Dr. Ben Bikman

Some would say it's muscle.

Some would say it's fat.

It's the fat.

In my view, very strongly, it's the fat tissue.

So insulin resistance in its earliest stages is high insulin, but normal glucose.

The problem with invoking a muscle-centric view or a liver-centric view, or I need to add one, an alpha cell-centric view, because that's also relevant of the pancreas for a reason I'll touch on in a moment, is

The moment those become insulin resistant, glucose is not going to be controlled anymore.

And so then you skip a step because insulin resistance, if you look at the progression of the person towards type 2 diabetes, the insulin has come up first.

And then the glucose is normal and the glucose will start to climb.

And that's when we detect the problem.

So my view is the fat cell falls first.

It's the first tissue to become insulin resistant as it starts to experience some degree of hypertrophy.

That then starts to facilitate the other tissues becoming insulin resistant.

And at that point, there's no order in my mind.

It'd be hard to distinguish if there's another order.

But I actually, when I teach this very idea to my students, one of my undergraduate assignments is a class called pathophysiology.

And these kids are fortunate enough to learn the true origins of type 2 diabetes from an expert.

But I actually show the fat cell first.

And then the next step, I say, I teach it in this concept of, all right, well, what flips the switch from prediabetes, insulin resistance to type 2 diabetes?

What is it that makes the glucose go up?