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Your A1C Is Normal. So Why Are You Insulin Resistant? · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: Your fasting glucose is normal.
• 0:02
  SPEAKER_00: Your A1C is normal.
• 0:04
  SPEAKER_00: So your metabolic health is fine, right?
• 0:07
  SPEAKER_00: Not necessarily.
• 0:09
  SPEAKER_00: You can be developing insulin resistance while both of these numbers still look completely normal for years before anyone tells you that you have prediabetes or even diabetes.
• 0:21
  SPEAKER_00: Meanwhile, you may start seeing other clues.
• 0:24
  SPEAKER_00: Your triglycerides creep up, you gain more fat around your middle, your blood pressure changes, maybe you develop fatty liver, maybe your cholesterol pattern starts changing, and no one has actually connected the dots.
• 0:39
  SPEAKER_00: This is one of the major metabolic health buckets I look at when I'm assessing cardiovascular risk.
• 0:45
  SPEAKER_00: I've touched on insulin resistance in several of my other videos: cholesterol, ApoB, exercise, stress, visceral fat, menopause.
• 0:55
  SPEAKER_00: But I've never opened up this bucket by itself.
• 0:59
  SPEAKER_00: So that's what we're going to do today.
• 1:01
  SPEAKER_00: And interestingly, Google just announced that Pixel Watch and Fitbit will start tracking insulin-resistant trends.
• 1:09
  SPEAKER_00: Your watch isn't diagnosing insulin resistance.
• 1:12
  SPEAKER_00: We'll get to that later.
• 1:13
  SPEAKER_00: But I had to smile.
• 1:15
  SPEAKER_00: Your smartwatch is starting to catch up to something I've been paying attention to in patients for years.
• 1:21
  SPEAKER_00: I'm Dr.
• 1:22
  SPEAKER_00: Mona Shaw, I'm triple board certified in cardiology, holistic medicine, and cardiac CT.
• 1:28
  SPEAKER_00: Today I'm going to explain what insulin resistance actually is, why your A1C can be normal when you have it, why I care about it as a cardiologist, what testing can and cannot tell us, and most importantly, if it's part of your picture, what can you actually do about it?
• 1:46
  SPEAKER_00: Let's make this simple.
• 1:48
  SPEAKER_00: When you eat, glucose enters into your bloodstream.
• 1:52
  SPEAKER_00: Your pancreas releases insulin, telling your muscle, liver, and fat cells, hey, we have energy available.
• 2:00
  SPEAKER_00: Take this and use it or store it.
• 2:03
  SPEAKER_00: When those tissues become less responsive to insulin, we call that insulin resistance.
• 2:11
  SPEAKER_00: But your body doesn't give up that easily.
• 2:14
  SPEAKER_00: Your pancreas compensates by producing more insulin.
• 2:18
  SPEAKER_00: And initially, that extra insulin can keep your glucose completely normal.
• 2:23
  SPEAKER_00: So imagine two people.
• 2:26
  SPEAKER_00: Both have a fasting glucose of 90, considered normal.
• 2:30
  SPEAKER_00: Person one needs a small amount of insulin to get there.
• 2:34
  SPEAKER_00: Person two needs much more insulin to land on that exact same number.
• 2:39
  SPEAKER_00: If all you looked at was glucose, they look identical.
• 2:43
  SPEAKER_00: Metabolically, however, they are not identical at all.
• 2:48
  SPEAKER_00: A1C mainly tells us about your average glucose exposure over the past few months, not how much insulin your body needed to get there.
• 2:58
  SPEAKER_00: As long as your pancreas can compensate, glucose stays normal.
• 3:03
  SPEAKER_00: Eventually, in some people, that compensation starts to fail.
• 3:08
  SPEAKER_00: Glucose creeps up, A1C enters into the prediabetes range, and eventually some people develop diabetes.
• 3:17
  SPEAKER_00: So glucose and A1C are absolutely useful tests.
• 3:21
  SPEAKER_00: They just don't always show us the earliest changes.
• 3:25
  SPEAKER_00: And I want to be careful here.
• 3:28
  SPEAKER_00: The science isn't as simple as insulin resistance always happens first, then the pancreas fails.
• 3:35
  SPEAKER_00: Insulin resistance, how much insulin your pancreas secretes, and beta cell function, beta cells are the cells that are inside your pancreas that actually produce insulin, all interact with each other.
• 3:49
  SPEAKER_00: The more accurate way to think about it is that your insulin-glucose system can be changing well before your glucose or A1C look clearly abnormal.
• 4:01
  SPEAKER_00: The opposite can happen too.
• 4:03
  SPEAKER_00: Some people have more of an insulin secretion problem.
• 4:06
  SPEAKER_00: Their pancreas doesn't compensate as well, so glucose starts rising with less insulin resistance than you'd expect.
• 4:14
  SPEAKER_00: And A1C itself isn't influenced by glucose alone.
• 4:18
  SPEAKER_00: Iron deficiency, red blood cell lifespan, blood loss, and certain hemoglobin disorders can all push it higher or lower than your actual glucose would predict.
• 4:29
  SPEAKER_00: So if someone's glucose and A1C are telling me two different stories, I don't just pick one and ignore the other.
• 4:38
  SPEAKER_00: I ask why they don't match.
• 4:41
  SPEAKER_00: This is exactly why I don't rely on one single number.
• 4:47
  SPEAKER_00: Looking at A1C, triglycerides, and insulin resistance scores together gives me a much more accurate picture than any one of them alone.
• 4:57
  SPEAKER_00: South Asians are a good example of why body size alone can be misleading.
• 5:01
  SPEAKER_00: On average, they can develop insulin resistance and diabetes at a lower BMI and a lower weight and a younger age, partly because they may carry more fat around the abdomen and liver and less muscle at the same body weight.
• 5:18
  SPEAKER_00: They may also lose the ability to compensate with extra insulin sooner.
• 5:23
  SPEAKER_00: So someone can look thin and still carry real metabolic risk.
• 5:28
  SPEAKER_00: I'm planning a separate video on South Asian heart and metabolic risks specifically.
• 5:32
  SPEAKER_00: There's a lot more to unpack there.
• 5:34
  SPEAKER_00: But for today, normal weight does not always mean normal metabolic health.
• 5:40
  SPEAKER_00: If this is landing differently than what you've been told before, that's exactly the point.
• 5:46
  SPEAKER_00: This channel is dedicated to early detection, prevention, and going deeper into scans, labs, and supplements most doctors don't have time to cover.
• 5:55
  SPEAKER_00: If that's what you're here for, subscribe and like for more.
• 6:00
  SPEAKER_00: Because this isn't just about diabetes.
• 6:04
  SPEAKER_00: Insulin resistance can contribute to the environment in which atherosclerosis or plaque develops.
• 6:12
  SPEAKER_00: Quick refresher the inside of your arteries is lined by a thin layer of cells called the endothelium.
• 6:20
  SPEAKER_00: Think of it as the protective inner lining of your blood vessels.
• 6:23
  SPEAKER_00: Healthy insulin signaling helps that lining function normally.
• 6:28
  SPEAKER_00: With insulin resistance, that system can become dysfunctional, more oxidative stress, more inflammatory signaling, less nitric oxide, and poorer endothelial function.
• 6:42
  SPEAKER_00: At the same time, insulin resistance often travels with higher triglycerides, more remnant particles.
• 6:50
  SPEAKER_00: That is a cholesterol particle that has dropped off its triglyceride cargo but still carries cholesterol into the artery wall.
• 6:59
  SPEAKER_00: More visceral fat, higher blood pressure, and sometimes even fatty liver.
• 7:04
  SPEAKER_00: Together, all of this creates a more favorable environment for plaque to develop.
• 7:11
  SPEAKER_00: Insulin resistance doesn't mean you have coronary plaque, and it's not the only cause of athosclerosis, but it's one piece of the larger risk picture.
• 7:21
  SPEAKER_00: And that's why I use buckets, genetics, cholesterol particles, and Apo B, blood pressure, inflammation, metabolic health, and lifestyle.
• 7:33
  SPEAKER_00: They all overlap.
• 7:34
  SPEAKER_00: We don't develop cardiovascular disease because one isolated lab number went bad.
• 7:39
  SPEAKER_00: I want to keep this simple because social media has made it way more complicated than it needs to be.
• 7:45
  SPEAKER_00: So sometimes I'll check a fasting insulin.
• 7:48
  SPEAKER_00: I also use an insulin-resistant score in some patients that incorporates markers like insulin and C-peptide.
• 7:55
  SPEAKER_00: These are tests available at labs like Quest and LabCore, nothing exotic.
• 7:59
  SPEAKER_00: There's no perfect diagnostic test for this, and I don't diagnose someone off one number.
• 8:04
  SPEAKER_00: I add it to the full picture, along with the A1C, triglycerides, and everything else we've talked about today.
• 8:11
  SPEAKER_00: I'm looking for the pattern.
• 8:13
  SPEAKER_00: This is where I think technology can actually help, in the right person.
• 8:18
  SPEAKER_00: A CGM, which is a continuous glucose monitor, lets you see what's happening to your glucose throughout the day instead of one fasting number once or twice a year.
• 8:29
  SPEAKER_00: One of the most interesting things people learn, we don't all respond identically to the same food.
• 8:35
  SPEAKER_00: One person eats oatmeal and barely sees a change.
• 8:39
  SPEAKER_00: Someone else eats the same oatmeal and sees a much bigger spike of glucose and sugar.
• 8:44
  SPEAKER_00: Even within the same person, how you build the meal matters.
• 8:48
  SPEAKER_00: A carb alone versus that same carb with fiber, protein, or fat, or a walk afterward changes the response.
• 8:57
  SPEAKER_00: That's where CGMs become educational, not my glucose hit 142, something terrible happened.
• 9:04
  SPEAKER_00: That's not how I use them.
• 9:06
  SPEAKER_00: I look for patterns.
• 9:07
  SPEAKER_00: Which breakfasts consistently spike you?
• 9:09
  SPEAKER_00: What happens when you add protein or fiber?
• 9:12
  SPEAKER_00: What happens after walk or after poor sleep?
• 9:15
  SPEAKER_00: One caveat: CGMs aren't perfect, especially without diabetes.
• 9:21
  SPEAKER_00: The same meal can read differently on different days.
• 9:24
  SPEAKER_00: I don't make decisions off of one spike.
• 9:26
  SPEAKER_00: I look at the patterns.
• 9:28
  SPEAKER_00: They matter way more than individual readings.
• 9:32
  SPEAKER_00: Google recently announced something called insulin resistant trends for Pixel Watch and Fitbit.
• 9:38
  SPEAKER_00: And I want to be clear about what it actually does.
• 9:41
  SPEAKER_00: It's not measuring your insulin.
• 9:43
  SPEAKER_00: There's no blood test coming out of your watch.
• 9:45
  SPEAKER_00: Instead, the wearable looks at multiple physiologic signals over weeks and flags changes associated with insulin resistance, then gives you a trend over time.
• 9:57
  SPEAKER_00: I would not diagnose insulin resistance from a watch, but I do think this is where medicine is headed.
• 10:04
  SPEAKER_00: Wearables, CGMs, and traditional blood testing eventually fitness more continuous picture than one fasting lab draw once a year.
• 10:14
  SPEAKER_00: For preventative medicine, that's genuinely interesting.
• 10:18
  SPEAKER_00: This is probably the most important part of the video.
• 10:22
  SPEAKER_00: I get tired of health information that tells people everything that can go wrong and then sends them home scared.
• 10:29
  SPEAKER_00: If insulin resistant is part of your picture, there's a lot you can actually change.
• 10:34
  SPEAKER_00: Notice I didn't say lose weight.
• 10:36
  SPEAKER_00: I said excess visceral fat, the metabolically active fat around your abdominal organs.
• 10:43
  SPEAKER_00: You can have it at a relatively normal BMI, and reducing excess visceral and liver fat can substantially improve insulin sensitivity.
• 10:54
  SPEAKER_00: The diabetes prevention program is one of our strongest examples.
• 10:58
  SPEAKER_00: The lifestyle group targeted about 7% weight loss and at least 150 minutes of activity a week and reduced progression to diabetes by 58% over three years.
• 11:14
  SPEAKER_00: But if you're already lean and insulin resistant, losing another 7% of your body weight may not make any sense.
• 11:22
  SPEAKER_00: This is why treatment has to be individualized.
• 11:25
  SPEAKER_00: This is one of my favorite interventions.
• 11:27
  SPEAKER_00: Muscle is one of the major places glucose goes, and exercise improves insulin sensitivity even without major weight loss.
• 11:36
  SPEAKER_00: I want both aerobic exercise and resistance training, about 150 minutes of moderate activity a week, and resistance training two or three times a week if you're able.
• 11:47
  SPEAKER_00: Easy one.
• 11:48
  SPEAKER_00: Take a 10 or 15 minute walk after you eat.
• 11:51
  SPEAKER_00: You don't necessarily need a supplement.
• 11:53
  SPEAKER_00: You may need shoes and 10 minutes.
• 11:56
  SPEAKER_00: This doesn't mean carbohydrates are evil.
• 12:00
  SPEAKER_00: I care much more about what carbohydrate, how it's processed, and how much, and what you're eating with it.
• 12:07
  SPEAKER_00: More vegetables, beans, and lentils, fruits, nuts and seeds, and whole grains where appropriate, adequate protein, healthy fats, especially fiber, less sugar-sweetened drinks, refined carbohydrates, and highly processed foods.
• 12:25
  SPEAKER_00: We want to limit those.
• 12:27
  SPEAKER_00: One simple strategy: don't eat the carbohydrate naked.
• 12:32
  SPEAKER_00: Pair it with protein, fiber, or a healthy fat.
• 12:36
  SPEAKER_00: This is exactly where a CGM can teach you something.
• 12:38
  SPEAKER_00: Maybe a certain breakfast doesn't work for you.
• 12:40
  SPEAKER_00: Maybe adding protein changes your response.
• 12:43
  SPEAKER_00: Maybe you walk after dinner makes a difference.
• 12:45
  SPEAKER_00: That's personalized nutrition.
• 12:48
  SPEAKER_00: Don't treat sleep as the optional part of your metabolic plan.
• 12:53
  SPEAKER_00: Experimental sleep restriction can worsen insulin sensitivity even without waking.
• 12:58
  SPEAKER_00: For most adults, aim for roughly seven to nine hours and consistency matters.
• 13:04
  SPEAKER_00: If you're technically sleeping enough but still exhausted, snoring loudly, or someone's told you that you stop breathing at night, talk to your doctor about sleep apnea.
• 13:13
  SPEAKER_00: It absolutely can coexist with metabolic dysfunction.
• 13:17
  SPEAKER_00: Stress usually isn't the only cause of insulin resistance, but chronic stress affects cortisol, sleep, appetite, food choices, and metabolic regulation.
• 13:29
  SPEAKER_00: Because I'm also board certified in holistic medicine, this isn't fluff to me.
• 13:33
  SPEAKER_00: Stress management can be meditation, breathing exercises, yoga, walking, journaling, time with people you love.
• 13:42
  SPEAKER_00: The best technique isn't the fanciest one, it's the one you'll actually do.
• 13:47
  SPEAKER_00: And this is important.
• 13:49
  SPEAKER_00: During menopause and perimenopause, changes in estrogen and body composition tend to shift fat toward the abdomen, and we tend to lose muscle as we age, unless we're actively working to preserve it.
• 14:03
  SPEAKER_00: Less muscle, more visceral fat, that combination can worsen insulin sensitivity.
• 14:10
  SPEAKER_00: Women tell me all the time, my weight hasn't really changed, but my body has.
• 14:15
  SPEAKER_00: Exactly.
• 14:16
  SPEAKER_00: The scale looks almost identical, but the waste changes, triglycerides change, glucose starts going up, blood pressure goes up, those shifts matter.
• 14:25
  SPEAKER_00: So menopause absolutely belongs in this conversation.
• 14:28
  SPEAKER_00: I actually have a dedicated video on menopause and heart and metabolic health coming soon.
• 14:33
  SPEAKER_00: What about supplements?
• 14:35
  SPEAKER_00: Because I'm also board certified in holistic medicine, people are absolutely going to ask me this.
• 14:41
  SPEAKER_00: There are some supplements with evidence, but they come after the things we just discussed.
• 14:48
  SPEAKER_00: Berberine probably has the strongest evidence for modest improvements in glucose and insulin resistance markers.
• 14:55
  SPEAKER_00: Cinnamon has some supportive evidence, though studies are inconsistent.
• 14:59
  SPEAKER_00: Magnesium and vitamin D matter when someone is actually deficient.
• 15:04
  SPEAKER_00: And you know from my supplement video, I am a big fan of magnesium and vitamin D.
• 15:10
  SPEAKER_00: And one of my favorites, because it's incredibly unglamorous, is cilium fiber, soluble fiber that can improve the glucose response to meals.
• 15:19
  SPEAKER_00: Chromium, gymema, apple cider vinegar, there's some research, but it's weaker or less consistent.
• 15:25
  SPEAKER_00: Please don't go online and buy an eight-supplement insulin-resistant stack.
• 15:30
  SPEAKER_00: Targeted supplementation can make sense, random supplementation doesn't at all.
• 15:35
  SPEAKER_00: And berberine specifically can interact with medication, so you really need to talk to your physician.
• 15:40
  SPEAKER_00: What about medication?
• 15:42
  SPEAKER_00: Yes, sometimes medication belongs in the discussion.
• 15:46
  SPEAKER_00: Metformin has decades of evidence and can be useful, particularly in certain people with pre-diabetes who are at higher risk of progressing to diabetes.
• 15:57
  SPEAKER_00: And if excess weight or visceral fat is a major driver, GLP1-based therapies can produce substantial weight loss and improve metabolic health in appropriately selected patients if done the correct way.
• 16:12
  SPEAKER_00: There are other medications we may use, depending on whether someone actually has diabetes, fatty liver, cardiovascular disease, or other conditions.
• 16:21
  SPEAKER_00: But I don't see an elevated insulin resistant score and automatically prescribe a drug.
• 16:27
  SPEAKER_00: We treat what's driving the metabolic problem and the person's overall risk, not one insulin number.
• 16:36
  SPEAKER_00: So instead of finishing this video and diagnosing yourself, screenshot this.
• 16:43
  SPEAKER_00: Could insulin resistance be part of my metabolic picture even though my A1C is normal?
• 16:50
  SPEAKER_00: Can we look at my glucose, A1C, triglycerides, HDL, and APOB together?
• 16:57
  SPEAKER_00: Would fasting insulin or an insulin-resistant score add useful information for me?
• 17:02
  SPEAKER_00: Could visceral fat or fatty liver be part of my picture?
• 17:06
  SPEAKER_00: If my A1C and glucose don't match, should we investigate why?
• 17:11
  SPEAKER_00: And for women, could perimenopause or menopause be contributing to these changes?
• 17:18
  SPEAKER_00: That's the conversation.
• 17:19
  SPEAKER_00: Not my fasting insulin's 11, the internet says I'm insulin resistant.
• 17:24
  SPEAKER_00: Look at the whole patient.
• 17:27
  SPEAKER_00: So let's bring this back to where we started.
• 17:30
  SPEAKER_00: Your fasting glucose can be normal, your A1C can be normal, and your metabolism may still be starting to change.
• 17:36
  SPEAKER_00: That's why insulin resistance is one of the major metabolic health buckets I look at.
• 17:41
  SPEAKER_00: And I'm not judging that bucket by one number, I'm looking at the whole pattern.
• 17:45
  SPEAKER_00: And here's the good news: this is a bucket where you can do a lot about it.
• 17:50
  SPEAKER_00: Build muscle, move your body, eat more fiber, whole foods, reduce excess visceral fat if you have it, praetor sleep, work on chronic stress, and use supplements or medications when they're actually appropriate.
• 18:05
  SPEAKER_00: Then follow the pattern over time.
• 18:07
  SPEAKER_00: Prevention isn't waiting until your A1C hits 6.5 and finally saying, now we have a problem.
• 18:15
  SPEAKER_00: Prevention is recognizing the trajectory while you still have the opportunity to change it.
• 18:20
  SPEAKER_00: That's what I want you to take away from this video.
• 18:23
  SPEAKER_00: If you found this helpful, subscribe.
• 18:26
  SPEAKER_00: And next up, I'm comparing coronary calcium scoring, CCTA, which is coronary CT angiogram, and CIMT head to head.
• 18:36
  SPEAKER_00: I'll be answering the questions that you've all been asking about this.
• 18:40
  SPEAKER_00: I'll see you in the next one.