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HOMA-IR: A Test of Insulin

Resistance + Ways to Decrease It
Medically reviewed by Ognjen Milicevic, MD, PhD, Puya Yazdi, MD | Written
by Biljana Novkovic, PhD | Last updated: January 15, 2021

C ONTE NTS

HOMA-IR tells you how much insulin your body needs to

keep your blood sugar levels in check. This test was
designed to measure insulin resistance, an early stage
of type 2 diabetes that increases your risk of many
chronic diseases. Read on to learn about what causes
high HOMA-IR and how to improve insulin resistance
with lifestyle and dietary modifications.

Insulin Resistance

Your blood sugar (glucose) levels may be normal, but if your

insulin levels are high, your body is likely struggling to maintain
blood sugar levels in balance.

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When cells no longer respond to insulin, your body needs to

release more insulin to control blood sugar levels. This
condition is called “insulin resistance” [1, 2].

Insulin is the hormone pancreas releases after you eat and it

signals an abundance of energy in the body. Insulin lowers
blood sugar by increasing its uptake and storage in tissues.
Muscles take up 60-70%, the liver about 30%, and fat tissue
around 10% of sugar from the blood [3, 1, 2].

What is HOMA-IR?

HOMA-IR (Homeostatic Model Assessment of Insulin

Resistance) tells you and your doctor how much insulin your
pancreas needs to make to control your blood sugar levels [4].

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HOMA-IR was developed in the 80s and is an indirect measure:

it is calculated from your fasting glucose and fasting insulin
levels. While it might not be the best model overall, it’s still the
most widely used model in clinical research [5, 6, 7].

Other recently-developed indirect measures of insulin

resistance include HOMA2, QUICKI, and the triglyceride/HDL
ratio [4].

Measuring insulin resistance directly is impractical, complicated,

and doctors rarely use it (the method is called hyperinsulinemic-
euglycemic glucose clamp) [1, 3].

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Normal Range

Different studies provide slightly different ranges for HOMA-IR.

But they all agree that the higher your HOMA-IR gets, the
more insulin resistant you are.

Generally, you have optimal insulin sensitivity if your HOMA-IR is

less than 1. Levels above 1.9 signal early insulin resistance, while
levels above 2.9 signal significant insulin resistance.

High HOMA-IR

If your HOMA-IR is high, your body is using more insulin than

normal to keep your blood sugar in balance. The higher the
number, the more resistant you are to insulin. Your doctor will
interpret your HOMA-IR in conjunction with your signs and
symptoms, medical history, and other test results.

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Insulin resistance is one of the symptoms of metabolic

syndrome and an early stage in developing type 2 diabetes.

Causes

In most “healthy” people, insulin resistance is mainly caused by

two factors: overeating and lack of physical activity. Eating too
much and being inactive can cause a buildup of fat in the liver
and muscles, which makes these tissues less responsive to
insulin [8].

Other causes of insulin resistance include stress, pregnancy,

and various disorders and diseases. Causes listed below have
been associated with higher insulin resistance levels. Work with
your doctor or another health care professional to get an
accurate diagnosis.

1) Overeating/Nutrient Excess

Chronic excessive overeating increases oxidative stress and

low-grade inflammation in the body [9, 10, 11].

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Studies have shown that an excess of glucose and protein lead

to insulin resistance in the muscles, while saturated fat
increases insulin resistance in the liver [12, 13].

When 6 healthy men were fed a diet of over 6,000 kcal/day,

they gained 3.5 kg on average in a week and developed insulin
resistance after only 2 – 3 days [14].

In another study, palm oil, which is high in saturated fat,

increased insulin resistance by 25% in 14 people (15% in the liver
and 34% in fat tissue) [13].

2) Obesity

Obesity is the most common cause of insulin resistance and

type 2 diabetes. Simply by being overweight (BMI >25), you
have a 3 times higher risk of developing type 2 diabetes [15,
16].

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In two studies with over 3k children and 137 adolescents, being

overweight or obese was persistently associated with higher
HOMA-IR [17, 18].

However, not all fat tissue is created equal. While the amount of
fat in the body does correlate with insulin resistance, how that
fat is distributed is more important.

Fat around internal organs, also known as belly fat or visceral

fat, increases your risk of insulin resistance and type 2
diabetes. Fat underneath the skin, known as subcutaneous fat,
decreases the risk [2, 15].

3) Sedentary Lifestyle/ Physical Inactivity

Early insulin resistance occurs rapidly after short-term

physical inactivity (1-7 days). Inactive muscles are probably the
primary cause, but the exact mechanism is still unclear [19].

In a study of over 3k children, lower physical activity was

associated with higher HOMA-IR [17].

Sitting for long periods of time without getting up was linked to

higher insulin resistance in a review of 3 studies with a total of
62 people. The higher the insulin resistance, the more the
people benefit from interrupting long sitting periods with
regular, brief activity breaks [20].

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4) Stress

Activation of the stress response, also known as the

hypothalamo-pituitary adrenal (HPA) axis, increases cortisol,
which impairs insulin function [3].

In 766 workers, job-related stress was significantly associated

with insulin resistance. What’s more, those with higher cortisol
levels had higher HOMA-IR [21].

Work-related stress was associated with increased HOMA-IR in

another study of 366 patients with polycystic ovary syndrome
(PCOS) and 325 controls. Additionally, higher HOMA-IR
increased the risk of PCOS [22].

Research has shown that stress also causes insulin resistance in

severe illness [3].

5) Not Enough or Too Much Sleep

Most people need 7-8 h of sleep per night for optimal health.
Getting more or less than you need may be detrimental. For
example, both shorter and longer sleep duration were
associated with higher insulin levels in a study with over 2.8k
people [23, 24].

In 245 high school students, those who slept less during the
night had higher HOMA-IR [25].

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In the short term, lack of sleep increases blood sugar levels by

activating the stress HPA axis and increasing cortisol. In the
long term, chronic sleep deprivation triggers insulin
resistance [3, 26, 23, 27].

In 5.8k people, excessive daytime napping was linked with

higher HOMA-IR [28].

6) Sleep Apnea

Researchers found that people with obstructive sleep apnea are

at an increased risk of insulin resistance and diabetes [29, 30].

According to a meta-analysis of 16 studies, people with sleep

apnea have higher HOMA-IR than healthy people [31].

In sleep apnea, overactivation of the HPA axis impairs insulin

function. Lack of oxygen may also contribute by increasing
inflammation, especially in fat tissue [3, 30].

7) Starvation

Insulin resistance develops within 2-3 days of starvation [32, 33,

34].

That is why some initially obese individuals can develop

diabetes on crash diets when they adopt strenuous weight-
reduction regimens [35].

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8) Muscle Damage Due To Exercise

In general, exercise beneficially affects insulin resistance and

HOMA-IR [36, 37].

But this isn’t the case if you exercise too much or incorrectly,
which can both cause muscle damage and inflammation [38].

Muscle damage is typical after eccentric repetitive activity such

as running or walking downhill. Your muscles are suddenly
forced to stay contracted over an extended period of time [39].

When 12 healthy women ran downhill for 45 minutes, their

insulin and HOMA-IR levels went up and stayed high throughout
the recovery period of 1-4 days [40].

This doesn’t mean you shouldn’t do eccentric exercise, but

keep in mind how it affects your insulin production and avoid it
before testing.

9) Hypothyroidism and Hyperthyroidism

Thyroid hormones are important for overall metabolism,

including blood sugar control.

Both high (hyperthyroidism) and low (hypothyroidism) thyroid

hormone levels disrupt insulin function. In hyperthyroidism,
insulin resistance in the liver disrupts glucose balance; in
hypothyroidism, the culprit is insulin resistance in the muscles
and fat tissue [41, 42, 43].

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A study of 60 people revealed that even those with mild

hypothyroidism (TSH ≤ 9.9 µIU/ml) can have higher insulin levels
and HOMA-IR [44].

10) Pregnancy

Insulin resistance increases during the course of a normal

pregnancy, reaching its peak in the third trimester [3].

In excess, insulin resistance in pregnancy can lead to

gestational diabetes [3].

In addition, insulin resistance can spike in subsequent

pregnancies. Insulin levels and HOMA-IR increased with
multiple pregnancies in a study that compared 100 women in
their first pregnancy and 100 women with multiple pregnancies
[45].

11) Pollution

Compounds called persistent organic pollutants (POPs) can

contribute to the development of insulin resistance and type 2
diabetes [46].

POPs can be found in pesticides, insecticides, fungicides, flame

retardants, paint, plastics (PCBs), etc.

Studies have found that workers who are regularly exposed to

these chemicals are more likely to develop diabetes [47, 48, 49].

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In a larger study of 2k adults, diabetes was strongly associated

with higher blood levels of six different POPs [50].

12) Genetics

Although insulin resistance is mainly an acquired condition,

your genes can make you more susceptible [1, 30].

How do we know this? Scientists found that people who

develop insulin resistance often have a history of type 2
diabetes in their families [30].

In addition, certain populations are more at risk than others.

Studies have found that in the US, black Americans and Pima
Indians have a higher risk of insulin resistance than whites. In
Asia, Indians and the Chinese are at high risk of insulin
resistance [30].

13) Aging

Insulin resistance is more common in seniors [30, 51].

This is, in part, because people get more belly fat and become
less active as they age. Additionally, your energy requirements
decrease as you age, making overeating more likely. But
additional factors, such as increased oxidative stress and
impaired mitochondrial function, may also play a role [30, 8].

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14) Diseases of the Pancreas

Insulin levels can increase in people with an enlarged pancreas

(pancreatic beta cell hyperplasia) [52, 53].

In addition, insulin levels increase in insulinomas, which are

mostly benign pancreatic tumors [54, 55].

15) Hormonal Disorders

Hormonal disorders can disrupt normal glucose metabolism.

For example, insulin levels increase in acromegaly, a disease in

which there is an overproduction of growth hormone [56].

Insulin also increases in Cushing’s syndrome, due to the excess

of cortisol [57].

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16) Other (Rare Disorders)

Insulin resistance is a major feature of some rare inherited or

acquired disorders, such as [3]:

Down’s Syndrome
Turner’s Syndrome
Klinefelter’s Syndrome
Thalassaemia
Hemochromatosis
Lipodystrophy
Progeria
Huntington’s
Myotonic dystrophy
Friedrich’s ataxia
Laurence-Moon-Biedel syndrome
Glycogen storage diseases type I & III
Mitochondrial disorders

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Health Effects

Scientists generally agree that insulin resistance can increase

the risk of developing [1, 3]:

Diabetes
Metabolic syndrome (including high blood pressure and
high cholesterol)
Heart disease
Liver disease
Polycystic ovary syndrome (PCOS)

1) Diabetes

The major consequence of insulin resistance is eventually

developing type 2 diabetes.

Insulin resistance precedes the development of diabetes by

10 to 15 years [1].

2) Metabolic Syndrome

Insulin resistance can precede a cluster of health problems

called “The Insulin Resistance Syndrome” or “The Metabolic
Syndrome” [58, 3, 30]. These include:

High blood pressure

High blood sugar
Excess belly fat
High bad cholesterol/low good cholesterol
High triglycerides

In a study with over 2,300 people, those with higher insulin

resistance at baseline had more than a 5 times greater risk of
developing metabolic syndrome 5 years later [59].

In another study that monitored 3,400 people over 20 years,

those with the highest insulin levels and HOMA-IR had a much
greater risk of eventually developing high blood pressure [60].

3) Heart Disease

According to a meta-analysis of 9 studies with over 22,000

people, those with higher fasting insulin were at an increased
risk of heart disease [61].

In addition, in a study that followed 2,500 people over 20 years,

the highest HOMA-IR values were associated with an almost
discount
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