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Getting close to a year ago, I talked about GOLO, a weight loss program that I heard about from an ad in a podcast I was listening to. I found it oddly satisfying, because they were trying to launder the standard science on CICO through explicit anti-CICO messaging; truly a beauty of capitalism. Their biggest tag line for what they think is going wrong with a lot of people was insulin resistance. Whelp, while I was at the gym this morning, what popped up in my podcast list? A two hour long Peter Attia podcast specifically on insulin resistance with MD/PhD Gerald Shulman, an academic researcher on the topic.
They talked about the prevalence of insulin resistance in the population. No, it is not obscure. Obesity basically causes it directly, and yeah, the population obesity numbers are high. They also talked about diabetes, both Type I and Type II, as well as some studies on healthy, lean young adults who had two parents with Type II diabetes and who displayed insulin resistance (i.e., at high risk of developing Type II diabetes). But yeah, lots of people do have insulin resistance, so things like GOLO are at least capturing a slice of reality, even though it's clear that they're not really specially targeting insulin resistant individuals. They're not testing people for insulin resistance and then tailoring their program accordingly; they're again just laundering the standard advice and giving it to all comers, whether they're actually insulin resistant or not.
They talked a lot about molecular mechanisms, evolutionary explanations, etc., in great gory detail, far more than I could do justice trying to reproduce here. I'll hopefully suffice by describing one concept; they distinguish between insulin resistance in muscle versus what happens in the liver down the chain (which can cause fatty liver disease, which is now working its way up to being one of the leading causes of death or other conditions that cause death). Apparently, many folks develop muscle insulin resistance, so glucose is not able to be deposited in muscle as glycogen, so it ends up in the liver, and all sorts of problems follow.
What can we do about this? "Exercise reverses this muscle insulin resistance ... exercise in muscle actually will prevent fatty liver and liver insulin resistance". [EDIT:
They talked about a couple different studies, butUpon further review in the comments below; I think this part was just one study. They did talk about other studies generally, but I had interpreted this section as referring to two different studies, but now I think it refers to just one] remember that population of otherwise healthy, lean, young adults with parents who have Type II diabetes? They had them do a singleboutsession of exercise (45min3 sets of 15min at 65% VO2Max), and that was sufficient to open up the necessary translocation pathway, resulting in "more glucose deposition as muscle glycogen and significant reductions in [something too technical for me to try to explain in this comment] and significant reductions in liver triglyceride."What about beyond that population, thinking about just other obese people? "What can we do about this? If we can get our patients to lose weight; this of course is the best. Diet and exercise of course is the best thing, and that's the first thing I tell my patients. We really drill into them how we can really fix everything that's wrong with them through this process. [Emphasis added; italics felt true to the audio; bold is my own focus]"
We know a lot about how this works. We know how to fix it. Exercise still is the single most effective medical intervention we know of. If exercise were a pill being prescribed, it would be hands down the most effective thing for all-cause mortality. Paired with diet, it's basically a superpower against a vast swath of modern maladies. Doctors know this, they know how it works and why, they've known this for a long time now, and they'll say it in public. Some, like this guy, will even say it so bluntly to patients. But many doctors know that patients don't want to hear it. They don't want to hear the science; they don't want to "follow the science" (i.e., actually do the thing). He also mentions that even though they try to drill this into patients, many of them still just don't do it. Patients get annoyed with doctors telling them the truth, and this results in a lot of doctors giving up and not even telling them anymore. Just avoid the topic. I had one obese friend tell me that she practically begged her doctor for advice with her weight, and he said, "You know, you're just getting older..."
You don't have to believe the GOLOs of the world. You don't have to believe the sign on the gym swearing that they'll help you lose 20lbs in 30 days. They're grifting, and they're helping to confuse many many people about how their bodies work. But the evidence is pretty solid that basically whatever the excuse is, in this case insulin resistance, the most well-documented and scientifically-supported solution is still diet and exercise.
I'm a bit familiar with the literature on endurance sports (mostly cycling, but some running -- the cyclists have better quantitative data), and I'd be curious to know more about this study. Very coarsely (unless you can afford real metabolic testing), my understanding is that VO2Max is roughly a maximal 5 minute effort. For me, 65 percent of that for 45 minutes would be a decently hard workout I'd maybe want an easy day after.
But my understanding is that there is a pretty wide variance of VO2 power and 60 minute power, and that it wouldn't be out of the question for a specialist in middle-distance (VO2-dominant) events to have trouble doing this workout. Was this research on mostly-untrained subjects? I'm not sure how hard an effort this would be for them. Did they report perceived efforts?
Regardless, I would agree on recommending more exercise generally.
Great intuition. I don't do much with endurance sports, so I didn't have a great intuition for that number. His reference to a study or studies in the podcast was a little difficult to follow, and I didn't actually look it up. My first interpretation was that he mentioned two separate studies, one that was a six week intervention, where he spelled out that they had three fifteen minutes "bouts" on a stairmaster at 65% VO2Max. Then, I thought he referred to a different study and said "a single 45 minute bout", which I just tried to interpret as "in a different study, instead of doing three fifteen minutes bouts, we had them do one 45 minute one" (and I only mentioned what I thought was the latter study in my comment). But now I think that interpretation was wrong. I think I found the study, and I think it's just the one study (that is not to say that I have any knowledge of replication/failure or whether there he's a man of one study; just that what I thought was two separate studies is just one study). It looks like in that same paper, they reported data after one session (that is, one day of doing three fifteen minute bouts) as well as data after the full six week intervention. So, I think he just misspoke to use the term "bout" ambiguously. From the paper, it looks like they had a five minute rest between each fifteen minute set. Does this seem more reasonable to you?
Three sets of fifteen minutes seems much more doable (although the original might not be out of the question), and it looks like they scaled it up over the six weeks as fitness improved. It would be interesting to see how much, but I didn't see that in a quick skim.
It doesn't seem that surprising to me generally: endurance exercise uses a lot of energy from blood sugar (and also from fat), and everything I've read suggests that the liver has a huge role in regulating that. I've also heard plenty of anecdotes about diabetes improving (or at least being easier to regulate) with exercise. The idea that reducing blood glucose without using insulin (exercise!) might improve insulin sensitivity sounds pretty reasonable: abstaining from caffeine for a while makes a cup of coffee hit harder when you do have one.
Exercise definitely does things to your insulin system. One of the interesting findings is that taking in sugar while exercising doesn't cause an insulin spike. Normally during exercise at that level you'd be using a combination of muscle glycogen, liver glycogen, and fat. Taking in sugar reduces liver glycogen use in favor of the newly introduced sugar. Then when you're done exercising, insulin sensitivity is increased, which helps replenish muscle glycogen.
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