instability, and I would say all of these things. So, kind of linked with the sleep is also what we call circadian rhythm disruption. So, that does have to do with cortisol. You know, one extreme would be somebody who works nights, right? Like, that circadian rhythm is definitely disrupted. Somebody who's been working nights, they've been a nurse in the hospital for a decade, for two decades, that's going to increase that person's risk of insulin resistance. But again, this is cumulative. These are things that are happening for years and decades, and then it takes a toll on overall metabolic health. So, I mean, basically, your body just gets used to living this way, and forming certain adaptions, and then before you know it, your body's not processing insulin properly, and you've got an accumulation of it in your bloodstream. Got it. So, I mean, with that said, I know we'll get into this in a moment, and with that said, can modifying lifestyle drastically help, and or start to reduce some of the symptoms, the, you know, these other things associated with insulin resistance? Yes. I would say, whether we want to say aggressively or drastically, modifying lifestyle behaviors is probably the most important thing you can do to reverse insulin resistance. Got it. Because everything you said, you know, circadian rhythm disruption, chronic, or even momentary stress, I mean, all those things will effectively give you insulin resistance for X amount of time, correct, to some degree? Like if you, you know, because haven't they looked into that, like the, you know, you disrupt someone's sleep cycle long enough, like they become insulin resistant for a short period of time, you get them re-regulated, and then it goes away. Yes, yep, correct. So, I mean, effectively, what can be done here is some lifestyle modifications to some degree for the people listening. Yes, absolutely. Lifestyle modifications is probably the biggest, biggest and best tool. Got it. So, with that said, where oftentimes, if lifestyle modifications are the biggest bang for our buck, sometimes when we go to our regular doctors, those concerns can either be dismissed, and or we can leave feeling that way, because I know not all doctors do that. And regardless, sometimes you can still feel that way. So, if someone does bring concerns to a regular doctor, a conventional doctor, let's say, or provider about insulin resistance, what's that typically look like? Yeah, so someone is concerned about insulin resistance, they come to their primary care provider. Usually, hopefully, there will be a review of symptoms and medical history why this person is concerned. Some standard labs that would be run would include a fasting blood sugar, fasting serum glucose, the hemoglobin A1C test, which I mentioned earlier, which is a better test than a fasting glucose. It's a three-month average of what your blood sugar has been. And they would basically be doing an assessment for diabetes or pre-diabetes. Maybe, you know, again, time dependent, they would maybe recommend some lifestyle changes. Sometimes, they're referred to a dietician. Sometimes, they're told, well, eat better and move more, which is not bad advice. It's just sometimes a little bit, there's, the person doesn't know what to do with that. But it's good advice. And maybe, depending on the blood work, they might be prescribed certain medications. But that would mostly be around the blood sugar, not for kind of like insulin resistance in general. Oh, got it, got it, got it. Okay. So, I mean, you kind of touched on the treatment options commonly used for this with conventional medicine. And short of pre-diabetic type medications, I'm not hearing a lot of help. Is that correct? In terms of? Yeah. So, basically, if depending on the blood work, depending on the person's weight, body composition, there may be some diet recommendations, some maybe exercise guidance, or usually, it's more just like go exercise, some weight management strategies. You know, again, hopefully, they would be given like a continuous glucose monitor, which is, you know, you can for 10 days, 10, yeah, 10 days, you can basically in real time have your, you know, see what your blood sugar is doing, how it responds to certain foods. If the person is usually, I would say diabetic, not even pre-diabetic, they may be given something like metformin. And so, I do think that diabetes, blood sugar, that is a place where conventional medicine is trying, is attempting to prevent, right? They're trying to prevent full-on diabetes. I just think as we have talked about a lot on this podcast is just the constraints of the typical primary care visit, not the fault of the provider, fault of the system. This is a perfect example of time, you really need time, you need time to figure out what is getting in the way for this particular person, what is this person doing currently and what do they need to do and it's not a one-size-fits-all. And if you have a seven-minute visit, you just can't figure that out about a patient and you don't have time to give them personalized treatments because you just don't. And as we have also talked about, you know, in that system, they are very constrained by insurance. And so, I do think that, you know, 99% of providers have their patient's best interest in mind and they do want to prevent all these comorbidities. It's just they don't really have the time or the tools to do that. So, I mean, with that said, how does functional medicine approach insulin resistance differently? Well, as I think we have kind of been at least alluding to, functional medicine is approaching insulin resistance not just from a blood sugar perspective. It includes blood sugar, but it's also looking at what's been happening for the last however many years to get to this point. So, looking at how, like I use the term stress resilience a lot. We all have stressors, but how is this individual actually handling stress? What's their internal response to it? What is their level of physical movement? Getting into the nitty-gritty in terms of nutrition and then we can't forget the really important things like where are they in this stage of life? What's their hormonal status? How is that playing a role? Inflammation is, again, I think a huge piece of insulin resistance and looking at what may be contributing to inflammation in this person. How can we modify that? How can we lower that? And it really wouldn't be functional medicine if we didn't do an assessment of what their digestive health looks like, their gut health. So, it's a lot more complex than what does your fasting blood sugar look like. It's really kind of looking at this person as an individual and because we do that, we can therefore create individualized treatment plans. So, not a one-size-fits-all and hopefully catching them early enough where it's like the beginning of this process. But even if it is more towards the end, with time, we can reverse a lot of things. Got it. And then I guess you kind of touched on this a moment ago. I know no two people are the same. So, how come two people with insulin resistance require completely different treatment plans? So, two people who show up, their blood work maybe looks somewhat similar. It's pretty clear that they have insulin resistance, but they walk out of MedMatrix, they walk out of their visit with one of the providers here with two different treatment plans. And that's not a mistake. Basically, part of personalized medicine, part of the personalized medicine that we practice is understanding that we all have different genetic makeups. We all have had our past histories are different and our current, like our past lifestyle, like how we've lived in the past is different, how we're living now is different. We've all had different environmental exposures, that's going to affect things. And we're obviously all somewhat different hormonally, right? I mean, there's not just like male and female, but there's what stage of life are you in? Are you a female who was on a birth control pill for 20 years? How many children have you had? Are you a man who's had low testosterone for 20 years and didn't know it? So, that is all going to play a role in how we assess the situation and what we recommend in terms of a treatment. I mean, we do comprehensive gut panels all the time. I can't tell you the variations we see on the test results of those comprehensive gut tests, very different. And then stress. So, not just what stressors have been handed to this person, but how, again, internally, what's their stress resilience? How have they handled these stressors? How has that really impacted their nervous system, their cortisol regulation? And so, by kind of recognizing what we call bioindividuality, we are therefore able, again, to tailor the treatment to that person. Personally, it's the most fascinating part of what I do. It's just so great that it's not the same every time. It's never the same every time. It's creative and it's really, you know, the old way of saying it is, like, meet the person where they're at. And kind of figuring that out with somebody and letting them see that this is not the same thing I give every person. It's very much about, like, where they are in their health and what they're able and willing to do usually leads to a much more successful outcome. Okay. So, I guess with that said, you touched on a bunch of different things, but when someone comes to MedMatrix concerned about insulin resistance, where does the process begin for them? What are you looking for? And, like, in practice, what does this look like for you? Yeah. So, before they're even sitting in front of me, I have information. They've had kind of their initial discovery call. I have a lot of information in terms of why they're reaching out, like, what's going on with their health, what they're feeling, maybe what test results they've had with other providers. I have all of that information. I also have the information from that in-body scan that I mentioned earlier, which gives us not only weight, but skeletal muscle mass, water weight, BMI, visceral fat. I have all those metrics. I have the very comprehensive lab panel that every patient gets, and I have all those results. So, before they're even sitting in front of me, I have a lot of information, and I have time to review that. And then, when they're sitting with me, then I can get into kind of, well, what are you really eating, and what, you know, all the questions that are going to kind of fill in the gaps. And, at that initial meeting, we're really kind of getting on the same page in terms of what their goals are. We do a very, so we do a really thorough evaluation of nutrition, sleep, stress, physical activity, and, again, starting to get a sense of what have the environmental factors been for this particular individual. That, plus, again, the lab results, all these other kind of metrics, the data, I can kind of piece that together for that customized treatment plan. And so, once you've identified what's contributing to someone's insulin resistance, or anything else for that matter, what might a treatment plan look like? Well, it's going to be multifactorial. So, we're going to most likely have a pretty personalized nutrition strategy. Sometimes, I am starting that outline, or I'm giving them maybe what they need. Some people have, they've done the work at other times in their life. They tell me that, oh, I know that I did better when I ate this way. It's just been five years since I've done it. So, they kind of know that. I can direct them back to that. It's familiar to them. That's great. Other times, it's kind of, this is brand new information for somebody. And so, I will often refer to one of our health coaches for that kind of more nitty-gritty guidance, right, kind of getting in the weeds and to have somebody to be kind of accountable to maybe a little bit more often than when I'm going to see them. So, at least the start, I'll say, of a personalized nutrition strategy. Same thing with movement and exercise. Some people are like, oh, yeah, I know what I need to do. I'm just not doing it. Other people say, I've never stepped foot in a gym, or I really don't know if, they just don't know what to do, right? It's basically like getting somebody off the couch and where to start. And again, that health coach or a personal trainer is a great place to start with that. But at least we start with something that's going to sort of make sense to the person and is realistic. Definitely talking about sleep, optimizing sleep. Definitely talking about stress management techniques. And that is very personalized. Like, what might work for me to reduce my stress is not going to work for you. Like, I might find yoga to be, like, so great for me. You might say, I can't stand it. I really need to go just unplug my phone for 48 hours and sit by the lake. Great. So, again, very customized, but definitely starting to regulate cortisol, starting to kind of bring somebody out of that fight-or-flight mode. Usually, we're doing some targeted supplements. So, some high-quality nutraceuticals that are often based on what their lab results look like in combination with, again, like this overall metabolic picture. And then maybe, you know, when appropriate, there will be some medications if that seems like it's going to be a good tool. Some peptides, for example, that might be the right tool for fat metabolism, for metabolic support, for kind of giving them the energy to do the lifestyle pieces. And I'll say the same thing with, like, hormone replacement therapy. Like, sometimes that's the piece or a really important piece to get that metabolism going, to get them the energy and the motivation they need to actually get off the couch. So, putting that all together and then not just sending them on their way, but kind of whether it's me, whether it's me and the health coach, whether it's me and all the other fabulous staff members here, really being here to support them. And so, they don't feel like they're just out there kind of trying to figure it out on their own, because that, you know, usually doesn't work quite as well as when you have some consistent support. Yes, I mean, definitely. And so, for everybody listening at home, you know, who thinks, hey, this might be me, I might be experiencing this, or I have a bunch of those things that you mentioned earlier, like fatty liver disease and all these other things. What are three steps you would want them to take, or some things they could do, you know, today that might help them? So, the first one, I think, would be to take kind of a real honest look at quality of sleep. And that, again, I said earlier, I said it's not just like how long you're sleeping, but what's the how long, but what's the quality of your sleep. And so, sleep hygiene, if the listeners don't know, is really like having a consistent schedule of going to bed pretty close, like around the same time every day and waking up the same time every day. Looking at the environment of your bedroom, like the temperature, the light, the noise, all of that is really important. And when not eating right before bed, you know, not having alcohol right before bed, you know, for some people, it's like hydrating earlier in the day, not right before bed, so you don't wake up frequently to go to the bathroom. How much are you on your phone or a screen right before bed? That's all kind of under that sleep hygiene category. And so, really realizing that sleep is pretty crucial. And that's tied into, I would say, cortisol regulation and stress resilience. The higher quality of your sleep, the better the stress resilience. And then the other one that I like to ask people, they'll often say, well, I don't really eat sweets. And then I ask them, do you stop at Dunkin' Donuts? Do you stop at Aroma Joe's? Do you stop at Starbucks frequently? And what are you getting? Because those coffee beverages are really sugar beverages. And some people are more aware of that than others, but like they may not be eating whoopie pies every day, but they're getting their Frappuccino every day. So, just kind of looking at those, what I call like hidden sources of sugar, or maybe you put in a, you know, two full heaping tablespoons of sugar in your own coffee every morning, looking at sugar and energy drinks. So, those kind of things that might be contributing when you don't even realize it. And then I would say, really important is somebody can kind of start looking at things that may be contributing to inflammation for them. So, yes, food. So, looking at kind of what we call pro-inflammatory food consumption, fast food being at the top of the list. And then, you know, high gluten, high refined carbs, you know, kind of bad fats, super high salt, all of those are kind of what we call pro-inflammatory. Most home-cooked meals are going to be less inflammatory than what you get out at a restaurant or a takeout place. So, that's one example of just kind of taking an honest look at what you're consuming. And then one nutraceutical supplement that's beneficial for pretty much all of us is an omega-3 fatty acid. And that's, there's just so much research behind omega-3 fatty acids lowering inflammation systemically. And that would include these factors that are contributing or playing a role in insulin resistance. So, I'm usually aiming to get most people close to 2,000 milligrams of omega-3 fatty acids per day. You do want a decent quality on fish oil or fatty acids. A lot of minerals or vitamins, the kind of the brand isn't as important, but you do want to kind of spend a little bit more money to get a high quality omega-3 fatty acid. Got it. All good things, all great suggestions. Sleep one is something that most people could probably do without much money or time investment really. So, very, very good suggestions. Thank you so much. Anything else? Oh, wait a minute. We got a question. I think this is a glucose, I think this person's asking about a glucose tolerance test. Okay. I believe that's what the question is. So, good question in terms of like assessing insulin resistance. I think what you're asking is, would we run or would we recommend a glucose tolerance test? Definitely when assessing for diabetes, absolutely. If we think that it's kind of progressed to that level, a glucose tolerance test definitely makes sense. You basically get like your blood sugar tested, you eat a very high glycemic meal. So, orange juice, pancakes with syrup, come back two hours later and have that repeated and it's a way to kind of test how well your insulin is working, how well the insulin is actually shuttling all that glucose into the cells. So, I think, yes, if things have progressed to that point, but I guess I would say, say that comes back negative, that doesn't necessarily mean that there's no insulin resistance or that there's no metabolic dysfunction. It just means that it's not to the level of pre-diabetic or diabetic. Yeah. So, I think that's what we got. Got it. Okay. So, if you're interested in becoming a patient, we'd love to just have you click the link. I'm sure you can do that down below. If this was at all valuable for you, please drop a like in and or share it with a person that you think might benefit. Thank you so much, Dr. Rose, for doing this. It's not a small ask to take an hour out of your day. You did see patients all day, I think it's worth mentioning. We'll be doing that again on Friday or Thursday, Wednesday night, Thursday. So, thank you so much for ending your day with this. I know a lot of people get a lot of value. So, thank you. That's great. Thank you. I really appreciate it. It was really fun working with you on this. Thank you. I'm looking forward to more of these.