Fundamentals
Many individuals experience a subtle yet persistent shift in their vitality, a gradual dimming of the energetic spark that once defined their daily existence. This often manifests as a pervasive fatigue, a diminished drive, or a sense that their physical and mental sharpness has dulled.
These feelings, while common, are not simply an inevitable part of aging; they frequently signal a deeper imbalance within the body’s intricate hormonal communication network. Understanding these internal signals is the first step toward reclaiming optimal function and well-being.
When considering hormonal optimization protocols, particularly testosterone replacement therapy, a key player in the body’s endocrine orchestra is Sex Hormone-Binding Globulin (SHBG). This protein, primarily synthesized in the liver, acts as a carrier for sex hormones, including testosterone and estradiol. Think of SHBG as a specialized transport vehicle, ferrying these vital messengers through the bloodstream.
When a hormone is bound to SHBG, it is largely inactive, unable to interact with target cells and exert its biological effects. Only the “free” or unbound portion of testosterone is biologically active, ready to engage with cellular receptors and drive physiological processes.
For individuals undergoing exogenous testosterone administration, the circulating levels of SHBG become particularly relevant. The goal of such therapy is to restore physiological testosterone concentrations, thereby alleviating symptoms associated with insufficient androgenic activity. However, the effectiveness of this external supply of testosterone is profoundly influenced by how much of it remains unbound and available for cellular use.
If SHBG levels are excessively high, a significant portion of the administered testosterone may become sequestered, limiting its therapeutic impact despite seemingly adequate total testosterone measurements. Conversely, if SHBG levels are too low, the free testosterone fraction might be higher than desired, potentially leading to other considerations.
SHBG acts as a critical regulator of sex hormone bioavailability, determining how much free testosterone is available for cellular action.
The body’s internal systems are not isolated; they operate as a deeply interconnected web. This principle holds true for hormonal health, where metabolic function, liver health, and even inflammatory states directly influence SHBG production and activity. The food choices made each day, the very fuel supplied to the body, possess the capacity to modulate these internal dynamics.
This connection between dietary composition and SHBG levels represents a powerful lever for optimizing hormonal balance, especially for those navigating the complexities of testosterone replacement.
A personalized wellness protocol recognizes that each individual’s biological system responds uniquely. Therefore, a blanket approach to nutrition often falls short. Instead, a precise understanding of how specific macronutrient ratios ∞ the proportions of carbohydrates, fats, and proteins in the diet ∞ can influence SHBG offers a pathway to more refined and effective outcomes. This level of dietary precision moves beyond general healthy eating guidelines, aiming to fine-tune the body’s internal chemistry for superior hormonal support.
Understanding Sex Hormone-Binding Globulin
Sex Hormone-Binding Globulin is a glycoprotein, a protein with attached carbohydrate chains, predominantly manufactured by the liver. Its primary function involves binding to sex steroid hormones, including testosterone, dihydrotestosterone (DHT), and estradiol. The affinity of SHBG for these hormones varies, showing a stronger binding preference for androgens like testosterone and DHT compared to estrogens. This differential binding capacity plays a significant role in determining the relative bioavailability of these hormones.
The liver’s role in synthesizing SHBG means that its metabolic state directly impacts SHBG production. Conditions affecting liver function, such as non-alcoholic fatty liver disease, can alter SHBG levels. The liver acts as a central processing unit for nutrients, converting them into energy, building blocks, or storage compounds. This metabolic activity is intricately linked to the liver’s capacity to produce and regulate proteins like SHBG.
The Bioavailability of Hormones
Hormones circulate in the bloodstream in various forms. A small fraction remains unbound, known as free hormones, which are biologically active and can readily enter cells to exert their effects. A larger portion is loosely bound to albumin, another protein, allowing for relatively quick dissociation and cellular uptake. The most significant portion, however, is tightly bound to SHBG. This tight binding renders the hormones largely unavailable for immediate cellular use.
The dynamic equilibrium between these bound and unbound forms is crucial for maintaining hormonal homeostasis. When SHBG levels are high, more testosterone is bound, leading to lower levels of free, active testosterone. Conversely, lower SHBG levels mean more free testosterone is available. This delicate balance is what makes SHBG a critical biomarker in assessing hormonal status, particularly during exogenous hormone administration.
Why Macronutrient Ratios Matter for Hormonal Balance
The composition of the diet provides the fundamental building blocks and energetic signals that influence virtually every physiological process, including hormone synthesis and regulation. Macronutrients ∞ carbohydrates, fats, and proteins ∞ are not merely sources of calories; they are powerful signaling molecules that interact with the endocrine system in complex ways.
Consider the body as a sophisticated chemical factory, constantly adjusting its output based on the raw materials it receives. The ratio of incoming carbohydrates, fats, and proteins dictates the metabolic environment within this factory. This environment, in turn, influences the production of various enzymes, transport proteins, and signaling molecules, including those involved in SHBG synthesis and regulation.
For individuals undergoing testosterone replacement, optimizing macronutrient ratios becomes a strategic tool. It allows for a more precise modulation of SHBG, aiming to maximize the therapeutic benefit of administered testosterone while minimizing potential side effects. This proactive approach to dietary management empowers individuals to take a more active role in their health journey, moving beyond passive treatment to active biochemical recalibration.
Intermediate
Moving beyond the foundational understanding of SHBG, we now explore the specific clinical considerations and the intricate mechanisms through which macronutrient ratios exert their influence. The body’s metabolic machinery is highly responsive to dietary inputs, and these responses directly impact the liver’s production of SHBG. For those engaged in hormonal optimization protocols, particularly testosterone replacement therapy, a precise understanding of these interactions offers a pathway to enhanced outcomes.
Carbohydrates and SHBG Levels
The role of carbohydrates in modulating SHBG levels is complex, depending significantly on their quality and glycemic impact. Not all carbohydrates are created equal in their effect on the endocrine system. The speed at which carbohydrates are digested and absorbed, leading to a rise in blood glucose, profoundly influences insulin secretion.
High glycemic load and high glycemic index diets, characterized by rapid glucose spikes and subsequent insulin surges, have been consistently associated with lower circulating SHBG concentrations. This relationship suggests a direct link between insulin dynamics and SHBG production.
When the body is frequently exposed to large influxes of simple sugars and refined carbohydrates, the pancreas works overtime to produce insulin, aiming to manage blood glucose levels. This state of chronic hyperinsulinemia can signal the liver to reduce its output of SHBG.
Conversely, dietary fiber, a type of carbohydrate that resists digestion, tends to correlate with elevated SHBG levels. Fiber slows down glucose absorption, leading to a more gradual and sustained release of insulin. This gentler metabolic response may contribute to a more favorable SHBG profile. Including ample amounts of fiber-rich foods, such as vegetables, fruits, and whole grains, can therefore be a valuable strategy in dietary planning for hormonal balance.
High-quality carbohydrates, rich in fiber and low in glycemic impact, tend to support healthy SHBG levels.
For individuals on testosterone replacement therapy, managing carbohydrate intake becomes a strategic consideration. While adequate carbohydrate intake is necessary for energy and metabolic function, prioritizing complex, fiber-rich sources over refined sugars and processed grains can help maintain SHBG within a desirable range, thereby optimizing the bioavailability of administered testosterone.
Dietary Fats and SHBG Levels
Dietary fats, often misunderstood, play a multifaceted role in hormonal health. They are essential for steroid hormone synthesis, as cholesterol serves as the precursor for all sex hormones. The type and quantity of fats consumed can influence SHBG levels, although research findings present a varied picture.
Some studies indicate that a high-fat diet might lead to a decrease in SHBG levels, while a low-fat diet could result in an increase. This observation suggests that the overall fat content of the diet can influence the liver’s SHBG production. However, other research suggests that total fat intake, whether from animal or vegetable sources, might not be a primary determinant of SHBG concentrations. This apparent discrepancy highlights the importance of considering the specific types of fats.
Polyunsaturated fatty acids, particularly omega-3 fatty acids, are known for their anti-inflammatory properties and their role in cell membrane fluidity. These fats may influence the binding of steroids to SHBG, potentially altering the dynamics of hormone availability. While the direct impact of specific fatty acid ratios on SHBG requires further elucidation, a balanced intake of healthy fats, including monounsaturated and polyunsaturated varieties, is generally supportive of overall metabolic and hormonal health.
When considering dietary fats within a testosterone replacement protocol, a balanced approach is prudent. Adequate intake of healthy fats is essential for hormone production and cellular function. The focus should be on incorporating diverse sources of beneficial fats, such as avocados, nuts, seeds, and fatty fish, rather than relying heavily on highly processed or inflammatory fat sources.
Proteins and SHBG Levels
Protein intake holds a significant, and often inverse, relationship with SHBG levels. Research consistently suggests that lower protein consumption is associated with higher SHBG levels, while a higher protein intake can contribute to a reduction in SHBG. This connection is partly mediated by insulin. Protein consumption, particularly from certain sources, can stimulate insulin release. As previously discussed, insulin has an inhibitory effect on SHBG synthesis in the liver.
The quality and source of protein may also play a role. For instance, one study observed that greater animal protein intake was positively associated with estrone and inversely with SHBG in a cohort of girls at puberty onset. While this specific finding relates to a different demographic and hormonal context, it underscores the potential for different protein sources to elicit distinct metabolic responses.
For individuals undergoing testosterone replacement, ensuring adequate protein intake is a foundational dietary strategy. Protein provides the amino acids necessary for tissue repair, muscle synthesis, and numerous enzymatic processes. By supporting a healthy metabolic environment and potentially influencing insulin dynamics, appropriate protein intake can contribute to optimizing SHBG levels, thereby enhancing the bioavailability of administered testosterone.
A well-structured dietary plan for hormonal support often emphasizes a sufficient protein intake at each meal. This approach aids in satiety, supports lean muscle mass, and contributes to a stable metabolic state, all of which indirectly influence SHBG regulation.
Macronutrient Ratio Considerations during TRT
Integrating macronutrient insights into a testosterone replacement protocol requires a personalized strategy. The optimal ratio is not universal; it depends on individual metabolic health, activity levels, and specific therapeutic goals. However, general principles can guide dietary adjustments.
A balanced approach that prioritizes nutrient density and metabolic stability is key. This involves:
- Carbohydrate Quality ∞ Favoring complex carbohydrates with a low glycemic index, such as vegetables, legumes, and whole grains, over refined sugars and processed foods. This helps to mitigate insulin spikes and supports a more stable SHBG profile.
- Healthy Fats ∞ Including a diverse range of healthy fats, such as monounsaturated and polyunsaturated fats, which are essential for hormone synthesis and overall cellular function.
- Adequate Protein ∞ Ensuring sufficient protein intake from high-quality sources to support muscle mass, satiety, and metabolic regulation, which can indirectly influence SHBG levels.
The interplay between these macronutrients creates a synergistic effect on the endocrine system. For example, pairing carbohydrates with protein and healthy fats can slow down glucose absorption, leading to a more modulated insulin response. This integrated approach to dietary planning helps to create an internal environment conducive to optimal hormonal function during testosterone replacement.
Consider the following general guidelines for macronutrient distribution, which can be adjusted based on individual response and clinical monitoring:
| Macronutrient | Typical Percentage of Total Calories | Primary Impact on SHBG (General Trend) |
|---|---|---|
| Carbohydrates (Complex, High Fiber) | 30-45% | Supports stable SHBG by modulating insulin response. |
| Fats (Healthy, Diverse Sources) | 25-40% | Variable, but adequate intake is essential for hormone synthesis; some fats may lower SHBG. |
| Protein (High Quality) | 20-35% | Tends to lower SHBG, partly via insulin stimulation. |
These percentages serve as a starting point, requiring careful titration based on individual metabolic markers, symptom resolution, and laboratory values, including SHBG and free testosterone. The goal is to achieve a state of biochemical recalibration where the body’s systems operate with enhanced efficiency and balance.
Academic
The deep exploration of how specific macronutrient ratios influence Sex Hormone-Binding Globulin levels during testosterone replacement therapy requires a rigorous examination of underlying endocrinological and metabolic pathways. This involves dissecting the hepatic synthesis of SHBG, its transcriptional regulation, and the profound impact of metabolic states, particularly insulin sensitivity and hepatic steatosis. Understanding these molecular interactions provides the clinical translator with the tools to truly personalize wellness protocols.
Hepatic Synthesis and Regulation of SHBG
SHBG is a glycoprotein primarily synthesized and secreted by hepatocytes, the main cells of the liver. The liver acts as a central metabolic hub, and its physiological state directly dictates the rate of SHBG production. The gene encoding SHBG, located on chromosome 17, is subject to complex transcriptional regulation. Several transcription factors are involved in controlling its expression, including hepatocyte nuclear factor 4-alpha (HNF-4α), a key regulator of liver gene expression.
The activity of HNF-4α is highly sensitive to the metabolic environment within the liver. Conditions that promote hepatic lipogenesis, the process of fat synthesis in the liver, tend to downregulate HNF-4α expression. This reduction in HNF-4α activity subsequently diminishes SHBG synthesis and secretion. This mechanistic link explains why conditions like non-alcoholic fatty liver disease (NAFLD) are frequently associated with lower SHBG levels.
Furthermore, various hormones and signaling molecules modulate SHBG synthesis. Thyroid hormones and estrogens generally increase SHBG production by upregulating HNF-4α. Conversely, androgens, insulin, and certain inflammatory cytokines tend to suppress SHBG synthesis. This intricate regulatory network ensures that SHBG levels are finely tuned to the body’s overall hormonal and metabolic status.
SHBG synthesis in the liver is a dynamic process, intricately regulated by metabolic signals and hormonal cues.
Insulin Sensitivity and SHBG Interplay
The relationship between insulin sensitivity and SHBG levels is a cornerstone of metabolic endocrinology. Hyperinsulinemia, a state of elevated insulin levels often accompanying insulin resistance, is a potent suppressor of hepatic SHBG production. While the exact molecular mechanisms are still being elucidated, it is understood that insulin directly inhibits SHBG gene expression in liver cells.
This connection means that dietary patterns that promote insulin resistance ∞ such as those high in refined carbohydrates and sugars ∞ can indirectly lead to lower SHBG levels. When insulin signaling becomes dysregulated, the liver receives persistent signals to reduce SHBG output, regardless of the body’s need for free testosterone. This creates a cascade where poor dietary choices contribute to insulin resistance, which then lowers SHBG, potentially reducing the bioavailability of endogenous or exogenously administered testosterone.
Studies have demonstrated a strong inverse correlation between SHBG and fasting insulin levels, as well as various measures of insulin resistance. Improving insulin sensitivity through dietary interventions, such as reducing glycemic load and increasing fiber intake, can therefore lead to an increase in SHBG levels. This highlights a powerful therapeutic avenue for optimizing hormonal balance during testosterone replacement therapy.
How Do Specific Carbohydrate Types Influence Hepatic SHBG Production?
The impact of carbohydrates on SHBG extends beyond simple glycemic index. The type of sugar, particularly fructose, plays a distinct role. Fructose, metabolized primarily in the liver, can directly induce hepatic lipogenesis. This increased fat synthesis within the liver can then downregulate HNF-4α, thereby suppressing SHBG expression. This mechanism provides a direct link between high intake of added sugars, especially high-fructose corn syrup, and reduced SHBG levels.
Conversely, complex carbohydrates rich in dietary fiber, such as those found in whole grains, legumes, and non-starchy vegetables, promote a more gradual glucose absorption and a milder insulin response. This helps to maintain insulin sensitivity and reduces the burden on the liver, thereby supporting healthy SHBG synthesis. The fermentation of soluble fiber in the gut also produces short-chain fatty acids, which can have beneficial effects on liver metabolism and insulin sensitivity, indirectly supporting SHBG levels.
Dietary Fats and Liver Metabolism
The relationship between dietary fats and SHBG is more nuanced, with conflicting findings in some literature. While some older studies suggested that high-fat diets might decrease SHBG, and low-fat diets increase it, the specific types of fats consumed appear to be more significant than total fat quantity.
Saturated and trans fats, particularly when consumed in excess and in conjunction with high carbohydrate intake, can contribute to insulin resistance and hepatic steatosis. This accumulation of fat in the liver directly impacts SHBG synthesis by influencing HNF-4α activity. The liver’s metabolic burden from excessive or unhealthy fat intake can therefore indirectly suppress SHBG production.
Conversely, monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs), especially omega-3 fatty acids, are generally associated with improved insulin sensitivity and reduced hepatic fat accumulation. These beneficial fats can support liver health, thereby indirectly promoting optimal SHBG synthesis. For instance, the anti-inflammatory properties of omega-3s can mitigate systemic inflammation, which is also known to influence SHBG levels.
The liver’s metabolic machinery, including the expression of genes involved in SHBG synthesis, is highly responsive to the composition of dietary lipids. A diet rich in healthy, diverse fats supports a metabolic environment conducive to balanced SHBG levels, which is paramount for effective testosterone replacement.
Protein Intake and SHBG Regulation
The inverse association between protein intake and SHBG levels is well-documented. This relationship is partly explained by the thermic effect of food and the metabolic pathways activated by protein digestion. Protein consumption, particularly from animal sources, can stimulate a more significant insulin response compared to fats, though less acutely than simple carbohydrates. This insulin surge, as discussed, can suppress SHBG production.
Beyond insulin, the amino acid profile of dietary protein may also play a role. Certain amino acids can influence hepatic metabolism and gene expression. For example, branched-chain amino acids (BCAAs) have been implicated in insulin signaling pathways. While the precise molecular mechanisms linking specific amino acids to SHBG regulation require further investigation, the overall metabolic impact of a higher protein diet appears to favor lower SHBG levels.
For men on testosterone replacement therapy, a sufficient protein intake is not only vital for muscle protein synthesis and overall anabolism but also serves as a strategic dietary lever to modulate SHBG. By ensuring adequate protein, individuals can support a metabolic environment that optimizes the free fraction of administered testosterone, thereby enhancing its biological activity.
The following table summarizes the mechanistic pathways through which macronutrients influence SHBG:
| Macronutrient Category | Key Mechanisms Influencing SHBG | Observed Effect on SHBG |
|---|---|---|
| High Glycemic Carbohydrates (Refined Sugars) | Induce hyperinsulinemia; promote hepatic lipogenesis (fructose); downregulate HNF-4α. | Decrease |
| Dietary Fiber (Complex Carbohydrates) | Improve insulin sensitivity; slow glucose absorption; support gut health and liver metabolism. | Increase |
| Saturated/Trans Fats (Excessive Intake) | Contribute to insulin resistance; promote hepatic steatosis; indirectly affect HNF-4α. | Decrease |
| Healthy Fats (MUFAs, PUFAs, Omega-3s) | Improve insulin sensitivity; reduce hepatic fat; anti-inflammatory effects. | Variable, generally supportive of optimal levels. |
| Protein (Adequate/Higher Intake) | Stimulates insulin release (acute); supports lean mass and metabolic rate; amino acid signaling. | Decrease |
The Interconnectedness of Endocrine and Metabolic Systems
The influence of macronutrient ratios on SHBG is not isolated; it is deeply intertwined with the broader endocrine and metabolic landscape. The Hypothalamic-Pituitary-Gonadal (HPG) axis, which regulates testosterone production, is sensitive to metabolic signals. Insulin resistance, for example, can directly impair testicular function and gonadotropin secretion, further compounding hormonal imbalances.
Chronic low-grade inflammation, often driven by poor dietary choices and excess adiposity, also plays a role. Inflammatory cytokines, such as interleukin-6 (IL-6) and C-reactive protein (CRP), have been shown to influence SHBG levels. Some studies indicate an inverse association between inflammatory markers and SHBG, while others show more complex relationships. This suggests that mitigating systemic inflammation through dietary strategies can indirectly support SHBG regulation.
The liver, as the primary site of SHBG synthesis, is also central to metabolic health. Conditions like non-alcoholic fatty liver disease (NAFLD), which are often driven by dietary factors, are strongly associated with reduced SHBG. This highlights the importance of liver-supportive nutrition in any hormonal optimization protocol.
Consider the following points regarding the complex interplay:
- Insulin Resistance as a Central Driver ∞ The most consistent finding is the strong inverse relationship between insulin resistance and SHBG. Dietary patterns that improve insulin sensitivity ∞ such as those emphasizing whole, unprocessed foods, adequate fiber, and balanced macronutrients ∞ are likely to have a beneficial impact on SHBG.
- Liver Health as a Foundation ∞ Given that SHBG is synthesized in the liver, any dietary strategy aimed at optimizing SHBG must prioritize liver health. Reducing hepatic fat accumulation through appropriate macronutrient ratios is therefore paramount.
- Inflammation’s Modulatory Role ∞ While the precise mechanisms are still under investigation, chronic inflammation can disrupt hormonal signaling and influence SHBG production. Anti-inflammatory dietary components, such as omega-3 fatty acids and antioxidants from fruits and vegetables, can contribute to a more favorable hormonal environment.
The objective in testosterone replacement therapy extends beyond simply normalizing total testosterone levels. It involves optimizing the bioavailability of this vital hormone, which necessitates a comprehensive understanding of SHBG regulation. By meticulously adjusting macronutrient ratios, individuals can exert a powerful influence over their internal biochemical landscape, supporting the liver’s function, enhancing insulin sensitivity, and ultimately maximizing the therapeutic efficacy of their hormonal optimization protocol.
This deep level of physiological understanding empowers individuals to become active participants in their own biochemical recalibration, moving toward a state of sustained vitality and function.
References
- Reed, M. J. et al. “Dietary lipids ∞ an additional regulator of plasma levels of sex hormone binding globulin.” Journal of Clinical Endocrinology & Metabolism, vol. 64, no. 5, 1987, pp. 1083-1085.
- Longcope, C. et al. “Diet and Sex Hormone-Binding Globulin.” Journal of Clinical Endocrinology & Metabolism, vol. 85, no. 1, 2000, pp. 290-293.
- Haemaläinen, E. et al. “Diet and serum sex hormones in healthy men.” Journal of Steroid Biochemistry, vol. 20, no. 1, 1984, pp. 459-462.
- Selva, D. M. et al. “Sex hormone-binding globulin gene expression and insulin resistance.” Journal of Clinical Endocrinology & Metabolism, vol. 91, no. 7, 2006, pp. 2808-2812.
- Simons, G. et al. “The Impact of Macronutrient Intake on Sex Steroids During Onset of Puberty.” Journal of Clinical Endocrinology & Metabolism, vol. 106, no. 12, 2021, pp. e504-e514.
- Pugeat, M. et al. “Sex hormone-binding globulin ∞ pathophysiology and clinical implications.” Endocrine Reviews, vol. 26, no. 4, 2005, pp. 469-491.
- Rosner, W. “Plasma protein-binding of steroid hormones.” Endocrine Reviews, vol. 11, no. 1, 1990, pp. 87-99.
- Wallace, I. R. et al. “The regulation of sex hormone binding globulin.” Clinical Endocrinology, vol. 79, no. 3, 2013, pp. 309-319.
- Hickman, J. R. et al. “Relationship between dietary carbohydrates intake and circulating sex hormone-binding globulin levels in postmenopausal women.” Journal of Clinical Endocrinology & Metabolism, vol. 99, no. 10, 2014, pp. 3721-3729.
- Traish, A. M. et al. “The dark side of testosterone deficiency ∞ II. Type 2 diabetes and insulin resistance.” Journal of Andrology, vol. 33, no. 1, 2012, pp. 27-42.
Reflection
As you consider the intricate dance between macronutrients and your body’s hormonal systems, particularly SHBG during testosterone replacement, recognize that this knowledge is not merely academic. It is a powerful lens through which to view your own unique biological landscape.
Each meal, each dietary choice, represents an opportunity to influence your internal environment, to send specific signals to your liver, your endocrine glands, and your cells. This journey toward understanding your own biological systems is deeply personal, a continuous process of observation, adjustment, and recalibration.
The information presented here serves as a guide, a framework for asking deeper questions about your own health. It invites you to move beyond generic advice and to seek a truly personalized path, one that respects your individual metabolic responses and supports your specific wellness goals.
Your body possesses an innate intelligence, and by providing it with the precise inputs it requires, you can unlock a renewed sense of vitality and function, without compromise. This ongoing dialogue with your own physiology is the true essence of reclaiming optimal health.
Glossary
particularly testosterone replacement therapy
hormonal optimization protocols
free testosterone
shbg levels
liver health
testosterone replacement
hormonal balance
macronutrient ratios
sex hormone-binding globulin
non-alcoholic fatty liver disease
hormone synthesis
metabolic environment
shbg synthesis
individuals undergoing testosterone replacement
biochemical recalibration
testosterone replacement therapy
hormonal optimization
glycemic load
dietary fiber
dietary fats
omega-3 fatty acids
healthy fats
protein intake
amino acids
shbg regulation
insulin response
during testosterone replacement therapy
insulin sensitivity
gene expression
conditions like non-alcoholic fatty liver disease
insulin sensitivity and shbg
insulin resistance
fatty acids
