Why We Treat Insulin Before We Treat the Joint

We treat insulin before the joint. That is because, for a large share of chronic pain patients, insulin resistance is the soil the pain grows in. The same procedure does more and lasts longer once insulin comes down. That is why the first thing we order is often a fasting insulin.

Patients come to a pain clinic expecting to talk about their back, their knee, or their neuropathy. They are often surprised when the first thing we order is a fasting insulin.

That is not a detour. For a large share of chronic pain patients, insulin resistance is the soil the pain is growing in. Treat the joint without treating the soil, and you get what those patients have already lived through again and again. The pain eases for a while, then comes back.

The number most patients are told is fine

The conventional thresholds are familiar. An HbA1c under 5.7% is normal. Between 5.7 and 6.4% is prediabetes. At 6.5% and above, the diagnosis is type 2 diabetes.

Those cut-points are labels, not cliffs in the body. A patient at 6.1% was not well until the moment they crossed 5.7. What really happened was a steady rise in fasting insulin. It often went on for years before the HbA1c moved at all. The pancreas worked harder and harder to hold glucose in the normal range.

That is why we aim lower than the diagnostic cutoff. It is also why we look at fasting insulin alongside HbA1c rather than glucose alone. Insulin moves first. Glucose lags behind. By the time it is abnormal, much of the inflammatory damage is already underway.

We treat this as changing the disease, not as a number to manage. The mechanism linking high insulin to pain is set out in hyperinsulinemia and chronic pain.

Why this belongs in a pain clinic

Body fat is not dead storage. It is a hormone and immune organ. It pumps out signals that drive inflammation all day long. The more visceral fat (belly fat around the organs), the louder that baseline signal runs. We go through that biology in visceral fat and the metabolic problem you cannot see.

A raised inflammatory baseline changes pain directly. It lowers the point at which tissue signals start to hurt. It slows healing. It feeds the central sensitization that keeps pain going after the first problem has healed.

Here is what that means in practice. A shot into an inflamed joint in a metabolically inflamed patient does less, and for less time. The same procedure in a patient whose insulin has come down does more, and lasts longer. That is what we see in clinic, and it sets the order of care. It is why the metabolic work is not an add-on to the pain treatment — it often is the pain treatment.

One more link is worth naming. The overlap between obesity, chronic pain and addiction is no accident. All three run through the same inflammatory and dopamine territory. We wrote about that convergence in addiction, chronic pain and type 2 diabetes share one substrate.

Cerebral blood flow, and why this is not only about joints

Brain imaging with SPECT has reported lower blood flow across many brain regions. It was seen in association with rising body mass. That includes people who are overweight, not just obese. Low blood flow is one of the more consistent warning signs. It tends to show up before memory and thinking slip.

That finding should be read as an association in cross-sectional imaging, not as demonstrated causation. But it fits what we see in clinic. It is part of why we treat metabolic problems hard in patients who come in for pain, not memory. The related mechanism is covered in what untreated chronic pain does to the brain.

The bias problem, in both directions

A point from the video deserves to be repeated plainly. A doctor’s bias about weight affects the care patients get, and it runs in both directions.

Doctors who carry extra weight themselves are less likely to raise the subject at all. Lean doctors who never struggled with it often underestimate how hard the problem is. Their words land as judgment, not help. Both failures end at the same place — the patient does not get useful advice.

The fix is not to pretend the bias is gone. It is to look at it directly and learn the patient’s real situation. And it is to accept that most people did not design the metabolic world they live in.

The food environment is not an accident

The modern American food supply was shaped by policy choices that made sense at the time. Mid-century farm subsidy and distribution programs were built to move calories across a large country. They were built to stockpile against shortage — a goal driven by national security, not nutrition.

That system was tuned for shelf life and efficiency. Long shelf life favors refined carbs and industrial oils, which do not spoil. It does not favor nutrients.

The system is therefore not broken. It is functioning exactly as designed — the design simply did not have today’s problem in view. Seeing that changes the talk with patients. It moves the frame from personal failure to environment. See treating metabolic disease at the dietary root cause.

What that looks like at street level

The argument stops being abstract when the map narrows. The City of St. Louis paid for a household survey covering a nine-square-block area. It found overweight or obesity in very nearly every adult woman surveyed.

Two things need saying about that number. It is a small sample from one specific place, and it is not a figure for St. Louis, for Missouri, or for any group nationally. Anyone quoting it that way is misusing it. And read as what it really is, a snapshot of one neighborhood, it is more damning, not less.

Several hundred adults living within nine blocks of each other did not each reach the same metabolic result through several hundred separate failures of willpower. Something in that place is producing the same result. It is what is sold there, at what price, within what walking distance, on what budget. That is what a food environment is. It is why the talk in the exam room cannot stop at personal advice.

Figure presented by Dr. Padda in a professional educational presentation, sourced to a City of St. Louis household survey.

The inversion, in one comparison

The clearest way to see what changed is to look at why the country first cared about nutrition at all.

In the 1940s, the worry driving federal food policy was that roughly 40% of military recruits were ineligible for service because of malnutrition — they were underweight. Today the figure that disqualifies recruits has flipped: on the order of 70% of Americans cannot qualify for military service, substantially because of overweight and obesity.

Same policy machine. Opposite failure. What we have now is the malnutrition of excess — high in calories, low in nutrients, and everywhere.

The subsidy setup that produced it has not been retired. By Dr. Padda’s account, around 10% of every SNAP dollar is spent on sugar-sweetened beverages — roughly $7 billion a year, which works as a back-door subsidy to the sugar industry. About two-thirds of SNAP recipients are also on Medicaid. So the same public purse pays for the exposure and then for the disease.

What this costs, and where it is heading

The projections presented in the same talk:

• Around 85% of US adults overweight or obese by 2030.
• Roughly 80% of those patients becoming insulin resistant, prediabetic or diabetic.
• Insulin therapy exceeding $800 per month, and about $10,000 per year in total cost per insulin-dependent patient — before renal dysfunction, before dialysis, before anything else downstream.
• Obesity and insulin resistance accounting for somewhere between a third and two-thirds of national healthcare expenditure — on the order of $1.7 trillion a year.

These figures were presented by Dr. Padda in a professional educational presentation to a clinical audience. Projections are projections; the wide band on the expenditure share reflects genuine disagreement about how much disease to attribute to metabolic dysfunction.

There is one more number worth sitting with, because it changes the time frame. Roughly 8% of our genes carry environmental edits — including dietary ones — that persist for life and may carry forward into subsequent generations. If that is right, the food environment is not only a problem for the person eating in it.

That is the case for treating insulin resistance as changing the disease, not as a number to be managed. The damage builds in one direction unless something breaks the chain.

Related treatment: Orthobiologic treatment for knee arthritis explains your options and offers the free knee guide.

Frequently asked questions

My HbA1c is normal. Why are you testing my insulin?

Because insulin rises years before glucose does. A normal HbA1c with a high fasting insulin means the pancreas is keeping up — for now. Catching that stage is the whole point. See hyperinsulinemia and chronic pain.

What does my weight have to do with my back pain?

Less than you would think as a matter of load, and more than you would think as a matter of chemistry. Visceral fat (belly fat around the organs) sends out inflammatory signals. They lower pain thresholds and slow healing, whatever the load. See visceral fat and the metabolic problem you cannot see.

Will treating this get me off pain medication?

It is often part of how that happens. Lowering the inflammatory baseline makes procedures work better and last longer. That is what makes room to cut back on medication. See opioid tapering: medication is a bridge, not a destination. Do not start, stop, or change any medication without consulting your physician.

Is this a weight-loss program?

No. The target is insulin resistance and inflammation, not a number on a scale. Weight often changes as a result, but it is not the goal we track.

For why insulin resistance is the target and how a glucose test misses it, read Insulin Resistance Comes Years Before Diabetes — and Your Glucose Test Will Miss It.

Where can I be evaluated?

Padda Institute, 4477 Woodson Rd, Suite 100, St. Louis, MO 63134, serving the St. Louis region across Missouri and Illinois. Call (314) 481-5000 or text (314) 886-5902.

The office, hours and directions are on our Locations page.

Key takeaways

• Insulin rises years before glucose. A normal HbA1c does not rule out a metabolic problem.
• Body fat is an immune organ, and its inflammatory output changes pain thresholds directly.
• Metabolic treatment makes interventional pain treatment work better and last longer.
• A doctor’s bias about weight hurts advice in both directions and has to be faced openly.
• The food supply was built for shelf life, not nutrition — which shifts the blame off the patient.

This article is educational and is not a substitute for evaluation, diagnosis, or treatment by a physician. Individual results vary. Do not start, stop, or change any medication without consulting your physician.

Medically reviewed by Gurpreet Singh Padda, MD, MBA, MHP — Board Certified in Anesthesiology, Pain Medicine, Interventional Pain Management, Addiction Medicine, and Obesity Medicine. Last reviewed August 2026.

Dr. Gurpreet Singh Padda, MD, MBA, MHP