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Getting Insulin Resistance in Check Recommended Reading: “Outlive: The Science & Art of Longevity”

Nov 16, 2023

Given my abiding interest in fitness and health, I was intrigued by the recently published “Outlive” from physician Peter Attia—a book rich in information about the diseases most likely to assail us as we age.  Attia refers to those chronic disorders as the Four Horsemen:  cancer, heart disease, neurodegenerative disease (e.g., Alzheimer’s), and type 2 diabetes.  His discussion of type 2 diabetes—prevention and intervention—caught my attention in particular, as 1 in 10 Americans suffer from this disease, along with some of my friends.

Attia received his M.D. at Stanford University, followed by training at Johns Hopkins Hospital and a fellowship with the National Institutes of Health at the National Cancer Institute.  Attia’s approach to “healthspan” and lifespan is grounded in science, offering evidence that exercise is a potent preventative “drug” for both cognitive and physical decline.  To maintain metabolic health, it is essential.

Metabolic health means that you are able to properly use and dispose of the glucose in the blood for energy and for storage in the cells.  Unfortunately, a diet of “abundance” and sedentary lifestyles, often lead to impaired metabolic function, a continuum of insulin resistance, pre-diabetes, and type 2 diabetes at the extreme.  Insulin resistance, resulting in elevated levels of glucose in the blood, precedes type 2 diabetes and is also linked to greater risk of heart attack, stroke, nonalcoholic fatty liver disease (NFLD), some cancers, and dementia.

While there is no argument that physical activity helps to control diabetes, there has been some controversy as to whether aerobic or anaerobic exercise is best.  As Attia notes, there are three primary differences between aerobic and anaerobic activity as it relates to blood glucose management and type 2 diabetes:

  1. The amount of oxygen required to perform the activity
  2. The intensity and duration of the activity
  3. Where the body draws fuel for the activity (muscle or liver)

As we know, the word “aerobic,” meaning “requiring oxygen,” refers to activities like walking, cycling, or swimming that can be performed for an extended period with the body maintaining heart and breathing rates at elevated but steady levels.  Such extended aerobic activity improves the body’s ability to utilize blood glucose, which lowers blood sugar levels and, over time, increases insulin sensitivity—an advantage in managing diabetes.

The word anaerobic is used to define vigorous, short-term activities like weight training and high-intensity interval training. During anaerobic activity the heart rate is too elevated to use blood sugar as fuel. Instead, the body burns glycogen (the storage form of glucose) stored in your muscles and liver.  Anaerobic activity can actually increase blood sugar levels for an hour or so as glycogen stores are replenished, but this elevation is temporary.  Ultimately, vigorous activity improves proper metabolic function.

The physiology is complex,* but in brief, involves the liver, which plays an essential role in converting stored glycogen to glucose and releasing it to maintain glucose homeostasis.  Additionally, the pancreas secretes insulin, which shuttles the glucose to where it’s needed.  In a sedentary person, who is not using blood sugar or stored glycogen, excess energy largely ends up as triglycerides within fat cells, driving conditions like type 2 diabetes.

Attia asserts that both aerobic and anaerobic exercise are essential to proper metabolic function.  Beyond increasing cellular insulin sensitivity, aerobic training improves cardio-respiratory efficiency, measured in terms of VO2 max—another powerful marker for healthy aging.  Anaerobic activity builds muscular mass and strength, which expands the storage capacity for blood sugar in the muscle preventing the build-up of blood sugar and again, improving insulin sensitivity.  Any activity “north of zero” is good according to Attia, and all will create the strength, stability, and endurance we need for everything we do in life.

While there is much more to be gleaned from Attia’s detailed discussion, the importance he places on the need to “get our metabolic house in order” was new to me, as was the knowledge that 34 million people in the U.S. suffer from type 2 diabetes.  The good news, per Attia, is that “we have tremendous agency over” our own path and attention to exercise, a healthy diet, and sufficient sleep “can completely turn the tables in our favor.”  Good news, indeed.

Attia hosts a weekly podcast, “The Drive.” Videos on various subjects are available on YouTube and on his web site


“Outlive:  The Science & Art of “Longevity”
Peter Attia, MD, with Bill Gifford
Publisher:  Harmony, First Edition (March 28, 2023)

*Per the NIH, The body has four major sources of energy: plasma glucose derived from liver glycogenolysis, free fatty acids (FFAs) released from adipose tissue lipolysis and from the hydrolysis of triacylglycerol (TG) in very low-density lipoproteins (VLDL-TG), and muscle glycogen and intramyocellular triacylglycerols (IMTGs) available within the skeletal muscle fibers.