LOOKING BEYOND THE OBVIOUS - INSULIN RESISTANCE
Looking beyond hot flushes at what is happening underneath, starting with insulin resistance.
One of the things I feel most strongly about, after years in clinic, is looking beyond the symptoms we can see and feel. It’s very easy, especially around menopause, to focus entirely on hot flushes, disrupted sleep, changes in body shape, mood swings, brain fog, or the dreaded “bingo wings.” Those things absolutely do matter, and I’m not dismissing them for a second. But some of the most consequential changes happening during midlife are the ones we can’t see, feel, or catch on a routine GP test.
As oestrogen declines through perimenopause and into menopause, there are parallel shifts happening in bone turnover, muscle mass, insulin sensitivity, cardiovascular health and background inflammation. None of these announce themselves the way a hot flush does. You could feel completely “fine” symptom-wise and still have significant changes unfolding underneath. That’s exactly where preventive nutrition becomes so interesting to me. Rather than waiting until something becomes a diagnosed problem, what can we understand and act on now that shapes our health over the next ten, twenty, even thirty years?
This is the first of six issues where I’ll work through each of these invisible areas properly, one at a time, in the depth they deserve:
Insulin resistance (this issue)
Bone health
Cognitive function
Chronic, low-grade inflammation
Cardiovascular health
Pulling it all together: a midlife prevention framework
WHY INSULIN RESISTANCE, AND WHY FIRST?
Insulin resistance is arguably the most under-discussed of all the “invisible” menopause changes. Inflammation, cardiovascular risk and even cognitive decline are all linked back to how well our cells respond to insulin, so it’s the piece that quietly underpins several of the others, which is why I wanted to start here.
If you read last month’s article on immune resilience, steady blood sugar was one of the four foundations I described. This is the deeper dive I promised.
THE MECHANISM: WHAT’S ACTUALLY HAPPENING
Oestrogen isn’t just a reproductive hormone. It plays a direct, measurable role in how sensitive our cells are to insulin. Oestrogen receptors sit on muscle, liver and fat tissue, and when oestrogen is present in healthy amounts, it supports how efficiently muscle cells take up glucose from the bloodstream, helps regulate how much glucose the liver releases, and influences where the body preferentially stores fat.
As oestrogen falls through perimenopause and menopause, several of these mechanisms shift at once:
Muscle becomes less efficient at glucose uptake. Muscle is normally responsible for clearing the majority of glucose from a meal out of the bloodstream. When this becomes less efficient, blood glucose stays elevated for longer after eating, and the pancreas compensates by releasing more insulin.
The liver becomes less well “braked.” Oestrogen helps suppress excess glucose production by the liver overnight and between meals. With that brake loosened, fasting glucose and fasting insulin can both drift upward, often still within a “normal” range but higher than they would have been for the same woman five years earlier.
Fat distribution shifts toward the abdomen. Visceral fat, the fat stored around the organs rather than under the skin, is metabolically active tissue that releases inflammatory signals and further worsens insulin sensitivity, creating a self-reinforcing cycle.
WHY THIS MATTERS EVEN WHEN YOUR BLOODS LOOK “NORMAL”
This is the part I think is important, and it’s the reason I wanted this to be the opening topic of the whole series: you can have a completely normal fasting glucose or HbA1c on a standard GP blood test, and still have insulin quietly working much harder behind the scenes to keep it that way
WHAT YOU CAN ACTUALLY DO ABOUT IT
The encouraging news is that insulin sensitivity is one of the most responsive things in the body to lifestyle change and, in fact, arguably more responsive than almost anything else we can influence through nutrition.
One thing worth doing regardless: ask about fasting insulin, not just glucose, next time you’re due bloodwork. It’s not routinely offered on the NHS, but you can request it, or it may be included in a private hormone or metabolic panel. I regularly run cardiometabolic bloodwork with clients in clinic where fasting insulin is included, precisely because glucose and HbA1c alone so often miss what’s happening.
Beyond that, it’s largely about what you eat, when you move, and how well you sleep. I’ve put the full practical list below.
TIPS FOR BLOOD SUGAR MANAGEMENT
So whether the driver is menopause-related oestrogen decline or an underlying PMOS picture, the practical strategies for improving insulin sensitivity are largely the same. These are the strategies I rely on most in clinic.
1. Change the order you eat your food, not what you eat
Eating vegetables and protein before the starchy or sugary part of a meal, rather than mixing everything together or eating carbohydrates first, has been shown to meaningfully blunt the resulting blood sugar spike, using exactly the same plate of food. In practice: eat your salad or vegetables first, then your protein, and finish with the rice, pasta, bread or potatoes.
2. Walk after your largest meal
A 10 to 15 minute walk after eating, even a gentle one around the block or up and down the stairs a few times, activates muscle glucose uptake directly, independent of insulin, and can significantly lower the post-meal blood sugar peak. This is one of the highest-return, lowest-effort tools available, and it doesn’t need to be a “workout.”
If you’re desk-bound, seated soleus (calf) raises are a great alternative. Research from the University of Houston found this simple seated movement can meaningfully reduce post-meal glucose and insulin spikes. It’s most effective done steadily over a longer stretch, so where you can, aim for at least 20 to 30 minutes continuously at your desk rather than a few quick reps between emails.
3. Don’t eat carbohydrates alone
Pairing any carbohydrate with protein, fat or fibre slows gastric emptying and the resulting rate of glucose absorption. Toast alone, or with butter and jam for example, tends to spike blood sugar quickly and sharply; toast with eggs or a nut butter still raises it, but more gradually and to a lower peak, and it’s often no more effort to prepare.
4. Prioritise protein and fibre at every meal, breakfast especially
I expand on this further below, as it’s such a key point. Breakfast is where most people’s blood sugar strategy quietly falls apart before the day has even started.
5. Build and maintain muscle through resistance training
Aim for some form of resistance or strength training at least twice a week. Muscle tissue is the primary site where glucose is cleared from the bloodstream after a meal, and more muscle mass directly translates to better glucose disposal capacity. It is one of the most protective things you can do for long-term insulin sensitivity, alongside everything it does for bone density (more on that in next issue’s bone health deep-dive). I encourage all my midlife female clients to include some resistance work and regular strength training in their week.
6. Protect your sleep
Even a single night of poor or shortened sleep measurably reduces insulin sensitivity the following day. The research on this is solid, and it matches exactly what I see with clients in clinic. Sleep isn’t a wellness extra when it comes to blood sugar; it’s one of the actual drivers.
7. Manage stress deliberately
Cortisol, the primary stress hormone, directly raises blood glucose by stimulating glucose release from the liver. Chronic stress means chronically elevated cortisol, which means a constant upward pressure on blood sugar that no amount of “eating well” can fully offset on its own. Even a few minutes of deliberate downregulation, whether that’s breathing exercises, a short walk outdoors, or stepping away from a screen, genuinely counts.
8. Consider trying a continuous glucose monitor (CGM) for a short period
You don’t need to be diabetic to use one. Wearing a CGM for two to four weeks can be genuinely eye-opening, showing you in real time exactly which of your usual meals, food combinations and habits are driving the biggest spikes, so you can make targeted changes rather than guessing.
BRINGING IT TOGETHER
You don’t need to do all eight at once. Choose the one or two that fit your life right now, and let them become ordinary before adding more.
We are all different, and sometimes it helps to look beneath the surface. If you’d like to understand your own insulin picture, including fasting insulin, you can book via my contact page here.
REFERENCES:
The role of estrogens in control of energy balance and glucose homeostasis.
Skeletal muscle insulin resistance is the primary defect in type 2 diabetes.
Increased visceral fat and decreased energy expenditure during the menopausal transition.
Food order has a significant impact on postprandial glucose and insulin levels.
The efficacy of soleus push-up in individuals with prediabetes: a pilot study.