Normal Blood Glucose Could Still Mean Insulin Resistance

PCOS Awareness
Written By Rachel Ruha
 
PCOS | Insulin Resistance | Massachusetts
 

There are days when I don’t even want to read the term “insulin resistance” because I am so fatigued hearing about it when it comes to PCOS. I’m sure you feel the same way, but today I feel compelled to share with you what I’ve learned.

If your doctor is saying your A1c and blood glucose levels are normal and you’re not insulin resistant, do yourself a favor and read this post! The typical protocol of testing for insulin resistance isn’t telling us the full story.

 

Weight does NOT cause insulin resistance!

You may have heard it’s estimated that 65-80% of those with PCOS have insulin resistance. I’ll say this a little louder for the people in the back and for the fatphobic crew in particular, it appears to be independent of weight. Weight gain does not appear to cause insulin resistance, rather they seem to move together in a sort of cycle. Effectively, the more weight we gain, the more insulin resistance we have, and the more insulin resistance we have, the more weight we gain. They perpetuate each other, but don’t necessarily cause each other.

 

So if weight doesn’t cause insulin resistance, what does?

While research is still emerging to understand the root cause of insulin resistance, we are definitely starting to catch up. Theories range from underlying inflammation, physiological stress, oxidative stress, to potentially an undiscovered hormone causing our bodies to become insulin resistant. So, if your doctor is telling you that weight loss is the answer to all of your problems, tell them to think again. According to the CDC, you do not have to be overweight to have insulin resistance. A number on the scale, or what you look like, does not indicate insulin resistance! I will mention, though, that since insulin resistance and weight appear to move in tandem, untreated insulin resistance can continue to feed the cycle of weight gain and worsen insulin resistance. But it’s the balanced, healthy measures we take to lose weight, not drastic measures, that typically help insulin resistance!

“Lean PCOS” Fam: Listen up!

This is especially important for individuals with lean PCOS (a term I absolutely despise, by the way) but is currently how the medical community is designating it. Often, when doctors see your weight falls into an “acceptable” BMI, they kind of write you off as a PCOS patient and tell you your PCOS is a “mild case” or “not that bad”, despite all the symptoms you may be telling them about. You will want to bear in mind that insulin resistance and prediabetes are still of concern for you. In addition to this, our response to insulin, according to a 2012 study by John C. Marshall and Andrea Dunaif, appears to directly influence androgen production. An imbalance of androgens can have a trickle down effect to further disrupt our hormones, wreaking havoc on just about any bodily function. Insulin resistance can also cause fatigue, brain fog, headaches, poor sleep, anxiety, depression, mood and emotional dysregulation.

 

So, have I caught your attention yet?

Have I convinced you it’s important to pay attention to insulin resistance, regardless of your weight?

Okay, good. Because now I’m going to dive into why many of our doctors are missing early indications of insulin resistance.

 

Insulin resistance is really hard to test for!

With how often we hear about the omnipresence of insulin resistance, you’d think it would be super easy to test, right? Well that’s what I thought, and I couldn’t have been more wrong! Currently, the most accurate way to test for insulin resistance uses something called the hyperinsulinemic euglycemic glucose clamp technique. It directly estimates insulin resistance as it measures how effective insulin is in promoting glucose utilization. It’s expensive, requires insulin infusion and repeated blood sampling. It is impractical, so doctors have to use surrogate methods to make their best guess as to whether someone has insulin resistance or not. There are even mathematical algorithms that have been suggested as a method to estimate insulin resistance, but procedures have not been standardized.

 

Why I had to dive deeper for my own sanity

Here’s the kicker and what led me down this path. I’ve long suspected insulin resistance was at play in my body. I just knew something more was going on. I have always reacted very poorly to unbalanced, high carbohydrate meals, or meals that I now understand are high on the glycemic index scale. I would have intense sugar highs and subsequent crashes, even with small portions. My weight has always been excessively stubborn, and while I’ve done a lot of work on healing my body image, it still drives me up a wall that I have stubborn weight around my midsection and various parts of my body. It slows down my athletic performance, contributes to pain in my body like in my low back, and just flat out annoys me. I’m constantly drinking water because I’m always thirsty. When I fall off my moisturizing regimen, my skin gets so dry I want to scratch it off.

Yet, blood test after blood test, I kept hearing the same thing from doctors. “Your A1c is great, no worries there. Even your fasting glucose - in fact, that’s really right at the lower bound of the typical range! You might even be hypoglycemic (more on how this can be an indicator of insulin resistance later). You don’t have insulin resistance. Even on your lipids panel, your triglyceride to HDL ratio is great. Nothing to worry about here!”

Right…nothing to worry about.

*Proceeds to pull hair out as I feel once again like my symptoms are being ignored*

 

Issues With Common Surrogate Measures of Insulin Resistance

The most common surrogate measures of insulin resistance that doctors will use check your hemoglobin A1c levels and your fasting plasma glucose levels. The issue is partially, these are not telling us the full story because blood sugar levels can be the last thing to rise when all the while, insulin was secretly rising behind the scenes for YEARS beforehand. The other issue is the ranges we are told are acceptable are often not optimal.

Fasting Plasma Glucose Test

After an overnight fast, your doctor will take blood to assess your blood glucose levels. This measures for a particular point in time, how much sugar is in your blood after you haven’t eaten or had anything to drink for about 8-12 hours.

Drawbacks:

  1. We can’t see how blood sugar responds to what we eat

  2. It’s a point in time analysis - it’s affected by what we have eaten most recently

  3. We can have normal fasting glucose levels with rising insulin

  4. “Normal” ranges are not optimal ranges:

  • “Normal” fasting blood glucose levels: 70-99 mg/dL (according to the CDC)

  • Optimal fasting blood glucose levels: 80-99 mg/dL range (used in functional medicine)

  • 100-125 mg/dL indicates prediabetes

  • 126 mg/dL indicates diabetes

Hemoglobin A1c

Hemoglobin A1c shows our average blood glucose levels over the lifespan of a red blood cell, which is about 3 months. It’s measuring the percentage of hemoglobin to which sugar has bonded.

Drawback: While it’s more helpful to see a 3-month average rather than a point in time measurement, we can still have elevated insulin levels behind the scenes, along with normal blood glucose and A1c levels.

  • The CDC guidelines state A1c below 5.7% is normal

  • Prediabetic levels at 5.7 to 6.4%

  • Optimal range is below 5.3% (used in functional medicine)

Fasting Insulin: Why You Need To Test It for Early Detection!

According to Dr. Mark Hyman, insulin levels can rise even decades before blood sugar levels rise, or you get a diabetes diagnosis, but it’s rare that our providers test this value. There is a considerable correlation between fasting insulin levels and “insulin action”, or how effective the insulin in your body is at facilitating glucose utilization. An ideal range for this fasting value is about 3-7 uIU/mL, and early detection of elevated values is key to preventive protocol. We can detect insulin resistance before clinical disease ever appears! This is so empowering!

Note: fasting insulin is most helpful for individuals who have “normal” or even low fasting glucose levels. If you are glucose intolerant, prediabetic, or have diabetic hyperglycemia, this test won’t be very helpful.

Lipid Panel: Another Insulin Resistance Early Indicator

Your lipid panel can also offer insight into whether you have insulin resistance. The triglyceride to high density lipoprotein ratio is key here. If you are 40-60 years of age, one study suggests that a ratio of greater than 3.0 can be a predictor. For younger individuals, the same study posits a ratio of 2.5 or greater may predict or signal insulin resistance and/or prediabetes, once again regardless of weight. In general, high triglycerides can be an early indicator of insulin resistance. According to Dr. Howard J. Luks, if we have typical insulin function, carbohydrates get stored in our muscles as glycogen. With insulin dysfunction or insulin resistance, insulin sends those carbohydrates to the liver, where they are turned into triglycerides. HDL, or high density lipoprotein, production is suppressed, leading to presence of high triglycerides and low HDL, or dyslipidemia. So don’t forget to check this indicator!

Hypoglycemia: Don’t ignore it! More research is needed, but it seems it could be another insulin resistance early indicator

I mentioned earlier that many functional medicine doctors posit the ideal range for fasting glucose is 80-99 mg/dL. Some want to see it in an even tighter range, around 85-99 mg/dL. Interestingly, the CDC states this range is more like 70-99 mg/dL, with <70 mg/dL classified as low blood sugar. So technically, with my fasting glucose levels coming back consistently around 70-72 mg/dL, I was still considered “within the normal range”. Normal range? No way. I’d get lightheaded, dizzy, and my vision would get blurry. And hangry? I made that term look generous. I started wearing a continuous glucose monitor for a couple months, and saw there were days my fasting glucose was falling to 53 mg/dL. Welp, that was horrifying, considering the CDC considers blood sugar below 55 mg/dL to be dangerously low.

Hypoglycemia linked to insulin resistance: A case study in India that may answer some of my questions

By this point, I was convinced I had low blood sugar. Fine, I thought, but what’s the link, why do I still feel like I have insulin resistance? My digging continued, and I found a 2019 case study out of New Delhi, by a Professor in Medicine and Endocrinology and a clinical tutor of general medicine. They analyzed a woman who had very low levels of glucose after fasting, at 62 mg/dL. However, at fasting, her insulin levels were 14 uIU/mL, indicating hyperinsulinemia. 4 hours after eating, her insulin spiked even further to 22 uIU/mL. This suggested inappropriate insulin secretion to the researchers, effectively indicating her insulin resistance. While of course this was a case study on one individual, it suggests that even having hypoglycemia, or low blood sugar, could be a sign of insulin resistance or a predictor for type II diabetes. A 2011 study by Myriam Ensling et. al. hints at this as well, stating that inordinate decrease in blood glucose levels occur more frequently in patients at risk for insulin resistance, and encourages more research on the topic. 

AHH!! I felt so excited to start to have an explanation and some answers. I’m not mad. I do know my body better than anyone else does! And that’s why, even though I’m so sick of hearing the words “insulin resistance”, I had to share with you.

 

Key Takeaways

  1. Insulin resistance is incredibly common in individuals with PCOS, regardless of weight. It’s really hard to test for it, so there may be hidden indicators of it even if your labs testing common surrogate measures seem normal.

  2. If your A1c levels and blood glucose levels are “normal”, check to see if they are optimal. Remember that “normal” is defined by a huge bell curve composed of individuals who may be very different from you.

  3. If your A1c and blood glucose levels are optimal, either ask your doctor for a fasting insulin test or try an at home one to see what’s at play.

  4. Don’t forget about your lipids panel! Make sure you’re checking for high triglycerides, or a high ratio of triglycerides to HDL. These can also signal insulin resistance.

  5. Don’t ignore low blood glucose levels, or symptoms of hypoglycemia. They may also be warning signs of insulin resistance.

  6. Tackling insulin resistance as early as possible is your best bet to managing the associated PCOS symptoms, preventing prediabetes, and preventing diabetes! Early intervention is the best type of care we can ask for.

 

Physical Signs of Insulin Resistance

  • Extreme difficulty losing or maintaining weight

  • A waist to hip ratio of 0.8 or greater

  • Unexplained weight gain, especially in midsection

  • Eczema or dry, itchy skin

  • Blurred vision

  • Skin tags

  • Patches of dark, thick, velvety skin in body creases/folds

  • Swollen ankles

  • High blood pressure

  • Fatigue

  • Extreme thirst

  • Frequent urination

  • Intense hunger or cravings

 

Keep in mind:

No one other than you lives day to day in your body. Take my account with blood glucose levels and hypoglycemia as proof that we know our bodies best. Empower yourself to listen to your body and advocate for yourself. The power is in you, you got this and I’m rooting for you!

 
Rachel Ruha
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