Lecture 40 in Dr. Bikman’s Metabolic Classroom

Dr. Ben Bikman

Learn how Dr. Ben Bikman measures and reverses insulin resistance using practical lab markers, nutrition strategies, and lifestyle tools that you can start applying today.

Synopsis

This video features Dr. Ben Bikman explaining how to accurately measure insulin resistance and, more importantly, how to reverse it using evidence-based lifestyle strategies rather than focusing only on blood sugar or calories. He outlines why traditional glucose-centered testing often misses insulin resistance for 10 to 20 years, and then walks through specific markers such as fasting insulin, triglyceride-to-HDL ratio, and the adipose tissue insulin resistance (AT-IR) score. Dr. Bikman then shows how elevated insulin drives hunger, weight gain, and metabolic disease, and presents three core nutrition pillars—control carbohydrates, prioritize protein, and do not fear natural dietary fat—plus structured fasting and targeted exercise as powerful ways to lower insulin, restore metabolic flexibility, and shrink overfilled fat cells. Throughout, he uses memorable metaphors and practical cutoffs to help viewers understand their own numbers and design a sustainable plan to improve metabolic health.

Summary

Insulin resistance is often missed when clinicians focus only on glucose, because insulin can be elevated for years while glucose appears normal, making insulin the “canary in the coal mine” of metabolic health.
Key lab markers to evaluate insulin resistance include fasting insulin (ideally under about 6 micro units per milliliter), the triglyceride-to-HDL ratio (healthy if under about 1.5), and the adipose tissue insulin resistance (AT-IR) score, which reflects insulin resistance at the level of the fat cells.
The AT-IR score combines fasting insulin and free fatty acids and can reveal early insulin resistance, with different healthy cutoffs for men (under about 5) and women (under about 8) due to sex hormone differences in fat metabolism and free fatty acid levels.
Dr. Bikman explains that high insulin with reduced calories creates an “energetic crisis,” driving intense hunger and weight regain, which helps explain why many “eat less and exercise more” approaches fail in the long term.
Lowering insulin first—by controlling carbohydrates (favoring whole fruits and vegetables), prioritizing high quality protein (preferably animal sourced), and not fearing natural fat that comes packaged with protein—can increase metabolic rate, increase satiety, and allow the body to tap into stored fat and produce ketones.
As insulin comes down and fat burning increases, structured fasting can be layered in as a second step to address overall energy intake, with Dr. Bikman emphasizing that how you end a fast with real, unprocessed foods matters more than achieving extreme fasting durations.
Exercise further improves insulin sensitivity by lowering insulin, increasing glucose uptake into muscle (which can account for up to around 80 percent of glucose clearance after a meal), and sustaining metabolic benefits for hours or days beyond each workout.

Transcript Summary

Measuring insulin resistance beyond glucose

Dr. Bikman opens by explaining that this class is the final part of a series on insulin resistance and now shifts from the problem to the solution. He stresses that the traditional view of insulin resistance is too glucose-centric, because clinicians usually only measure blood sugar and ignore insulin, even though insulin can be elevated for a decade or more before glucose rises. Insulin resistance, he explains, is fundamentally a state of chronically elevated insulin, and glucose can remain normal during much of that time, so relying solely on glucose testing delays diagnosis.

Fasting insulin as an early marker

He first focuses on fasting insulin as a direct marker of insulin resistance. In a fasted state of roughly 12 hours, he notes that a fasting insulin level under about 6 micro units per milliliter suggests insulin sensitivity, while 7 to the mid-teens is a gray zone that may or may not reflect insulin resistance, and levels in the high teens and above strongly suggest insulin resistance. He points out that insulin has a circadian rhythm and fluctuates throughout the day, so a single fasting value may occasionally catch insulin on an upswing, which is why additional markers can be helpful.

Triglyceride-to-HDL ratio and metabolic risk

Dr. Bikman then explains the triglyceride-to-HDL ratio as a more stable, indirect indicator of insulin resistance. He emphasizes that triglycerides and HDL are routinely measured on standard lipid panels, making this ratio easy to access, and recommends dividing fasting triglycerides by HDL cholesterol, with a ratio under about 1.5 considered a very good sign and higher values suggesting metabolic trouble and probable insulin resistance. He notes that this ratio can help flag issues even when insulin has not been directly measured.

Adipose tissue insulin resistance (AT-IR) score

Next, he introduces his favorite test, the adipose tissue insulin resistance (AT-IR) score, which specifically measures insulin resistance in fat cells. He explains that fat tissue is likely the first site to become insulin resistant and thus may signal early metabolic dysfunction before it appears at the whole-body level, as shown in research on women with polycystic ovary syndrome who had elevated AT-IR scores even when other markers looked normal. The AT-IR score is calculated by multiplying fasting insulin (in micro units per milliliter) by fasting free fatty acids (in millimoles), and he gives cutoffs of under about 5 for men and under about 8 for women as indicating insulin-sensitive adipose tissue.

Sex differences in fat metabolism

He pauses to describe why the AT-IR cutoffs differ by sex. Women naturally have higher free fatty acid levels—up to 40 to 50 percent higher—because estrogens drive higher fat turnover, meaning more fat is constantly leaving and entering fat cells. As a result, women tend to burn more fat at any given moment than men, even though they may store more fat overall, which is why their AT-IR score threshold for healthy adipose tissue needs to be higher.

Simple “no-lab” indicators of insulin resistance

For those without access to lab tests, Dr. Bikman offers a “quick and dirty” approach using clinical signs. He notes that high blood pressure is very often associated with insulin resistance and can function as a rough clue that insulin is elevated. Additionally, he recommends measuring waist circumference and comparing it to height: if twice your waist circumference is greater than your height, that suggests unhealthy central fat storage and likely insulin resistance, whereas a height number greater than twice the waist circumference suggests a healthier fat distribution pattern.

Why “eat less, exercise more” often fails

He then transitions to how to fix insulin resistance and reviews the three main causes: stress, inflammation, and hyperinsulinemia. While stress and inflammation can be difficult to control directly, he says, elevated insulin is highly modifiable and provides the most immediate leverage. Using a metaphor of a “fat cell shrinking journey,” he critiques the traditional calorie-centric approach of eating less and exercising more, explaining that cutting calories without lowering insulin traps energy in storage tissues, starves the brain of fuel, and drives intense hunger, which often leads to failure and weight regain.

Lowering insulin before cutting calories

Dr. Bikman argues that the first “step” on the journey should be lowering insulin, not slashing calories. When insulin drops, stored fat becomes more available, ketone production rises, and the brain has steady access to energy, lowering hunger signals and increasing satiety. He adds that low insulin lifts the “brakes” on metabolism, increasing metabolic rate and energy expenditure, while ketones themselves carry caloric value that is partially wasted through breath and urine, effectively causing the body to spill energy and supporting fat loss.

Nutrition pillars: control carbs, prioritize protein, do not fear fat

To lower insulin, he returns to three core nutritional pillars: control carbohydrates, prioritize protein, and do not fear fat. Controlling carbs means focusing on carbohydrates that do not come from bags, boxes, and barcodes, but instead from whole fruits and vegetables that are eaten rather than drunk. Prioritizing protein involves consuming ample high quality protein, preferably from animal sources, every day, while not fearing fat emphasizes accepting the natural fat that accompanies protein in whole foods, which he notes is essential, does not raise blood sugar or insulin, and is necessary for health.

Adding structured fasting appropriately

Once insulin is lowered and a person has already achieved meaningful progress, some individuals may plateau. At that stage, Dr. Bikman suggests layering in explicit energy management by using structured fasting instead of counting calories. He cautions not to fixate on long fasts that lead to extreme hunger and binge eating but instead to plan in advance exactly how to break a fast with appropriate foods, and he emphasizes that how you end a fast with real, minimally processed food is more important than the duration of the fast itself.

Exercise as an insulin-sensitizing tool

To close, he discusses the role of exercise in improving insulin sensitivity. Exercise lowers insulin because insulin’s job of storing energy conflicts with the body’s need to mobilize and burn energy during physical effort, so during exercise, insulin recedes while muscles increase their uptake of glucose. He notes that muscle is the major consumer of glucose after a meal, accounting for up to around 80 percent of glucose clearance, and that the benefits of a single bout of exercise on glucose and insulin can last for hours or even days, making movement a powerful tool for long-term metabolic health.

Explore these additional videos…

How diet, exercise, and sleep can help you reverse insulin resistance (Dr. Ben Bikman and Dr. Rhonda Patrick) – VeryHealthyBody post: https://veryhealthybody.com/how-diet-exercise-and-sleep-can-help-you-reverse-insulin-resistance
Which burns fat faster, fasting or Ozempic, with Dr. Jason Fung – VeryHealthyBody post: https://veryhealthybody.com/which-burns-fat-faster-fasting-or-ozempic

How to Measure and Fix Insulin Resistance