The Metabolic Chain: Where Did It All Start? Insulin Resistance, Diabetes, MASLD, High Triglycerides

Chapter 5 · Vihang Rahul Vasa

The Real Beginning: Where Diabetes Actually Starts

For many years, I believed that diabetes was the starting point of everything: high plasma glucose (blood sugar) came first, and then slowly damaged the liver, the kidneys, the heart. But after years of reading, asking questions, and consulting Prof. Michal Vrablík of Charles University, Prague (see Appendix A), I now understand the picture is very different, and much more interesting.

Diabetes is not the starting point. It is one of the results.

Let me explain this in the simplest way I can.

The Story of Stored Fat

Think of your body like a household. When you eat more than you need, the extra energy must be stored somewhere: just like a household stores extra rice in the storeroom when there is surplus. The body’s natural storeroom for fat is right under your skin: that is why some people gain weight on the arms, thighs, or hips. This kind of fat, in its right place, is generally not considered dangerous. It is a normal part of how the body stores energy.

But what happens when the storeroom is full? The fat has nowhere to go: so it begins to spill over and settle in places it was never meant to be. It settles in the belly, around the organs. It settles in the liver. It settles around the heart and kidneys. Doctors call this “ectopic fat”, which simply means “fat in the wrong place.”

This is where the problem begins.

Why “Fat in the Wrong Place” Matters

When fat settles in the wrong organs, those organs slowly stop working properly. The liver becomes fatty, this is what we call MASLD (Metabolic dysfunction–associated steatotic liver disease, liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance). The pancreas, which makes insulin, becomes sluggish. The muscles stop responding to insulin properly. This is called insulin resistance: the body still has insulin, but the cells refuse to listen to it.

And once insulin resistance sets in, plasma glucose (blood sugar) starts climbing. That is when Type 2 Diabetes appears.

So you see: diabetes did not start with high plasma glucose (blood sugar). It started years earlier, quietly, with fat being stored in the wrong places.

MASLD and Diabetes: Brothers, Not Father and Son

This is something I want every reader to understand clearly:

MASLD (Metabolic dysfunction–associated steatotic liver disease: liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance) and Type 2 Diabetes are not father and son. They are brothers: born from the same parent. That parent is insulin resistance, caused by fat stored in the wrong places.

This is why, in Indian populations, roughly two out of every three people with Type 2 Diabetes also have fatty liver, not because diabetes caused the liver to become fatty, but because both conditions came from the same underlying problem. They walk hand in hand. They feed each other and make each other worse over time.

This also explains why managing your diabetes alone is not enough. You must also pay attention to your liver, your blood pressure, your cholesterol, your kidneys, and your heart, because they are all part of the same metabolic family. Doctors today use a new term for this connected family of problems, “cardio-reno-metabolic”, meaning the heart, kidneys, and metabolism are all linked. Trouble in one area silently affects the others.

And What About Inflammation?

For a long time, I believed inflammation was the starting point of all this trouble. But after careful study, I now understand that inflammation is not the cause: it is a consequence. Once fat starts settling in the wrong organs and insulin resistance sets in, the body’s defence system gets agitated and creates low-level inflammation everywhere. This inflammation then makes everything worse, like adding fuel to a slow fire. But it is not where the fire started.

The Indian Story: Why We Are More Vulnerable

Here is something fascinating. For thousands of years, our ancestors lived through cycles of feast and famine. Scientists believe the bodies that survived were those that could store every calorie efficiently for the lean times. These “thrifty” genes, the theory goes, were a great blessing then. This is a theory, not a proven fact, but it is a useful way to understand what follows.

But today, in an age of processed food, a sedentary lifestyle, and constant stress, those same genes have become our enemy. They make us store fat too easily, develop diabetes faster, and at lower body weights than Western populations. That is why a thin Indian can have diabetes while a heavier Western person may not. This is a pattern to understand, not a rule: many thin Indians never get diabetes. It is not laziness or weakness: it is our genetic story meeting the modern world.

The Good News

The most important thing I want you to understand is this:

Your genes set the tendency. Your lifestyle decides the outcome.

You can navigate this through careful lifestyle choices: what you eat, how you move, how you sleep, how you manage stress. It is not easy. It takes effort, every single day. Sometimes it feels exhausting and impossible to keep up.

But it is the most powerful medicine you have. And unlike any tablet, it has no side effects: only benefits.

How It Usually Unfolds

In modern lifestyles, too many calories, too little movement, poor diet, the body slowly develops insulin resistance. Here is one common pathway, a simplified picture of what is often seen:

• Step 1: Insulin resistance begins silently: Cells stop responding properly to insulin. There are no symptoms. Plasma glucose (blood sugar) may still appear normal on a routine test.

• Step 2: Fat metabolism becomes abnormal: Blood triglycerides begin to rise. Fat starts collecting in the liver, MASLD (Metabolic dysfunction–associated steatotic liver disease, liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance).

• Step 3: Compensation phase: The body produces more and more insulin to keep plasma glucose (blood sugar) normal. Outside, you feel fine. Inside, your pancreas is working overtime.

• Step 4: Breakdown phase: Over time, the pancreas cannot keep up. Insulin production starts to fail. Plasma glucose (blood sugar) begins to rise. This is when Type 2 Diabetes is diagnosed.

Why MASLD Is Now in Focus

MASLD (Metabolic dysfunction–associated steatotic liver disease: liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance) has always existed. Three things have changed. It has become far more common, because we eat more and move less. It has become easy to find, with ultrasound, Fibroscan and Magnetic Resonance Elastography (MRE) (see Chapters 7 to 9). And doctors now see it as an early warning of metabolic trouble: often showing up years before diabetes itself is diagnosed. That is why your liver deserves the same attention as your plasma glucose (blood sugar).

Why the Order of Diagnosis Varies

Different people are diagnosed at different stages, depending on which test is done first: some discover MASLD (Metabolic dysfunction–associated steatotic liver disease: liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance) through an abdominal scan; some find high triglycerides through a routine lipid profile; some are diagnosed with Type 2 Diabetes through a plasma glucose (blood sugar) test. The order does not matter. What matters is this: if you have any one of the three, ask your doctor to check for the other two, and keep watching all three. Managing one without watching the others is like fixing one damaged leg of a three-legged table.

A Final Word

This whole process usually has no symptoms in its early years, so routine check-ups are how it gets caught in time. Caught early, and with disciplined lifestyle changes under medical guidance, it can be managed and in many cases slowed or held back. Lifestyle changes should always be made with your doctor’s guidance: intensive exercise, fasting, or dietary restriction may not be suitable for everyone. Make preventive yearly tests a habit. The body is remarkably forgiving when you give it the chance to heal, and a routine check-up is how you give it that chance.

(References for this chapter, the link between insulin resistance, Type 2 Diabetes and MASLD, and the Indian MASLD consensus and prevalence studies, are listed in Appendix A and B.)

Illustration: Chapter 5 illustrated summary. Connected metabolic health: insulin resistance, fatty liver, cholesterol and triglycerides, and Type 2 Diabetes are linked.

Chapter 5 Connected metabolic health: insulin resistance, fatty liver, cholesterol and triglycerides, and Type 2 Diabetes are linked. The illustration connects the liver, pancreas, heart, arteries and kidneys.

Chapter at a glance: an AI-generated illustration to be read with the chapter, not instead of it. The people shown are not real.