Chapter 3: Metabolic Syndrome


Why You’re Fat and Sick

If you are a true fat ass (or young and pre-fat ass), you probably have metabolic syndrome.  Likely, you have never heard it called that before.  But I’ll bet the attendant conditions sound familiar.  These conditions include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.  There is also some more recent evidence that high uric acid levels are also present (this is associated with gout and kidney disease).  Don’t think so?  If you are a fat ass, see your doctor and get some lab work done.  It is possible to have one of these symptoms in isolation. Still, the odds are they are a cluster of symptoms that define metabolic syndrome.  If you do have it, you aren’t alone: About one-third of US adults have it.  (And that’s the ones we know about).

Metabolic syndrome is closely associated with obesity. Always remember the social scientist’s mantra: Correlation does not demonstrate causation. I seriously question whether obesity is the cause of metabolic syndrome, as that statement suggests. I argue that obesity is just another symptom of metabolic syndrome.

Dieleman and his colleagues (2020) undertook the laborious task of breaking down healthcare costs in America over 20 years, ending in 2016.  These authors noted that “US health care spending has continued to increase and now accounts for 18% of the US economy….”  They observed that lower back and neck pain was the most expensive part of the mix.  Most of the Top 10 can be associated with metabolic syndrome.  Diabetes ranked 3rd.  Hypertension, a chronic disease with no widely recognized cure and treated with simple medications, cost the US economy around $79 billion annually.  The bottom line is that if we want to make America more healthy and keep providing health care for the elderly, we desperately need to get America’s insulin problems under control.

As Dr. Fonseca suggests, “Metabolic syndrome is prevalent in the United States and developed nations, and patients with this disorder are at risk for type 2 diabetes mellitus and cardiovascular disease, underscoring the need for prompt patient identification and management” (Fonseca, 2005).  To this, I only add, “No shit.”  Fonseca adds, “The first-line approach to control of metabolic syndrome is weight control and exercise” (Fonseca, 2005).

I’m unsure whether her intent here is to describe the status quo or advocate this position, but I call bullshit.  Obesity is a concurrent symptom of the more significant problem, not the causal factor.  When you want to solve a problem, figure out the cause and attack that.  It is well established that insulin resistance is the proximate cause of metabolic syndrome. I argue that America could reduce its collective healthcare expenditure by 75% if we eliminate insulin resistance.

Problems With Too Much Insulin

The world has gone mad when it comes to diet.  Nowadays, you are considered abnormal if you don’t eat an extraordinary amount of carbs and make yourself fat and sick.  We used to call this the Standard American Diet (SAD), but we have exported it.  Nowadays, we can just call it the “Standard Diet.” (But keto and fasting fans obviously like the acronym SAD).  It is projected that over half of Americans will have type II diabetes in the near future.   The problem is not limited to America anymore.  The “Western” world, as well as China and India, now share in the trend.  It is truly a pandemic of obesity and metabolic disease.

When we eat all this sugar, we raise the blood sugar levels, and insulin levels rise to deal with it.  Insulin is the fat-storage hormone.  It forces the glucose into cells, where it is converted to fat.  This isn’t just caused by what we consider “sugar.”  All digestible carbs turn to sugar, which quickly turns to fat.  All of that fat can’t be dealt with by the infamous Eat Less – Move More diet that researchers have shown over and over again will fail to achieve lasting results.  We must take the body out of fat-storage mode to burn the fat.

Ketogenic diets and fasting reverse this status quo way of eating.  It is what you need to repair and maintain the body’s tissues.  Fat replaces glucose as fuel.  The question arises, why do we care if we’re burning fat?  Fuel is fuel, right?  No!  If you are constantly burning sugar, you will probably get sick. I say “probably” because I believe there is a vital genetic component to all of this.

Not all people are made using a single blueprint.  Some people tolerate a massive amount of carbs well, and others simply don’t (Yes, fellow fat asses. It’s us.)   Global disease statistics suggest that very few people can tolerate 400 grams of carbs per day without falling prey to metabolic disease.  The sad, unfair fact is that some people can do everything wrong and still not get fat and sick.  Some people can do a pretty good job and still get fat and sick.  For those of us who got dealt a bad hand, it takes much more work and sacrifice to get healthy and stay that way.

High Blood Pressure

Hypertension is the fancy medical word for high blood pressure.  About ten percent of people with hypertension have it because of other problems, like kidney disease or a tumor.  Get your doctor to rule this type of hypertension out before assuming you have the most common kind.  The vast majority of people diagnosed with hypertension are diagnosed with essential hypertension.  The “essential” part of the term means that doctors don’t have a good idea of what is happening.  As you suspected, I will link hypertension with insulin resistance.  Insulin is known to be a vasoconstrictor, meaning it shrinks blood vessels.  One reason this happens is that it reduces levels of nitric oxide.  In other words, insulin causes nitric oxide depletion in the blood.

Nitric oxide is a vasodilator, meaning it causes blood vessels to get bigger.  This lowering of nitric oxide by insulin causes hypertension (high blood pressure).  It also causes men to experience erectile dysfunction (ED).  Manipulating nitric oxide is how most ED drugs (e.g., Viagra) work. (I speculate that many men on Hormone Replacement Therapy could have fixed the problem by improving metabolic health).  Legend has it that most ED drugs were first developed to target hypertension, not ED.  They weren’t so good at lowering blood pressure (they do a little), but they work great for…other things.

Suppose insulin is the (or at least a major) culprit in high blood pressure. In that case, essential hypertension isn’t at all essential.  The problem can be made better by dropping insulin levels.  The converse is true; when doctors give patients insulin, blood pressure increases (see Salvetti, Brogi, Di Legge & Bernini, 1993 for a discussion of these mechanisms).  We do know there is a strong relationship between hypertension and the other symptoms of metabolic syndrome.  Perhaps the most vital link is obesity (see Leggio et al. 2017 for a full discussion).

If being a fat ass was just a matter of not being pretty, we dad bods would be fine.  But it’s about more than being pretty; it’s a matter of life and death.  Obesity is widely recognized as a significant cause of high blood pressure, and the combination of obesity and hypertension is recognized as a preeminent cause of cardiovascular disease and death. This does not, however, preclude higher-order causes of both obesity and high blood pressure, such as insulin resistance and fructose poisoning.

It seems evident that the American Heart Association is in bed with Big Pharma.  Doctors report that the AHA conferences are really just advertisements for pills pushed by the drug companies.  They doubled down on the cholesterol causes heart disease, and interventions based on that hypothesis haven’t worked.  They can’t abandon the failed hypotheses because Big Pharma has invested billions of dollars in cholesterol drugs, so “professional” associations like the AHA continue to double down on the failed strategy because they don’t want the money spigot shut off.

Similarly, Big Pharma makes a ton of money selling blood pressure pills. Given the state of medical practice in this environment, you will likely be given a handful of pills, each of which has nasty side effects, to control your hypertension.  You need a handful because none of them do a very good job.  Lifestyle interventions, like getting fructose out of your diet, are the real keys to restoring health.

Type II Diabetes

Before the invention of injected insulin, a dietary modification was the primary therapy for diabetes. However, the diet recommendations during that time were completely different from the current low-fat, high-carbohydrate dietary recommendations for patients with diabetes. For example, Dr. Elliot Joslin’s Diabetic Diet in 1923 consisted of meats, poultry, fish, clear soups, gelatin, eggs, butter, olive oil, coffee, and tea, providing approximately 5% of energy from carbohydrates, 20% from protein, and 75% from fat.

Diabetes is a pervasive sickness for which medical science has no cure.  Medical science can be taken to mean no drug will fix the problem.  Too much insulin is a dietary problem and requires a dietary solution.  There is convincing evidence that diabetes can be reversed, and patients can be taken off insulin through nutritional strategies such as fasting (Fung, 2018).  Bariatric surgery results in significant weight loss and remission of diabetes in most patients. Kashyap et al. (2010) observed, “ After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.”

Fung is quick to point out that if the benefit comes from “enforced caloric restriction,” why do the surgery if fasting will do the same thing?  Bariatric surgery is dangerous, fraught with complications, and irreversible.  If you don’t like how you feel when fasting, eat something.  A major takeaway from all this is that diabetes is not the chronic, ultimately fatal condition your doctor likely told you about.  The literature may talk about “remission” rather than using the term “cure,” but I’ll take it.

The idea that a type II diabetic needs any sugar in their diet is ludicrous.  Everyone suffering from this malady should be on some version of a very low carbohydrate diet and get rid of refined sugars completely.


According to the WHO, Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a health risk. A body mass index (BMI) over 25 is considered overweight, and over 30 is obese. The issue has grown to epidemic proportions, with over 4 million people dying yearly from being overweight or obese.  Such high rates of obesity were once considered the plague of rich countries. Still, now it has spread to developing countries as well.  The likely cause is that we have exported the Western diet to the rest of the world.  Industrial sugars and ultra-processed grains have made most of the world fat and sick by this point in history.

Being a fat ass isn’t about looking sexy.  Fat serves a basic human need.  Fat is food storage, like the gas tank on a car.   Cars are better in a way: When you fill the tank capacity, the gas pump will shut off.  You can’t overfill the tank.  Your ass isn’t like that; if you take in too much fuel, you will expand your storage capacity.   When we were tall hunter-gatherers, this wasn’t a big deal.  The big problem was starving to death during hard times, and storing as much fat as possible was the key to survival.  In other words, your body is hardwired to make you fat if you have the available food resources.

Obesity is closely linked to insulin because insulin is the hormone that signals the body to store fat.  When we pour carbs into our bodies every waking hour and insulin levels never drop, we can’t take the fat out of storage.  We burn only glucose and add the balance that we didn’t burn to the fat stores.  We keep getting fatter and sicker by this simple yet overlooked mechanism.  Most doctors, it seems, have forgotten that insulin is a storage molecule.  Fat is simply not available to the body for burning when insulin levels are high.

There is a lot of overlap between obesity and insulin problems.  For example, the CDC tells us that 55% of diabetic patients are obese, and 85% are overweight.  That means some folks are metabolically ill, but the illness doesn’t manifest as obesity.  If obesity is missing in 15% of people, it stands to reason that obesity isn’t the causal agent here.

A significant reason that obesity is associated with insulin is that insulin blocks the function of the satiety hormone leptin.  Rather than the easy (for your doctor) explanations of gluttony and sloth, the lack of a proper leptin response signals to the brain that you are starving and need to eat.  This is the primary reason a fat ass keeps eating vast amounts of food and getting fatter.  It isn’t gluttony (in the moral sense); it’s biochemistry.  This makes it very hard to modify diets in obese people with insulin resistance successfully; They may know intellectually that they should eat less, but every cell in their body is screaming that they are starving and eating should be a top priority.  Suppose you can get insulin levels under control and restore leptin sensitivity. In that case, the weight will start to drop as if by magic.

So why are we all hyperinsulinemic today?  The answer is obviously sugar.

Heart Disease

By this point, it may sound like I’m beating a dead horse by bringing up heart disease.  After all, all of the symptoms of insulin resistance are intricately related.  The correlations are well documented, but the basics of what is causing what is still very murky.  Still, heart disease (aka cardiovascular disease or CVD) is the leading cause of death globally. Older populations are especially vulnerable to CVD, with incidence and mortality rates almost three times higher in those older than 74 years than in younger people.

To beat that dead horse one more time, many diseases attributable to high levels of insulin overlap. People with metabolic syndrome have 50-60% higher cardiovascular risk than those without (Quiao et al., 2007).

When considering a ketogenic diet, you have to replace the missing carbs in your diet with something if you don’t want to be in a caloric deficit.  Most keto advocates point out that the logical choice is fat.  Fat has been much maligned in the last several decades, so this sounds like a terrible idea.  We have a visceral response to the suggestion; we know our arteries will clog up, and we will die if we eat a high-fat diet.

Inflammatory Disease

Hyperglycemia (the fancy name for high blood sugar) activates the body’s inflammatory defense mechanism, causing the release of numerous inflammatory mediators and cytokines, eventually leading to organ damage.  Interestingly, insulin alone is thought to be an anti-inflammatory (Sun & Gao, 2014).  So it seems that the most harmful inflammatory effects occur when sugar levels elevate and stay that way, as with prediabetes and diabetes.  High blood sugar is likely very dangerous long before it is advanced enough to result in a diabetes diagnosis.

A large volume of evidence indicates that obesity is closely associated with an increased risk of metabolic diseases such as insulin resistance, type 2 diabetes, dyslipidemia, and nonalcoholic fatty liver disease (Jung et al., 2014).

Dementia and Depression

Low levels of BDNF go along with impaired glucose metabolism. Decreased BDNF may be a causal factor involved in dementia and depression and type 2 diabetes, potentially explaining the clustering of these conditions in epidemiological studies (Krabbe et al., 2006).  As I’ve pointed out before, correlation can’t be used to infer causation.  We do know that BDNF tends to rise in people who are fasting.

Fatty Liver

Insulin puts all your extra calories into the liver, pancreas, and visceral gut.  These calories start as sugar and are turned into fat by the organs.   This fat isn’t regular fat.  It is metabolically active.  This is commonly recognized as a “beer gut.”  (Sadly, beer has a lot of carbs).  A little bit of this is fine, but noticeable fat in the liver is dangerous.  Fatty liver disease (steatosis) is a common disease caused by having too much fat build up in your liver. A healthy liver contains a small amount of fat. It becomes an issue when fat reaches 5% to 10% of your liver’s total weight.  This can lead to big problems as it progresses.  Cirrhosis of the liver is a result of severe damage to the liver. The scar tissue that replaces healthy liver tissue slows the liver’s functionality. Eventually, it can block liver function entirely.


The causes of metabolic syndrome are complex and reflect several interrelated disturbances of glucose and lipid homeostasis (Fonseca, 2005).  Too much insulin causes good cholesterol to go down and bad cholesterol to go up.  When there are too many (hyper) fat (lipid) particles in the blood, you will be diagnosed with hyperlipidemia.

The triglyceride to HDL ratio predicts CVD way better than LDL alone (an amalgamation of two types, only one of which is dangerous).  Low-fat, high-carb processed foods increase this dangerous ratio.

We should consider some things to help keep us reasonable in this debate.  Humans must consume fat; we fall over dead if we don’t. The word “essential” in nutrition means something that we must consume. The body absolutely must have two essential fats (omega-3 and omega-6) and four fat-soluble vitamins (A, D, E, and K).  All foods containing fat contain all three natural fats (saturated, monounsaturated, and polyunsaturated).

It is impossible to consume unsaturated fat without saturated fat (and vice versa)  in natural food. Saturated fat is not an evil that comes from eating animals, and plants are not some magical source of only “healthy” unsaturated.  All food that contains fat—plant or animal in origin—contains all three natural fats.  It is just the proportions that vary.

What about statins?  The idea of taking statins is to lower LDL (“bad cholesterol”).  Does it keep you from dying?  That depends.  You should probably take statins if you have already had a cardiac event.  If you have not had such an event, the scientific studies suggest it doesn’t do you much good and may not justify the side effects.  A meta-analysis study by Kausik et al. (2010) concluded that “ These data indicate that over an average treatment period of 3.7 years, the use of statin therapy did not result in a reduction in all-cause mortality….”

More and more cardiologists and other healthcare professionals are now saying that blaming cholesterol for heart disease is like blaming firefighters for house fires.  Firefighters are always present at house fires, right?  They must be causing the problem.  You can’t infer causation from correlation.  An alternate explanation is that coronary disease is primarily driven by inflammation (another insulin problem) and that the presence of cholesterol is the body trying to defend itself against the inflammation.

Will eating all the fat from a ketogenic diet cause a rise in cholesterol?  The evidence suggests that the answer is no.  In one study that compared a low-calorie diet with a ketogenic diet, diabetic and non-diabetic participants in the low-calorie ketogenic diet group showed a significant decrease in triglycerides, total cholesterol, and LDL levels. In contrast, the HDL level was significantly increased (Hussain et al., 2012).

The role of cholesterol in heart disease is murky at best.  It is challenging for the average person to sort it out.  What has become apparent is that the standard of practice isn’t keeping up with the science.  LDL is a pretty lousy metric. If your doctor prescribes statins based on that single number, then the decision is based on dogma rather than science.  The scientific literature clearly shows that insulin resistance is a much more powerful predictor of heart disease risk than LDL.  Whether you want to worry about cholesterol is something you should take up with a trusted physician.  But it seems logical to put that battle off until after you’ve gotten firm control over your insulin issues and dealt with immediate concerns like unchecked hypertension.

Sadly, you can’t depend on many doctors to help you sort this out; they all seem obsessed with LDL and pushing pills.  In a way, most doctors have abdicated their responsibility to patients.  They practice medicine like a computer program, where if a number is above a benchmark, then write this prescription.   I think this leads to a situation where we treat what we can easily measure, regardless of its impact on health.  Unfortunately, LDL is straightforward to measure.

High Uric Acid

High uric acid levels have long been associated with gout and kidney problems. There is some compelling evidence that this condition is a nasty one, and it is associated with the other issues of metabolic syndrome. Traditionally, your doctor wouldn’t worry about uric acid levels if you didn’t have gout.  That may change as popular books like Drop Acid shed light on the problem.

Insulin Resistance

Insulin resistance is a physiological decrease in sensitivity to the actions of insulin.  In a sense, I’ve saved the best for last by putting insulin resistance at the end of this list.  It is not “best” in the sense of being good, but because it is the best predictor of why you are so fat and sick.  This book’s central premise is that insulin resistance causes all the other problems on the list.

The precise mechanisms of insulin resistance are difficult to explain; there are many individual differences in who develops it.  After considering the important roles of being a fat ass, age, sex, and race/ethnicity, up to 50% of the individual variability in insulin resistance remains unexplained (Van Cauter, 2011).  However, the vast majority of insulin resistance can be explained logically by the presence 0f too much insulin.  The most straightforward way to lower insulin is to eliminate the signal to the body to create more of it.  That can be accomplished by reducing the amount and frequency of sugars consumed (and, to a lesser degree, protein).

The bottom line is that if we could get our collective shit together and solve the hyperinsulinemia problem, we could rid the modern world of 75% of chronic diseases.  


High Blood Pressure

For the classic view on how to reverse high blood pressure with a plant-based diet and lifestyle modifications, check out the video below:

For a completely different take that aligns with this book, see Dr. Ken Berry’s take on this:

Type II Diabetes

Most doctors will tell you that you can’t cure diabetes.  You can only manage the symptoms until you ultimately die.  Dr. Fung has a different take.  He explains his ideas in the brief video below:

Check out Dr. Fung’s guide to fasting if you want to know a whole lot more about his solution.


I tried to avoid long videos for these “further reading” sections, but the video below is definitely worth the hour of your life to truly understand how to really lose weight and get healthy.

High Uric Acid

High uric acid levels have long been associated with gout and kidney problems. There is some compelling evidence that this condition is a nasty one, and it is associated with the other problems of metabolic syndrome. Traditionally, your doctor wouldn’t worry about uric acid levels if you didn’t have gout.  That may be changing as popular books like Drop Acid shed light on the problem.  


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Last Modified: 01/06/2023


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