#096 – Casey Means, MD (Levels): Continuous Glucose Monitors, Blood Sugar And Inflammation, Insulin Resistance, Metabolic Fitness, Healthy Blood Sugar Ranges, Diabetes Prevention, And More!

In this episode of the Melanie Avalon Biohacking Podcast, Dr. Casey Means gets into the technical details of how metabolism works and what we can do to improve it. She explains the science behind CGMs, the glucose ranges that we should be aiming for, and why the truth about diets means everyone can benefit from biowearables like Levels.

Micro-decisions impact health

It’s sometimes easy to forget that big-picture health is shaped by small everyday decisions that accumulate over time.

I saw in my patients that so many of them that were dealing with chronic ENT disorders, were also dealing with other issues of metabolism. So things like obesity and diabetes and many of the other sequella that are associated with, insulin resistance and poor glucose control, things like liver disease, chronic kidney disease, depression, anxiety, brain fog. There’s so many things that are linked to metabolic disease and I was seeing a lot of this in my patient base, but also noticing how people who had poor metabolic function did worse after surgery. Wounds don’t heal as well when your blood sugar is not controlled and you just have trouble bouncing back. So it was very important to me to address this and think about this more deeply. Really what it comes down to is improving and moving the needle on metabolic function really has to do with behavior change. It has to do with changing the hundreds of micro-decisions we’re making every day.

How CGMs work with Levels

By partnering existing health tech with an innovative app, Levels allows you to both see and understand your blood sugar levels.

This technology of glucose monitors, otherwise known as CGMs, this is actually been around for over 10 years. And like you said, this is a technology that has been traditionally used for individuals with diabetes. This is a prescription-only FDA-approved device for the treatment of type one and type two diabetes. What it is, is it’s a tiny wearable sensor. You can kind of think of it like Fitbit for glucose. So you’re sticking this quarter-sized sensor on the back of your arm and it’s got a tiny little, four-millimeter hair-like probe that goes just under the skin painlessly and it is tracking glucose for anywhere from between every five and 15 minutes. Those data points are being sent to your smartphone, so you can see a continuous reading of this internal biomarker, which is fascinating because for sleep monitors, activity monitors, stress monitors that are looking at heart rate and HRV and things like that, these are not internal biomarkers, not things inside our body. These are more just transmitted through the skin. So this is an internal biomarker that you’re sensing painlessly 24 hours a day and getting this super-rich data stream.

People are eager to improve their lives

Interest in Levels has demonstrated that people aren’t just interested in being healthy when the New Year hits on January 1st. They are eager to improve year round.

People are really interested, even people without diabetes in understanding their metabolism and you see this with the keto movement and you see this with non-diabetic individuals starting to prick their fingers so that they can better understand sort of where they sit on the metabolic health spectrum because we know that so much now that the way glucose impacts insulin and other hormones in the body and the way other hormones like cortisol affects our glucose, all these things are so interrelated. If we stabilize and manage our glucose, we have this huge opportunity to really just up-level our current lives in so many ways, improve our energy, improve our mood, improve our cognitive performance, our memory, our athletic endurance, and of course, help prevent this movement towards so many of the chronic conditions down the roads that are associated with dysregulated blood sugar.

Levels completes the “heath stack”

Today, there are many pieces of tech that can help better inform your health and tailor your lifestyle for the better, and Levels in the first to close the loop on nutrition.

For this wider population, this is really completing that health stack. We’ve had stress sleep activity monitors, but we’ve never had a real-time wearable sensor that closes the loop on nutrition. That has not existed. The best we’ve had is like maybe six months from now, you’ll get a fasting glucose level or you’ll get a cholesterol check or maybe a weigh yourself the next morning, but there’s not really a closed loop between those outcomes and the exact thing that you did to cause them. So now, we do have that. We have that really close loop biofeedback for nutrition. So it’s just a super exciting time to bring this technology to a much wider population and pair it with intelligent software that really parses out the drivers of glucose control, and then helps people move in the right direction and consistently.

Glucose values to aim for

Data shows that a healthy range is likely somewhere from 71-120, despite the fact that published resources list higher numbers.

These are the studies where they’ve put CGMs on healthy populations and just looked at 24 hour patterns. And what you see in that research is that healthy people without diabetes will with CGMs on, will typically spend about 92% of their day between a glucose values of 70 and 120. So that sort of starts tightening up the range a little bit, that likely you want to be between about 70 and 120. So for levels, customers, this is really what we encourage people to shoot for. Don’t just shoot for below 140 after meals. Probably we should be shooting for more like 70 to 120. For fasting glucose, there’s been some really interesting research sort of breaking down this normal range of less than a hundred milligrams per deciliter, fasting glucose being normal. And what you actually find is that people in the lower range of normal do much better than the people in the higher range of normal. So people who have fasting glucoses between really about 70 and 85 have much lower risk for future diabetes, future heart disease, other health conditions than people whose fasting glucose is between 85 and a hundred, which is also considered normal by our standard criteria.

Glucose after a meal

Swinging through the drive-through can shoot your glucose up by hundreds of points. But on a typical day, you only want your glucose to rise about 15 points.

After a meal, we don’t want to see our glucose go up more than about 15 points. So kind of a little gentle rise and then back down, but what a lot of people find when they start taking their glucose is that some of their favorite foods might spike their glucose 80 points, a hundred points. We’ve seen people eat normal oatmeal and their glucose goes up literally 80 to a hundred points. Our CEO had a Chick-fil-A sandwich and a soda and his blood glucose went up to 210. So there are lots of foods that we just consider are quote, unquote, normal that don’t even keep us remotely in that range that I’m talking about. So what is next is to now that we are thinking more about metabolic health for the general population, we need to be doing more research to understand what ranges are associated with best current physical and future physical performance, and then of course, risk for future disease. And I would guess that we’re going to see that it’s these tighter ranges that we should shoot for.

Get your glucose into shape

Just like going to the gym, it can take time and effort to get glucose to a healthy level.

What we really focus on at Levels is improving metabolic fitness, which we like to think about it like going to the gym. It’s like you put in your reps to get stronger at the gym and you have to put in your reps to get more metabolically fit. And how do you put in the reps? Well, you decrease your glucose spikes day after day and each day that are minimizing your glucose spikes, your cells are seeing less insulin. And so they are going to perk up to future insulin signals. And so your body’s going to have to produce basically less of it to get the same amount of sort of bang for your buck and get the glucose in. So each day that we’re keeping those spikes minimized, we are letting the cells hear the signal of insulin more loudly, and ultimately regain our insulin sensitivity. It’s not something that happens overnight. It’s something that is going to potentially take weeks and months to really get those pathways back on track.

The truth about diets

A major study showed that when two individuals ate a cookie and a banana, they may have very different responses. This means that diet must be customized to the individual.

Two people like you and I, we could both eat the banana and the cookie and I could be a huge spiker on the banana and no spike on the cookie. And you could be the opposite. It’s just crazy because it flies in the face of the whole low-glycemic diet concept where we have this standardized chart and we should all follow it because we’re all going to have the same glucose rise with these foods. And this really showed that there might be so much more to it than that. And it’s painful to think that there might’ve been people who are following these diets very strictly and did not see the progress they wanted to. And it might’ve been because of these underlying factors that just for whatever reason changed the way that carbohydrate was processed in their body into glucose. And that super excites me about the future of personalized wearables.

Transformation requires education

Once people understand the different levers of health and how they can best control them, they can embark on a path of improved metabolic flexibility.

My mission as a physician is to help people understand these different factors and build as many of those into our product and our software. How can we educate people about sleep, stress, exercise, food pairing, food timing, even micronutrients, environmental exposures, all into one app that just helps people understand the comprehensive nature of metabolic health. And while food is a key driver in our metabolic outcomes, it is necessary, but not sufficient for metabolic health. You have to have these other ducks in a row as well. And so that’s really my mission in trying to build a software product that queues people into all these different aspects that ultimately feed into our metabolic health.

The 1-month plan for Levels

If you experiment with Levels for just one month, the team recommends a week of normal eating, followed by experimentation and then optimization.

I think that’s pretty fascinating the first week is just like try not to modify the diet and just eat what you normally eat and make some observations there. Then moving into the second and third week, it’s really about experimentation. So what happens when you’ve had a good night of sleep versus a bad night of sleep? What happens when you do yoga versus high-intensity interval training? What happens if you add a lot of fat to your carbohydrates versus no fat? What happens if you take berberine? What happens if you take an apple cider vinegar shot before your meal, which in many studies has been shown to lower glycemic responses. Like what happens if you had cinnamon to your oatmeal instead of no cinnamon, which cinnamon is shown to be an insulin synthesizer, try these different things. And also I really suggest try, you know, walking after meals and see what that does. And that’s really just like exploratory, and we have some challenges that we can, you know, guide people with too sort of help them create these experiments for themselves. And really just start to see how these other factors are impacting the response. And then fourth week I would really move into optimization phase. So take what you’ve learned from your experiences and just try and keep it flat and stable. So that’s really the time to see how much you can move the needle with everything that you’ve learned.

Dr. Casey Means: It’s a tiny wearable sensor, and it’s got a little probe that it was just under the skin, and it is tracking glucose and those data points are being sent to your smartphone, and so you can see a continuous reading of this internal biomarker. And each day that you are minimizing your glucose spike, your cells are seeing less insulin, and so they are going to perk up to future insulin signals and I would really love to see us to be able to clinically validate the results you’re seeing on a CGM and how those correlate with these other diagnostic tests so we can start moving towards this more nuanced diagnostic.

Melanie Avalon: Welcome to the Melanie Avalon Biohacking Podcast where we meet the world’s top experts to explore the secret of health, mindset, longevity, and so much. Are you ready to take charge of your existence and bio-hack your life? This show is for you. Please keep in mind, we’re not dispensing medical advice and are not responsible for any outcomes you may experience from implementing tactics lying herein. Are you ready? Let’s do this.

Melanie Avalon: Welcome back to the Melanie Avalon Biohacking Podcast. Friends, if you have at all been following me on Instagram, been listening to the Intermittent Fasting Podcast, been in my Facebook groups, you know I am completely obsessed with CGMs. Wearing a CGM has truly been one of the most eye-opening experiences of my life. I definitely went through quite an addiction period. If you are at all curious about your blood sugar levels, about how you respond to food, to fasting, to exercise, I cannot recommend enough that you do at least a trial run of a CGM. It provides so much valuable data, truly life-changing and this conversation that I had with Casey, I learned so much. I finally got to dive in so deep into blood glucose regulation, what different numbers actually mean, a lot of the misconceptions. I just am so grateful for this conversation and I can’t wait for you guys to check it out.

Melanie Avalon: Levels is actually currently on a huge wait list. We’re talking in the thousands and thousands and thousands, but there’s no wait lists for you guys. Pretty awesome. So if after listening to this conversation you’d like to get a CGM for yourself, no wait list. You can get it now. You just have to use the link melanieavalon.com/levelsCGM, and use the coupon code MelanieAvalon. That will let you skip the wait list, get that device and you will be good to go. If you’re nervous about putting on a CGM, definitely check out my Instagram. I’ve done a lot of videos about putting it on. I promise it doesn’t hurt. It looks really intimidating. I was really intimidated. Friends, it’s a breeze. You don’t even feel it. It is so easy to do.

Melanie Avalon: We do dive deep into a lot of science in this episode. So no worries. There will be a full transcript in the show notes. Those will be at melanieavalon.com/levels. There will be an episode giveaway for this episode. For that, just join my Facebook group, IF Biohackers, Intermittent Fasting plus real foods plus life. Comment something you learned or something that with you on the pinned to post to enter to win something I love. One more resource for you. If you are trying to find the foods that work for you while using a CGM or just in general, definitely get my app Food Sense Guide. I created it because I have my own personal challenges when it comes to food. There are so many different potential compounds in food that you can react to, things like gluten, lectins, FODMAPs, histamine, oxalates, salicylates, thiols whether or not something is a night shade. It can get really overwhelming.

Melanie Avalon: That’s why I made the top iTunes app Food Sense Guide. It’s a comprehensive catalog of over 300 foods for 12, yes, 12 potentially problematic compounds. I even added AIP recently. So if you’re doing an auto-immune paleo protocol approach, it’s got you covered there. You can learn about the compounds, make your own lists to share and print and so much more. That is at melanieavalon.com/foodsenseguide. But one more thing before we jump in, are you at all concerned with aging? Are you at all concerned with aging and your skin? Well, there are so many things I could say about this, but one of the largest factors aging our skin each and every day is actually our skincare makeup. Even though a lot of skincare makeup is promoted to make your skin better, conventional skincare makeup in the US is often full, full, full of toxins. These are endocrine disruptors, which mess with your hormones and ultimately contribute to the aging process.

Melanie Avalon: Europe has banned thousands of these compounds for their endocrine disrupting potential, as well as things like obesogens, which literally cause your body to store weight and carcinogens linked to cancer, and the US has only banned around 10. It’s honestly shocking. So even if you’re putting on an anti-aging cream, chances are, it probably has toxic compounds that are not good for your skin. Retinol, for example, is promoted to make your skin look younger. And yet it actually is toxic to your skin and accelerates aging in the long run. That’s why I’m so happy that there’s a company called Beauty Counter. They were founded on a mission to change this. Every single ingredient in their products is extensively tested to be safe for your skin. You can feel good about everything that you put on.

Melanie Avalon: If you are specifically concerned with aging, I definitely recommend two things. Their Countertime line was specifically formulated to be anti-aging. It has non-toxic alternatives, which work just as good as retinol, but aren’t toxic to you. People tell me all the time, how much it is a game changer. I’m also really, really obsessed with their C serum. It’s a potent high dose C serum for your skin. And friends, when I say it makes your skin glow, I mean it makes your skin glow. One of the products I actually haven’t tried, but I posted about it recently in my new clean beauty and safe skincare Facebook group, which you should also join, is the overnight resurfacing peel. Okay. I need to try it because I posted about it in the group asking for opinions and you guys freaked out. I got so many comments. Everybody’s obsessed with it.

Melanie Avalon: It basically apparently rivals chemical pills that you would get at a spa, but in the comfort of own home and it’s safe for your skin. Win-win. You can shop with me at beautycounter.com/melanieavalon. And if you use that link, something, really special and magical might happen after you place your first order. Also, definitely get on my clean beauty email list. That’s at melanieavalon.com/cleanbeauty. I give away a lot of free things on that list. So definitely check it out. And if you anticipate making clean beauty a part of your future, friends, become a band of beauty member. You will not regret it. It’s a year long membership and with it, you get 10% back and product credit on all your orders, free shipping on qualifying orders and a welcome gift, which includes the peel, which is worth more than the price of the membership. Totally worth it. And lastly, if you’re trying to find your perfect products, definitely check out my online quiz. That’s at melanieavalon.com/beautycounterquiz. All right. Without further ado, please enjoy this wonderful conversation with Casey Means.

Melanie Avalon: Hi, friends. Welcome back to the show. I am so excited about the conversation that I’m about to have. It is a topic that you guys have been begging, begging to have a show on. So here we are, and it comes with my personal experience for the past two weeks of trying out this device. So I really feel like in the whole biohacking world, there’s something that’s becoming increasingly more popular every single day and it’s something that’s been around for a while, but not really available to the general public. And that is continuous glucose monitors or CGMs. And we’re going to obviously dive deep into what that actually is, but I have been wearing one for the past two weeks, learning a ton about myself. You can learn so much about how you react to foods, how you react to fasting, to sleep. There’s just so much to learn here, so much potential.

Melanie Avalon: And what’s really exciting is that there are companies like Levels who I am here today with the co-founder and the chief medical officer of, Dr. Casey Means. There are companies like Levels that are, like I said, making CGMs available to the general public and integrating apps so that you can really interpret the data that you have and really make it really beneficial to your life. So I am so excited. I have so many questions, but Dr. Means, thank you so much for being here.

Dr. Casey Means: Thank you so much for having me, Melanie. I’m thrilled to be here.

Melanie Avalon: So I’ll let listeners know a little bit about you. So like I said, you are the chief medical officer and the co-founder of the company, Levels, that we’re going to talk all about, but you are a Stanford trained physician. This is so exciting. You’re the associate editor of the International Journal of Disease Reversal and Prevention. That’s when you know you’re a, bio-hacker, when you get really excited by journal people,, but you are an award-winning biomedical researcher. You’ve had a lot of other past research positions at the NIH, at Stanford School of Medicine and at NYU.

Melanie Avalon: Your work has been all over the place, Forbes, Entrepreneur, The Hill, Metabolism, Endocrine Today. You’ve even worked with Dr. Michael Greger, who was a nurse might be pretty familiar with, he wrote how not to die. He has nutrition video series, which I’ve actually watched quite a few of those when I was doing a nutrition certification program, but in any case, that’s a little bit about you, but to start things off, would you like to tell listeners a little bit about your actual personal story, and I’m dying to know what brought you where you are today with CGMs and with Levels and all of that.

Dr. Casey Means: Sure, absolutely. Thank you so much for the kind introduction. My background actually starts… Now, it’s in digital health and metabolic optimization, but it actually started in surgery. So I trained as a medical doctor. I was at Stanford for medical school, and then came up to Oregon for my residency training and head and neck surgery, ear, nose and throat. And it was there that I was treating a lot of conditions that were fundamentally inflammatory in nature. So lots of things that end in, “itis,” like sinusitis, thyroiditis, things that are fundamentally inflammation and the immune system being rubbed up and an up-regulated. And we treat a lot of these conditions with steroids, which tamped down the immune response. And then of course, antibiotics, and then really late stage, we’ll turn to surgery. After about four and a half, five years in this world of ENT, I became really interested in stepping back and saying, “Why is there so much chronic inflammation? Why are people dealing with these chronic inflammatory disorders that seem to persist and come back, even after rounds of steroids and antibiotics and even surgery?”

Dr. Casey Means: A lot of repeat surgeries you see in the hospital. So that really led me on a journey towards trying to understand the root causes of chronic inflammation. One of the key ones there is metabolic dysfunction and how we handle blood sugar and how efficiently we’re processing various substrates into energy in the body. So really became interested in how to metabolically optimize people. I saw in my patients that so many of them that were dealing with chronic ENT disorders, were also dealing with other issues of metabolism. So things like obesity and diabetes and many of the other sequella that are associated with, insulin resistance and poor glucose control, things like liver disease, chronic kidney disease, depression, anxiety, brain fog. There’s so many things that are linked to metabolic disease and I was seeing a lot of this in my patient base, but also noticing how people who had poor metabolic function did worse after surgery.

Dr. Casey Means: Wounds don’t heal as well when your blood sugar is not controlled and you just have trouble bouncing back. So it was very important to me to address this and think about this more deeply. Really what it comes down to is improving and moving the needle on metabolic function really has to do with behavior change. It has to do with changing the hundreds of micro decisions we’re making every day on how we eat and when we eat and how we respond to stress and how much we’re sleeping and how much we’re moving, and those are all choices we’re making every day. We really don’t have a lot of time in our 15 minute visits with patients to really get deep into this and be really effective agents of behavior change in the standard practice of medicine as it is now.

Dr. Casey Means: So I just became just laser-focused and fascinated on how could we leverage other tools to really scale behavior change in regards to metabolic health and how can we use our digital tools, our phones, wearables, things like that to really move the needle on this part of this aspect of health that’s so fundamental towards all aspects of our health and wellbeing? So that got me really interested in that topic and ultimately, drove me to start Levels, which does just this. it’s a program to help individuals understand and improve their metabolic health rapidly.

Melanie Avalon: I love all of this so much. Yeah, I think especially with metabolic health and blood sugar, for example, my audience, audiences in general, people in general are pretty familiar with the problems with blood sugar regulation issues, but I think a lot of people, it caps out at thinking it’s just about weight loss or hunger or appetite. But it goes so far beyond that and affects so many things. I know for me when I first changed my diet and stopped the standard American diet was when I went low carb and I wasn’t testing my blood sugar at the time, but the benefits that I experienced seemingly on my blood sugar levels and having that regulated was so huge.

Melanie Avalon: I’ve made a lot of tweaks since then and more recently, have been… I don’t know. I’ve been feeling like I’ve been struggling to get my blood sugar quite where I like it and getting the CGM was so validating because it was kind of showing a lot of things that I was sort of suspecting about myself, like kind of suspecting that my fasting blood sugar might be higher than I like. I was feeling intuitively that I was getting reactive hypoglycemic responses after meals, which is something that we can talk about. But yeah, that was a whole windy way of saying that I think everything that you’re doing is so incredible. So for the listeners, so the CGM… Until really recently… Because when did you found Levels? When did you start that?

Dr. Casey Means: We started the company last summer, so it’s been around for just over a year.

Melanie Avalon: It’s really recent that this it’s becoming a thing where people can have access to this device. So I guess just to start with what a CGM is because it’s often prescribed for diabetics. What is it? I can tell listeners about the experience of putting it on, which was not nearly as scary as I thought it was going to be. Yeah. What is it? Why is it prescribed for diabetics normally, and how is it now being made available to us?

Dr. Casey Means: Yes. This technology of glucose monitors, otherwise known as CGMs, this is actually been around for over 10 years. And like you said, this is a technology that has been traditionally used for individuals with diabetes. This is a prescription only FDA approved device for the treatment of type one and type two diabetes. What it is, is it’s a tiny wearable sensor. You can kind of think of it like Fitbit for glucose. So you’re sticking this quarter sized sensor on the back of your arm and it’s got a tiny little, four millimeter hair-like probe that goes just under the skin painlessly and it is tracking glucose for anywhere from between every five and 15 minutes. Those data points are being sent to your smartphone, so you can see a continuous reading of this internal biomarker, which is fascinating because for sleep monitors, activity monitors, stress monitors that are looking at heart rate and HRV and things like that, these are not internal biomarkers, not things inside our body. These are more just transmitted through the skin.

Dr. Casey Means: So this is an internal bio marker that you’re sensing painlessly 24 hours a day and getting this super rich data stream. For individuals with diabetes, this was a total game changer because prior to that, they were having to prick their fingers anywhere from one to four or five times a day to see what was happening to their glucose after meals and really to manage medications, particularly insulin and sort of track progression of the disease. But you can imagine the difference between four data points a day and hundreds of data points a day. It’s just monumental, and then taking away that fingerprint component, which is not fun and painful. So it’s bloodless and it’s just a huge acceleration of the technology.

Dr. Casey Means: So then you bring it into sort of our current culture where people are really interested, even people without diabetes in understanding their metabolism and you see this with the keto movement and you see this with non-diabetic individuals starting to prick their fingers so that they can better understand sort of where they sit on the metabolic health spectrum because we know that so much now that the way glucose impacts insulin and other hormones in the body and the way other hormones like cortisol affects our glucose, all these things are so interrelated. If we stabilize and manage our glucose, we have this huge opportunity to really just up-level our current lives in so many ways, improve our energy, improve our mood, improve our cognitive performance, our memory, our athletic endurance, and of course, help prevent this movement towards so many of the chronic conditions down the roads that are associated with dysregulated blood sugar.

Dr. Casey Means: So people have been interested in this and we certainly see that with the movement towards these types of low carb diets, but now there’s this technology that tracks glucose in real time, can tell people exactly where they stand every single day in terms of metabolic health, and really it’s just about getting that technology to a wider market, and then building tools that help people, health seeking individuals to interpret that data and understand the data stream. It’s not just about food in terms of what impacts glucose levels. It’s food, it’s food combinations, it’s food timing, it’s stress, it’s sleep, it’s exercise. All these things directly feed in to our glucose curve. So if we want to keep that curve flat and stable for optimal health, then having software that really integrates data and helps us understand where we’re at and how to make actionable changes and sort of close the loop between these decisions and actions and what’s happening to our health in real time, that’s just a game changer.

Dr. Casey Means: So for this wider population, this is really completing that health stack. We’ve had stress sleep activity monitors, but we’ve never had a real-time wearable sensor that closes the loop on nutrition. That has not existed. The best we’ve had is like maybe six months from now, you’ll get a fasting glucose level or you’ll get a cholesterol check or maybe a weigh yourself the next morning, but there’s not really a closed loop between those outcomes and the exact thing that you did to cause them. So now, we do have that. We have that really close loop biofeedback for nutrition. So it’s just a super exciting time to bring this technology to a much wider population and pair it with intelligent software that really parses out the drivers of glucose control, and then helps people move in the right direction and consistently.

Melanie Avalon: So I think listeners can now see why I am so excited by all of this. I’m also the host of the Intermittent Fasting Podcast and my cohost on that show, Jen Stevens, she went through using a CGM and it was for the predict two study, I believe. So they sent her one for that, which was, I think, a microbiome related study. In any case, the thing… I feel like we’re both the CGM fan girls half the episode now. We just talk about our CGMs, but I think one of the biggest epiphanies from all of this is seeing your pattern throughout the day and throughout the evening, like you said, 24/7 is just really, really incredible because I’ve always been testing myself. So in the past, I pretty much check my blood sugar every night once in the evening, and it would usually be around the same.

Melanie Avalon: Wearing the CGM, I’ve realized even if it’s smaller fluctuations, just how much blood sugar does fluctuate, even if it’s within a range. What I think is so interesting about that is it made me realize, if I’m getting blood tests and my number that I get from that blood test, it could be substantially different if I had gone, I think even like five minutes later. There are just so many factors and it’s just really made me realize how much more there is to know and how much just having one marker for blood sugar tells you… It tells you that one marker that one moment, but it doesn’t tell you that much, honestly. So for listeners, because I want to give them an idea of like what the experience is, so Levels you guys don’t actually make the CGM, correct> you’re using the FreeStyle Libre?

Dr. Casey Means: That’s correct. Yeah. We’re using off-the-shelf hardware and our real core competency is the software overlay, so helping people understand the data stream and we are integrated with Abbott and the FreeStyle Libre, which is one of the three pieces of hardware on the market. There’s three different types of CGMs, and soon to have a Dexcom offering as well.

Melanie Avalon: How are you making this prescription accessible? Does anybody qualify? Can anybody get it? What is the process like to get the CGM?

Dr. Casey Means: Yeah. So currently, we are a general health and wellness product. So we’re not a medical product. We’re not treating any diseases or conditions. We’re really just helping people understand their current level of health and optimize that. So this is really a product targeted towards health seeking individuals without clinical conditions who want to optimize their metabolic fitness. So the way that works for the Levels customer is that they would purchase this one month metabolic awareness experience. So it’s one month of really experimenting and testing lots of foods you love and understanding how to optimize to get that lower and flat glucose curve. So the first thing that happens is you’re connected with a telemedicine physician in our network who evaluates the person for a CGM.

Dr. Casey Means: This is actually a very, very quick process. It’s basically filling out a short questionnaire that the doctor in your state then reviews. If a person, if it’s safe for them to get a CGM, a CGM is then shipped from our partner pharmacy to the person’s house, two sensors. Each sensor lasts on the arm for 14 days. So together, those two sensors make a 28 day month long experience and then access to the Levels app, which interprets the data and helps make it really engaging and understandable. So that’s how the prescription products are made accessible to this population, is through our telemedicine network and shipment of these sensors from a pharmacy to their homes.

Melanie Avalon: I check my blood sugar a lot, like finger pricks. I will do subcutaneous injections of crazy things like glutathione. I’m not scared to stick things into my body. That said, it just looks intimidating, the applicator, to put it on. But oh my goodness, you don’t feel it at all. I was very much surprised. So for listeners, it’s not painful to put it on, even though it’s inserting it right beneath the skin, the sensor?

Dr. Casey Means: Yeah. It’s a four millimeter sensor. It’s less than a millimeter in width, so it’s almost like a piece of dental floss that’s four millimeters in length. So it’s very, very tiny, super flexible, but just like you, I had the exact… The very first time I put one on a year and a half ago, I’ve been wearing one now for that entire time, but it’s really intimidating because you see this thing and you’re like, “Wait, I’m about to impale this thing into my arm. Is there going to be a needle in the arm? Is it going to be rigid? Can I lay on it?” So many questions. I think I watched probably 15 YouTube videos of people applying it to see what it was going to be like.

Dr. Casey Means: And then of course, just like you, I finally did it. I think I had my Bose headphones on blasting music while I was doing it just to gear up. Then I did it. I just started laughing because I could not feel it, and pretty much no one feels it. A lot of people actually don’t even think that the applicator has functioned properly because they didn’t feel anything happen. It’s so quick. Then once it’s on, you just kind of forget it’s there. Then I think it’s also really reassuring when people take the sensor off after two weeks because then they can actually see that little probe that was inside for the two weeks and feel it and just realize how hair-like and flexible it is. You could just lay on it and it’s just going to bend. It’s so flexible. So it’s really, really reassuring. I’ve created some of our sensor application videos and make sure to really press on the probe, but use sensor and show people how flexible it is because I think it takes away some of the fear factor there. But yeah. Have you taken your first one off yet?

Melanie Avalon: No, I have like two days left, so I’m really excited to see it. But Jen said that, my co-host, she was like, “It was really exciting to take it off and see what it looked like on the flip side.” But yeah. So no need for any fear surrounding it. So as far as what it’s actually measuring, so it’s not actually testing your blood, correct? What is it measuring?

Dr. Casey Means: That’s correct. Yeah. It’s measuring interstitial fluid, which is the fluid in between yourselves. So you can imagine under the skin, there’s all your skin cells and in between each of those cells there’s fluid, which is the interstitium and glucose basically leaks out of blood vessels into that tissue as glucose travels to the cells to be taken up. That is the fluid that glucose is being tested from. So because of that, there is said to be basically a slight delay between a blood reading and a interstitial fluid reading that can be about 10 to 15 minutes as that glucose from the blood diffuses into the interstitial fluid. Yeah. I’ve certainly found that to be true on some days, but then other days I’ll eat something and within five to 10 minutes, I’ll see my glucose starting to rise on my sensor. So I think it sometimes happens really, really quickly. But yeah, there’s a little bit of a delay getting into the interstitial fluid, but that’s not going into your blood, just going sort of in the general tissue.

Melanie Avalon: Okay. So the interstitial fluid, is it still on the outside of the cell?

Dr. Casey Means: Yes.

Melanie Avalon: So the insulin receptors, are they on the cell? So the leaking from the blood to the interstitial fluid, is that at all dependent on insulin or does that happen regardless of everything?

Dr. Casey Means: Yeah, that’s just going to happen regardless. The insulin receptors are sitting the surface of these cells and glucose is going to come out of the bloodstream into the interstitium, and then it’s going to be insulin binds to a cell. That’s going to allow the glucose transporters called glute channels to go to the surface of the cell and then soak up that glucose from the interstitium. So it’s measuring in that area. So really you can just imagine that what’s happening in the blood is reflecting almost identically in the interstitium. Those are just with a time delay.

Melanie Avalon: Would that also mean that it might be slightly less accurate when you’re at a really low blood sugar level, because there’s less glucose to be leaking into the interstitial fluid? I know that’s really granular, but…

Dr. Casey Means: No, it’s a good question. Actually the sensors are less accurate at lower values. So it’s actually a perfect question. There is a specific range for which the sensors are the most accurate and that’s about 100-200. So, really a range that is going to be really relevant to the diabetic population. And then as you get down to glucose values between 60 and 80 or so, things are a little bit less accurate compared to blood, which may very well have to do with the lower concentration in the fluid. There’s actually an enzyme protein that is stuck onto the sensor.

Dr. Casey Means: This is what actually happens, is that there’s a chemical reaction between the glucose and then this enzyme that’s on the sensor called glucose oxidase and the glucose oxidase does a chemical reaction with glucose that converts glucose into a secondary bi-product. And in that process, it creates basically an electrochemical charge that’s picked up by the sensor and transmitted as the glucose level. So, you can imagine how at lower values that chemical reaction may not be happening as robustly, but it’s still very, very accurate, but you do see a little bit of a decline at the very, very low values.

Melanie Avalon: That’s so interesting. Is there a saturation level that happens in the interstitial fluid or does that happen in the blood as well? Where it just – there can’t be any more?

Dr. Casey Means: That’s an interesting question. You know, the glucose can get very, very, very, very high. So there are people who have glucose readings in the three, four, five hundreds that the sensor will not pick up that high, but in terms of biologic plausibility, you can have glucose levels that high. And sometimes you’ll see that in patients who are coming in with like diabetic ketoacidosis, but that is certainly an area, a range that we never ever want to get in. We want to stay much, much lower than that. And, one thing I’ll say just accuracy wise, if you look at the FreeStyle Libre, they’ve done tons of research on basically comparing glucose at all values to the blood reference range. And they’ve found that the mean agreement with reference tests for FreeStyle Libre compared to bloods – so the difference between blood and the Libre readings on average is about 9% on average.

Dr. Casey Means: So there may be an up to sort of 9% on average difference between what you’d see in the blood and what you’d see read by the Freestyle Libre. Interestingly, this is actually very similar to other consumer wearable devices like Fitbit, which is also in the range of about 9%. And so that’s fairly accurate and given that this product, especially in the non-diabetic population, it’s not intended for treatment decisions. We’re really looking at trends and sort of the Delta between a before and after of an intervention and seeing what happens, and so certainly that’s a range that we feel really comfortable with as still being very useful for someone using it.

Melanie Avalon: And how does that compare to pricking yourself? And then also a lab draw?

Dr. Casey Means: In the research that was done that’s reported, the research that basically had to be done for FreeStyle Libres to be approved by the FDA, this is looking at a lab draw, so a blood draw in the vein compared to the Freestyle Libre. And then for the finger prick, that’s going to sort of also vary depending on the finger prick monitor that you’re using. So these home monitors also have their own degree of variability between a lab test that’s done in a lab, versus the finger prick. So that one, it’s hard to know exactly what the difference is going to be between the Libre and your home finger stick glucometer, because each one is a little bit different, whether you’re using one drop or, Keto-Mojo, or any of these companies.

Melanie Avalon: When I’ve been using it, I’ve been checking it against a Bayer and then I just got the brand new Keto-Mojo. So I was testing everything altogether. And they were all typically around, within ten. I’m not sure what it’s measured in.

Dr. Casey Means: Milligrams per deciliter.

Melanie Avalon: Yeah, ten milligrams per deciliter. I always just use numbers. Really quick random rabbit hole question. Since using the enzyme and the sensor to detect the level of glucose, is that why the sensors only last two weeks? Is it because of something in the sensor not quote “expiring”, or is it there’s just a two week time limit?

Dr. Casey Means: Two reasons actually. So one is what you just said, which is the enzyme. A big part of making bio-wearables, like internal sensors that measure lab values, in real time that you’re wearing is stability of the enzymes used to test these things. So enzymes can be very, very fragile and basically, it won’t work. And that’s why we aren’t seeing a ton of bio-wearables on the market that are testing, basically doing lab tests at home. And a lot of it has to do with enzyme stability. Glucose oxidase just happens to be this brilliant enzyme that’s really stable, so we can do it for two weeks, but yes, that may decline over time. But the second thing is actually your body’s reaction to the sensor. And so, this is a foreign object under the skin. So over time you also could develop sort of an immune response to that and potentially create theoretically, like a capsule around it inside or create inflammatory tissue around it.

Dr. Casey Means: So the two weeks, it’s just sort of this perfect amount of time where you’re, you’re not really mounting an immune response to it, in the vast majority of people, the glucose oxidase is stable and it’s going to stay really accurate. Yes. So right now, the two main sensors on the market, Dexcom and FreeStyle Libre. Dexcom is a ten-day sensor and the FreeStyle Libre is 14. So that’s [inaudible] right around the sweet spot and certainly longer sensors. We’re really hopeful that these people will come online to ease the use of this.

Melanie Avalon: So taking it out and then putting it in another location, it’s kind of like starting afresh?

Dr. Casey Means: Yeah. That’s what I tend to recommend is kind of do it, at least a centimeter off from your last sensor or switch arms. To me, and this is really, I don’t have evidence for this, but to me, that makes a lot of sense, to give the tissue on one arm some time to just heal and forget that this ever happened and then do it on the other arm for the second sensor. But, if you prefer one arm, if it’s easier to scan your sensor with your phone on your left arm, if you’re right-handed, I would just probably recommend moving a centimeter down from your prior insertion so that the probe is in just a slightly different area.

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Melanie Avalon: And for listeners. So like we said, it’s a really small sensor, but then for like the levels, there’s a patch that you can put over it. And it actually made me really happy because this is crazy. But in order to get rid of decision fatigue, I have five copies of the same outfit that I wear, every single day. And it’s black with a white logo. And the cover for the CGM with levels was black and white. And I was like, this is perfect. Matches my outfit every single day. Super random. One more question about accuracy while we’re talking about that. I was talking with Tom at your company about the accuracy, because I, I noticed at night that I tend to eat pretty late, which may or may not be ideal, but I do. And I’ve always felt like I was getting reactive hypoglycemia and I definitely saw that reflected in the CGM data, but I also noticed a few nights that it would drop ridiculously low, like forties.

Melanie Avalon: And I was like, that seems a little bit low, but I’ve talked with Tom. And he was saying that if you lay on the sensor while you’re sleeping, that you’re cutting off circulation, which could be a problem. And he was also saying that there haven’t been a lot of studies actually on glucose levels all throughout the night. So we don’t even really know what might be normal for night-time levels. So if people do have it, have you seen people experience dips in general at night? And could it possibly be from laying on the sensor or something like that?

Dr. Casey Means: Yeah, that’s a great question. And definitely one that we get a lot because people get very alarmed by seeing values in the forties or fifties or thirties, so there’s three things I would say. So the first is what, what Tom mentioned, which is there is this very well-established phenomenon called pressure induced sensor error, and quite a few publications on this, where basically if you lay on the sensor and put your full body weight on it, which many of us side sleepers are going to do, that can create complete error in the sensor. So there’s been studies where people have been wearing these in hospitals and a research assistant will basically have video cameras on the patient and then see when their glucose goes low. And it tends to correlate really identically with when they rolled on their side. So they’ll monitor the videos on the glucose response and they’ve seen a correlation with that.

Dr. Casey Means: And then I believe double-checked it with an actual lab draw at that time. And no, it’s not actually that low. So really, really big lows it’s often are likely I think, going to be the pressure and do sensor error. But the second thing to know is that glucose does actually go lower during sleep. So during REM sleep, in particular, we tend to have glucose levels that are about 5% lower than at other sleep stages. So there may be just natural dips that we’re seeing in glucose. And the third thing is that, like Tom mentioned, we don’t exactly know what’s normal for a healthy person at night because, first of all, we haven’t really cared that much about glucose levels and in non-diabetic individuals traditionally, we were sort of a system that really focuses on these things once the disease has emerged.

Dr. Casey Means: So there’s just not a ton of data looking at what over 24 hours is the normal glucose levels for non-diabetic individual. And there’s about six or seven papers that have looked at that, but it’s not like an abundance of research and would be happy to talk a little bit about what those papers found. But specifically in terms of lows, something that’s been seen is that we may spend anywhere from five to 10% of our day below values of 70 milligrams per deciliter, which would be traditionally called hypoglycemic. But in these large populations of healthy people, it seems like they’re spending many, many minutes, if not hours a day, dipping below. And so often, asymptomatically without symptoms of hypoglycemia. So it may be somewhat normal that we kind of intermittently dip into the sixties or whatnot.

Dr. Casey Means: So that might be totally normal, but certainly as more non-diabetic healthy individuals, wear these overnight, we’ll have much, much more information about what is normal. And then very last thing is, you know, what you’re eating late at night may have a really big impact on the curvature and the shape of the glucose line over night. So people who are eating a high carbohydrate meal late at night are going to have the downstream insulin response of that. And potentially could get into a situation where they have this big insulin surge and then a big dip in their glucose because front end leading to reactive hypoglycemia. And then that could lead to sort of this little bouncing throughout the night of a little bit of hypoglycemia and then recovering and then back and forth. And so, certainly not eating high carbohydrate meals or more specifically not eating foods that for your particular body are going to cause a glucose elevation, cause that’s going to be different in each person.

Dr. Casey Means: That’s a good way to keep glucose levels a little bit more stable overnight. What’s more people who have glucose spikes at night tend to sleep more poorly. So it can cause you to be sleep hotter. If you have a glucose spike at night, it changes thermal regulation. And we know that people who sleep hotter tend to sleep worse and it can also, it’s been associated with just general insomnia. So keeping the glucose spike really minimized towards the end of the day, I think is a really super low hanging fruit for getting the best sleep possible. So those are some of the reasons for the low that’s potentially at night and some ways to potentially mitigate that.

Melanie Avalon: That ties into another huge foundational thing to talk about, which we talked about, how it’s measured in milligrams per deciliter for blood glucose. So what is a healthy range? You just mentioned that technically going below 70 is hypoglycemia, but like during the day, some people eat meals and people snack a lot of my listeners practice intermittent fasting. So they have some sort of fasting period during the day. What is a good range and what qualifies as a spike and what do we want to see and what do we not want to see? And what should it look like?

Dr. Casey Means: Yeah. So I guess just backing up for people. Part of the reason we don’t want these glucose spikes is because high glucose can cause a number of things in the body that we don’t want. So the first is that it can generate inflammation. Like I was talking about in the very beginning, a big glucose spike can tell your body that something’s off, something’s a little wrong, and cause you to up regulate immune chemicals like cytokines, TNF, alpha CRP, interleukin, [inaudible 00:41:51] things like that. So we don’t want that. It can also cause oxidative stress. So create free radicals in the body that can be damaging and it can also cause glycation. So when blood glucose concentrations are high, glucose can stick to proteins and other structures in the body and cause dysfunction. Glycation is a process that is when the body becomes almost like caramelized, like it’s literally changing the proteins and it’s just not a good thing.

Dr. Casey Means: So we don’t want glycation, or say, stress or inflammation. And then of course glucose spikes are going to cause corresponding insulin spikes and the higher glucose spike, most likely the higher the insulin spike and insulin spiking frequently, we really don’t want, because what happens is when that occurs over and over and over again, and insulin is required to get the glucose shuttled into the cells. Our body becomes a little bit tired of that and becomes resistant to that insulin signal. And the body then has to actually make more insulin to get the same amount of glucose into the cells. So now you’ve got higher insulin, higher glucose, and this process of insulin resistance is fundamentally the root of so many medical conditions that we see today, and also is a big problem with weight loss and obesity because when insulin is high, it’s a signal to the body that glucose is around, we’ve got this ready source of energy.

Dr. Casey Means: We don’t need to use other sources of energy. And of course that means we don’t need to use fat for energy. So insulin is a direct block on fat oxidation. So you can imagine if you’re trying to lose weight or if you’re trying to have a lot of endurance with a workout and just really want to be tapping into fat oxidation, insulin being high, big problem. So those are just five of the reasons why we don’t want glucose spikes to sort of set the stage for where should we be aiming. So the short answer is that for non-diabetic individuals, we don’t exactly know where people should be shooting for, for optimal glucose levels. And this is interesting because you know, right now all we’ve got is some criteria that are put out by the American Diabetes Association that say if you’re above this range of glucose, you’re in the pre-diabetic or diabetic categories, and if you’re below, you’re non-diabetic, but that actually doesn’t tell us what’s best for health.

Dr. Casey Means: So if you just looked at that criteria, what we would know is that we want our fasting glucose first thing in the morning to be less than a hundred to be considered non-diabetic. If it’s between a hundred and 125, you’re pre-diabetic, and if it’s 126 or above, you’re considered diabetic. There’s another test called the oral glucose tolerance test, which is where individuals will chug 75 grams of glucose in this standardized drink called Glucola. And then they’ll have their blood sugar measured at various intervals two hours after that drink. And if your glucose is below 140 milligrams per deciliter, after that drank two hours afterwards, you’re considered non-diabetic. If it’s above 200, you’re considered diabetic. And if it’s between one 140 and 200 that’s pre-diabetes. So from that sort of standardized clinical information, we’d say, okay, well we should shoot a fasting morning glucose below a hundred and we should plan to be less than 140 after meals.

Dr. Casey Means: But I personally think this is much too lenient, and doesn’t really tell us where we really ought to be for best health and avoidance of future disease. And so then you have to turn into sort of some more nuanced literature. So these are the studies where they’ve put CGMs on healthy populations and just looked at 24 hour patterns. And what you see in that research is that healthy people without diabetes will with CGMs on, will typically spend about 92% of their day between a glucose values of 70 and 120. So that sort of starts tightening up the range a little bit, that likely you want to be between about 70 and 120. So for levels, customers, this is really what we encourage people to shoot for. Don’t just shoot for below 140 after meals. Probably we should be shooting for more like 70 to 120.

Dr. Casey Means: For fasting glucose, there’s been some really interesting research sort of breaking down this normal range of less than a hundred milligrams per deciliter, fasting glucose being normal. And what you actually find is that people in the lower range of normal do much better than the people in the higher range of normal. So people who have fasting glucoses between really about 70 and 85 have much lower risk for future diabetes, future heart disease, other health conditions than people whose fasting glucose is between 85 and a hundred, which is also considered normal by our standard criteria. But actually, you start seeing this very steep slope of the line of increased risk of future disease. So we also encourage people to really think about tightening up their fasting glucose parameters and really shooting between about 70 and 85, not just 70 to a hundred. So summing that all up, we should probably be spending the vast majority of our day between a fairly tight range of 70 to 120 when we wake up in the morning, seeing our glucose between 70 and 85.

Dr. Casey Means: And ideally I would say after a meal, we don’t want to see our glucose go up more than about 15 points. So kind of a little gentle rise and then back down, but what a lot of people find when they start taking their glucose is that some of their favorite foods might spike their glucose 80 points, a hundred points. We’ve seen people eat normal oatmeal and their glucose goes up literally 80 to a hundred points. Our CEO had a Chick-fil-A sandwich and a soda and his blood glucose went up to 210. So there are lots of foods that we just consider are quote, unquote, normal that don’t even keep us remotely in that range that I’m talking about. So what is next is to now that we are thinking more about metabolic health for the general population, we need to be doing more research to understand what ranges are associated with best current physical and future physical performance, and then of course, risk for future disease. And I would guess that we’re going to see that it’s these tighter ranges that we should shoot for.

Melanie Avalon: This is so fascinating. Intuitively that’s how I’ve always felt. I’ve always felt like blood sugar in the seventies is when I feel good. And I’d been suspecting that it’s been creeping up. It’s still not that high, but like the eighties and nineties, but I just feel better on the lower side of that. A few different things you touched on that I just have to ask you about really quickly. One is actually not really blood sugar related. I’m just dying to ask you, you mentioned CRP, and for listeners, that’s C-reactive protein. If it’s really low, can you still be in an inflamed state?

Dr. Casey Means: That’s a great question. And I think the answer is, you know, yes, like inflammation is a, is a very complex set of pathways and CRP is just one snapshot of looking at that. And so it is a very, very good snapshot, but I think it’s possible that you could have, other inflammatory processes going on without the CRP necessarily being elevated, but we just don’t test a lot of the other inflammatory cytokines that are directly related to health, especially things like IL-6, IL-11, TNF alpha, some really longevity focused doctors are testing these things, certainly getting that sort of broader panel. If it’s something you’re really interested in, it might be interesting to do, but by and large, if CRP is really low, that’s a great thing it’s definitely associated with better cardiac outcomes. And, and we want it to be lower, but theoretically, yes, I think it’s possible. It could be low and there could be other inflammatory pathways that are still perturbed. But, I don’t know that for sure.

Melanie Avalon: Super random question. It’s just because I’ll feel this state of inflammation going on, but whenever I test my CRP, it’s ridiculously low. It’s like 0.1 and I’m like, huh. So confused. I feel inflamed. Okay. Some other questions that you touched on like glucose levels and things like that. So, glycation, a lot of people on low-carb diets, maybe in carnivore diets, I feel like I see a lot of reports of people having higher blood sugar levels, even while being potentially even severely low-carb. Can the negative effects of glycation occur on a carb-free diet if blood sugar levels are still high?

Dr. Casey Means: Yeah. So, if blood sugar levels in the blood are high, glycation can occur. Because really it’s like how much glucose is in the bloodstream. And if that’s able to then stick to things in the body. So if it’s high in the blood, it can glycate things. So, at the levels that people might be talking about on the carnivore diet, they still might be fairly low glucose levels like nineties or hundreds. And that might be higher than what they want to see. I’m not sure what levels they’re they’re necessarily referring to, but I’d assume they’re kind of still fairly, fairly low. Certainly glycation is going to happen at the much higher glucose levels. And it’s, I imagine is going to be really a linear increase from the lower levels to the higher levels in terms of glucose going up and how much glycation happens. So, if it’s in the blood, it can do some of these deleterious things.

Melanie Avalon: Yeah. That makes sense. And then also while we’re still in the low-carb world, people often think that the most insulogenic things are carbs, but I think meat and protein can release a substantial amount of insulin, even if it’s countered by glucagon, but can a person get insulin resistance from just releasing a lot of insulin, even if the insulin is not shuttling blood sugar necessarily into cells, like can that still create that insulin resistance problem? And I know that that’s also diving into the world of physiological insulin resistance that a lot of people say might happen on lower carb diets. So that whole world of insulin and low carb diets, and oftentimes people go on low carb diets and they feel like they can’t quite bring back carbs or they can’t tolerate carbs the way they used to. And we can talk more about how maybe people can practically, use a CGM and learn more about themselves with all of this. But, what are your thoughts on all that on all the issues that can go awry with insulin?

Dr. Casey Means: Yeah. So foundationally, we want to be really optimally insulin sensitive and keep our insulin levels low. Low insulin levels are where we want to be. And so this is not a lab test that we are often checking in standard practice, unfortunately, but I would really highly recommend that people push their doctors to get a fasting insulin level because it can give you so, so, so much information. I typically like to see people in like a range of two to six or so, which is quite low, but you can have people out there who have normal glucose levels in the quote, unquote normal glucose levels in the blood. They don’t meet criteria for pre-diabetes and diabetes, but have insulin levels, up in the twenties and thirties fasting.

Dr. Casey Means: And so, that’s someone with a fasting glucose of 85 who has an insulin level of two is very different from someone who has a fasting glucose of 85, who has a fasting insulin of 25 because that person with the fasting insulin of 25, their body appears to be pumping out so much more insulin to keep that glucose level at 85 than the other person, which means likely, they have gone down the pathway of insulin resistance and their cells just need so much more to drive that glucose in.

Dr. Casey Means: And that’s not a state that we want. And what we really focus on at Levels is improving metabolic fitness, which we like to think about it like going to the gym. It’s like you put in your reps to get stronger at the gym and you have to put in your reps to get more metabolically fit. And how do you put in the reps? Well, you decrease your glucose spikes day after day and each day that are minimizing your glucose spikes, your cells are seeing less insulin. And so they are going to perk up to future insulin signals. And so your body’s going to have to produce basically less of it to get the same amount of sort of bang for your buck and get the glucose in. So each day that we’re keeping those spikes minimized, we are letting the cells hear the signal of insulin more loudly, and ultimately regain our insulin sensitivity. It’s not something that happens overnight. It’s something that is going to potentially take weeks and months to really get those pathways back on track. So long story short, insulin being lower is where we want to be. Insulin affects every cell in the body in lots of different ways and drives a lot of these processes that are very, very well-established. So like you mentioned, there’s other things other than glucose that can increase insulin. So specifically ranking them, glucose and carbohydrates are going to be the most insulinogenic. They’re going to produce the largest and quickest spike in insulin, followed by protein, which can also increase insulin levels and then fat very, very, very little and borderline non-insulinogenic.

Dr. Casey Means: So, it is possible if we’re eating a very, very high protein, low carb diet. We’re actually going to be generating some of that insulin output and potentially moving down that pathway of insulin resistance. And you can imagine then if you… So if you’re focusing on low carb, high protein, and let’s say you are maybe a little bit insulin resistant, eating some carbohydrates then might actually show you a higher glucose level than you might imagine. Because you’re on a low-carb diet. So it’s pretty interesting and definitely more research needs to be done in this area. But yeah, definitely would put a plug in for people asking their physicians to test this. It’s one of those valuable pieces of information that we can get from a standard lab, in my opinion.

Melanie Avalon: Yeah. We talk about this a lot in the intermittent fasting podcast about testing insulin. And we just think it’s really sad that it’s not on a standard lab test. Yeah. But that’s a whole nother topic. You’re speaking about the spikes and you mentioned the area under the curve. I wonder this a lot. So is there something that’s better or is one worse? Because oftentimes we are told, or it’s suggested to have meals that lead to a slower, longer glucose response. And I guess maybe lower compared to a spike that goes up and comes down shortly or quickly. Is that okay? So say a person eats a meal and it spikes high, but then it goes down pretty fast and then they’re back to baseline. Compared to it spikes a little bit, it doesn’t go quite as high, but then their blood sugar that was elevated for longer but lower. Is one of those more beneficial or better? Do you get What I’m asking.

Dr. Casey Means: Yeah, absolutely. So a couple of things that brings up. One is just this general discussion of area under the curve. And I know your listeners know a lot about metabolic health. So normally I don’t get into this concept because it’s a little bit nuanced, but I think it’s actually really important to think about. So basically if you have a continuous glucose monitor, you can imagine it’s picking up data points every five minutes or so, and you’re going to eat something. And over the course of the next two hours, you’re going to build this bell curve essentially of what happened to your glucose after that. And if you shaded in everything under that curve and just shaded that in, that’s going to be some area. And you can imagine if you got a couple of different scenarios that could happen. You could go straight up and straight down like a super sharp peak.

Dr. Casey Means: And you know, that area under the curve is going to be medium, it’s going to be not super long in the time dimension, but it’s going to be high. Then you could have a really high peak that lasts for an hour and a half. So that’s a much wider curve. That’s going to have a much greater area under the curve. Then you could have a really low carb meal that barely spikes you and comes right back down. That’s going to be a virtually negligible area under the curve. Teeny little spike comes right back down. And then you could have more of a sustained carb that’s a low spike, but it lasts for an hour and a half or so, and then comes back down and that’s going to be a medium area under the curve.

Dr. Casey Means: So You said that so much better than me. That was perfect. And kind of the way I think about it as exposure to glucose. How much exposure is our body having to this? Is it having a lot for a long time or a little for a short period of time. And certainly I think the one that’s best for health is going to be that little spike for a very short amount of time. So basically no spike. Just a little gentle up maybe five, 10 points after a meal. Five, 10 milligrams per deciliter and then comes back down within an hour and a half. And so very little exposure of the body to glucose and probably very little exposure to insulin as well, versus the worst case scenario, which is it goes way up and it stays up for an hour and a half and then comes back down.

Dr. Casey Means: That’s just going to be a lot of glucose exposure to the tissues and a lot of insulin exposure. But then there’s that question of the high peak that comes right back down. And my feeling is that that is actually problematic even though it’s recovering quickly. And so this is for instance, you have a donut and a piece of cake and you’ve had very little protein or fat. You’re just eating straight, simple carbs. And you go up to maybe, let’s say you’re starting at 80 milligrams per deciliter before that food. And then you go up to 170, 180. Go up like a hundred points and then come. But you’ve got a good insulins in the [inaudible 00:59:27] and good insulin response. So you come right back down. Well, the problem with that is that one, you have slammed your pancreas.

Dr. Casey Means: You have made your pancreas do so much work and just put out so much insulin to soak all that back up really quickly. So that’s an insult to your body. You’re throwing that all on the cells and they have to respond to it and clear all of that. And that’s a lot of work. What also can happen when you have that big insulin surge is that you can overshoot, you can basically suck up too much glucose into the cells and have that episode of reactive hypoglycemia. So this is where you actually overshoot your baseline and go lower than you were before the meal. And reactive hypoglycemia is problematic for a few reasons. It’s been associated with that post-meal slump feeling. So having to go take a nap after a meal, brain fog and also anxiety, mood lability.

Dr. Casey Means: So there’s been very small observational studies that have been published about people who had generalized anxiety disorder. And when they moved their diet to one where it was less spiky and less glucose spikes and much more stable glucose levels, the anxiety really improved. And that’s not surprising. If you’re putting your body on a glucose roller coaster, you may also have energy mood gone in a roller coaster going on. And what I love about continuous biofeedback and why I think it’s really the future of medicine is that right now we may have a meal like the donut in the morning, because someone brought them to the office and had them in the workroom. We eat a donut and then a couple of hours later, we don’t feel great. We feel maybe a little bit jittery. We maybe feel a little bit tired, maybe feel a little bit anxious and you have no idea what to attribute that to.

Dr. Casey Means: You’re like, “Is this because I didn’t get good sleep last night? Is it because I just wrote a stressful email? Is it because I ate the donut? What, is it just my personality? what is it?” And so it’s very hard to make a change if you can’t attribute the cause. But if you have the glucose monitor, you can say, “Okay, this is how I feel. This is what happened to my data. It went to 170 and then crashed down to 55. And this is what I did. I ate the donut.” And then all of a sudden it’s not a mystery anymore. We have this whole new enhanced body awareness that’s basically biofeedback informed and we can start to close the loop, attribute correctly and then make changes.

Dr. Casey Means: And that’s really what we’ve been missing. So it’s been so much trial and error with nutrition and lifestyle. It’s like, “Well maybe I’ll tweak this, I’ll get off caffeine. I’ll sleep a little bit more. I’ll maybe try and avoid sweets.” But to just have that trifecta of action, data and subjective experience and be able to link those three things together. I think that’s just revolutionary for making sustained, efficient, behavior change and just something we haven’t really been able to do before in the nutrition realm. So I’m pretty excited about that. And the future of biofeedback and forum diets.

Melanie Avalon: It’s such an empowering tool, especially if you’re trying to figure out what foods work for you. I wish I had one of these for the past 10 years. But in any case, like I said, I originally cleaned up my diet when I went low carb and didn’t really struggle with blood sugar issues. And then I adopted a paleo diet and I went actually pretty high carb, lower fat, high protein, but with intermittent fasting. I felt I had really good blood sugar regulation. Went low carb again and it was still pretty good. But now I keep trying to bring back carbs and I just feel it’s not working for me. And this was before wearing the CGM just intuitively. I feel my blood sugar is not staying stable and I get hungry. And so when I first got put on the levels, it was when I was in one of my experiments of trying to bring back the carbs again.

Melanie Avalon: And I didn’t really like what I was seeing on the CGM. Like I said, my fasting blood sugar was in the nineties or even a hundred. And I was like, “Oh no.” And so I decided to try going back low carb while I had on the levels and everything really normalized a lot, which is a bummer for me because I’m trying to bring back carbs. But I think having this as a tool, because without it, it’s not that it’s a shot in the dark, but when you don’t have that 24 picture, like you said, it’s hard to know what’s what. But when you have a 24 hour monitoring, you can literally see how you’re reacting to foods. So I think especially with people trying to figure out the macros or the foods that work for them, that it’s just ridiculously empowering.

Dr. Casey Means: I would just jump in. I would say one thing that might be fun to experiment with is really trying to figure out what carbohydrates do work for you. Because this is what’s been so fascinating and really motivated me to really work on this. And the personalization aspect is that, and I’m sure you know this, but each person will respond to different carbohydrates differently in terms of how much their glucose elevates. And there was this great study five years ago out of the Weizmann Institute in Israel called Personalized Nutrition by prediction of glycemic responses and basically put glucose monitors on a bunch of non-diabetic individuals and then gave them all standardized carbohydrate meals, the same carbs for each of them and saw that everyone responded differently to the exact same meal.

Dr. Casey Means: Some people didn’t spike at all. Other people spiked hugely. And then they looked at what factors were… We could predict how someone was going to respond to this carbohydrate load. And they identified things like microbiome and anthropomorphic features. So body type and how much sleep people had gotten. So it could be interesting to experiment a little bit with all these other levers other than just the carb alone that can mitigate a glucose spike. So let’s say a sweet potato, fairly high carb food. For me that spikes my glucose highly. So how I would approach that using levels is take that carb that’s not working for me and start doing the modification. So pair it with fat or protein, both of which are known to mitigate a glucose spike. So adding to zucchini or an almond butter sauce or chia seeds and flax that have fiber and fat and see if that blends the spike a little. And then the second thing would be looking at food timing.

Dr. Casey Means: So if I eat it late at night, I’m going to likely have a much higher glucose response. And if I ate it in the morning, because later at night we have melatonin release, which impacts our ability to secrete insulin. And so we might actually see bigger spikes with the exact same food later at night then earlier in the day. And then experimenting with the other lifestyle modifier. So what if I eat that thing on a day that I did a high intensity interval training workout in the morning, and I know I’m going to be more insulin sensitive that day. Or make sure I’m not eating it during a high stress day because cortisol can increase our glucose responses. And then also do it on a day that I got a lot of sleep because even one hour less of sleep can reduce our insulin sensitivity.

Dr. Casey Means: So it’s looking at that whole toolbox of stuff that can mitigate our personal response to that exact same carb and see how to shape the overall context for which that carb comes into the body. So that has been definitely powerful for me. I’m vegan and I eat tons and tons of carbs and I’m able to keep the glucose flat really at this point because of that very much contextual approach to putting a carb in my body. So yeah, I am excited to hear what you learned over the course of the testing it out. But just really to say that I think there are ways to turn the other knobs so you can still eat those foods you like, and not have as much of a glucose spike.

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Melanie Avalon: Yeah, 100%. I’m so glad you said all of that because when I was doing the high carb, high protein, low fat in the past, it was all fruit carbs. And that’s what I’m trying to bring back. But I did two days ago, tried rice instead. Very, very bad idea. Oh my goodness. It actually went up to the two hundreds. I was like, “Okay, we’re not doing that.” So funny slash good thing is that I was stressing a little bit about the fruit initially, but now compared to that, I’m like, “Okay, I think I can work in the fruit world and make this work because at least it wasn’t going to two hundreds.”

Melanie Avalon: But in any case, yeah, it’s so much that you can learn from the tool. And I think I misspoke because I was saying that Jen Michael was just doing the predict to study. And I said it was a gut microbiome study, but I think that was one part of it, was they tested her microbiome. I’m pretty sure it’s the followup to that study that you just mentioned, which was mind blowing. Things like a banana would have a huge response in somebody and do nothing to another person. And a cookie would be the same way.

Dr. Casey Means: Oh yeah. And that two people like you and I, we could both eat the banana and the cookie and I could be a huge spiker on the banana and no spike on the cookie. And you could be the opposite even though… It’s just crazy because it flies in the face of the whole low-glycemic diet concept where we have this standardized chart and we should all follow it because we’re all going to have the same glucose rise with these foods. And this really showed that there might be so much more to it than that. And it’s painful to think that there might’ve been people who are following these diets very strictly and did not see the progress they wanted to. And it might’ve been because of these underlying factors that just for whatever reason changed the way that carbohydrate was processed in their body into glucose.

Dr. Casey Means: And that super excites me about the future of personalized wearables and over time, these studies predict and what Aaron Sickle’s lab is doing at the Weizmann Institute, really looking for, if we have big data sets in this stuff, how can we then potentially figure out these types of predictive models essentially. If you respond this way to X, Y, and Z, this is probably actually how you’re going to respond to A, B and C which is really exciting.

Melanie Avalon: I have a really random question. Well, I guess it is related. With diabetes, is it true that the primary cause of the elevated blood sugar levels is actually from gluconeogenesis in the liver and not from carbs in the diet?

Dr. Casey Means: Yeah. Gluconeogenesis is certainly one of the pathways through which we’re getting glucose into the bloodstream. It’s how we make glucose from other pathways. But I think that certainly my understanding of it is that it’s a lot to do with how our body is processing exogenous glucose that comes in the body and the underlying insulin resistance that causes us to poorly respond to it. But in terms of causes, It’s so, so, so multifactorial. There are so many different aspects that go into why someone would become insulin resistant and it’s anywhere from eating high carbohydrates over the course of years and decades and that subsequent, that constant insulin spikes and insulin resistance that develops. There’s lots of information now about more of an intracellular lipid accumulation theory of diabetes whereby we’re accumulating things like ceramides and diacylglycerol, DAG and other things inside the cell, which are actually causing the insulin receptor to be less responsive to the signal of glucose. There’s things like micronutrient status.

Dr. Casey Means: So, there are our metabolic pathways, like what happens in the mitochondria to actually process glucose. Require lots of different nutrient co-factors. So those processes like zinc and manganese, magnesium, B vitamins, and so chronic deficiency of these critical micronutrient co-factors can be involved in the pathogenesis. There’s of course genetic factors as well. And then there’s so many other things that can change glucose levels, the medications that we’re on, underlying illnesses that may raise glucose levels, chronic stress, and the chronic cortisol associated with stress that keeps glucose levels high, sleep deprivation, and the impact of sleep deprivation on insulin sensitivity. And you can imagine over the course of decades how much that can compound. There are just so many elements that are both intrinsic to our biology, but also environmental and our behavior base that are contributing to the development and the pathogenesis of this disease.

Dr. Casey Means: And actually last one that’s under-recognized, but very well-established at this point is environmental chemicals and their impact on our metabolic health and our endocrine system. So things like persistent organic pollutants, POPs and nitrogen dioxide in the environment, these things can actually blocks our metabolic pathways. So everything from food, insulin, intracellular lipids, liver function and micronutrients, genetics, environmental, sleep, exercise, stress over the years, all those things feed into the pathogenesis of this disease. And there’s a lot, it’s just amazing. And it’s just really a testament to how our current world and the world we live in right now. It’s really an uphill battle.

Dr. Casey Means: And so yes, certainly my mission as a physician is to help people understand these different factors and build as many of those into our product and our software. How can we educate people about sleep, stress, exercise, food pairing, food timing, even micronutrients, environmental exposures, all into one app that just helps people understand the comprehensive nature of metabolic health. And while food is a key driver in our metabolic outcomes, it is necessary, but not sufficient for metabolic health. You have to have these other ducks in a row as well. And so that’s really my mission in trying to build a software product that queues people into all these different aspects that ultimately feed into our metabolic health.

Melanie Avalon: Yeah. I could not agree more. I think it’s so huge. I’m recently become really obsessed with endocrine disruptors and obesogens in particular and all the messages and the signals that they send in our body that I think people don’t realize the potency of it because, “Oh, we’re not eating it. We’re not putting it in our mouth and we can’t see it.” It’s hard to understand the vast impact that it can have. The gluconeogenesis thing, I heard that. I was listening to I think a Peter Attia podcast, all on metformin. And they were saying that… That’s where I heard that idea that with type two diabetes, the main issue is with the liver producing excess sugar all the time. Actually speaking of metformin, I did not get metformin, but I did just order berberine, which has been shown to be comparable to metformin. And I’m really excited to try it with my CGM. And see what happens.

Dr. Casey Means: Yeah, I’m really curious to hear that. That one’s been well studied clinically in the diabetic population and I’ll be fascinated to hear what you learn with that. And then I guess I would say one other plug in terms of testing out supplements, there’s a really interesting supplement now on the market by Pendulum Therapeutics, which is a probiotic company that’s now approved for type two diabetics for lowering A1C and glucose levels. And has not been studied in non-diabetics. But first probiotic that I’m aware of on the market that’s actually clinically validated for lowering glucose levels.

Dr. Casey Means: So, yeah, and in that list that I gave earlier of all the things that contribute to the pathogenesis of diabetes, another huge one of course is microbiome. And so when you were talking about environmental chemicals, not only can they be endocrine disrupting in their own right and directly impact enzymatic pathways critical to metabolic health and hormones, but they also have such an impact on the microbiome. What we’re putting in our body, it’s on our food and our water, this is going to directly impact our microbial biodiversity in the gut which make these critical metabolic co-factors. And so yeah, I’m totally with you on that endocrine-disrupting chemical train, I think it’s way under-talked about and really something we got to address at the societal level.

Melanie Avalon: Yeah. I particularly think our skincare makeup is one of the worst exposures to it every single day. So that probiotic, is it a strain I’ve never heard of? Or is it a specific blend of lacto or bifidobacteria bacteria strains?

Dr. Casey Means: Yeah. So when I first thought about it, I thought it was going to be bacteroides or bifidobacterium or something like that. But it’s actually, and I’m forgetting the exact strain, but I believe it’s just one strain and it’s been clinically studied, and I’m really curious to try it even, certainly it’s not what it’s indicated for because it’s for people with type two diabetes and it hasn’t been studied in non-diabetics. But it’d be interesting to see if it can even move the needle in someone who’s fairly healthy. So.

Melanie Avalon: Yeah. That’s fascinating. I’ll have to look into that and I’ll put more information in the show notes. Quick question. Because I asked listeners for questions for this show. And one of the questions I thought was really good was she wanted to know is a two week monitoring period. Although you said it is a month, just could be used to get two sensors, but is that enough time to learn about yourself? And during that period, that two week or that month period, do you suggest following your normal diet for a certain amount of time, making changes? How should people best approach that two week or that one month trial period?

Dr. Casey Means: Yeah. So I think one month is really a perfect amount of time to do it. I certainly think doing it longer is excellent. And you can even learn more and then shift into like you’ve learned a ton. And then you’re using it more for like accountability, which is I think where I’m at. Where I’m really using it as my accountability tools.

Melanie Avalon: You said you’ve been using it how long?

Dr. Casey Means: Almost a year and a half. And I can’t even imagine taking it off.

Melanie Avalon: Like in not having it would be you feel naked.

Dr. Casey Means: Yeah, I feel super weird without it. And I do find myself making different decisions without it. And it also doesn’t hurt that my team, we all of course share our glucose data. And so can write each other a little bit if we’re going off course. So that accountability is super fun. But I think a month is a really great amount of time for developing metabolic awareness and starting to build out your metabolic toolbox of like, what are these levers you can pull to keep your glucose more stable? And I think the best way to approach the program, which we lay out in the app and in our program guide is the first week is really exploration, eat your normal foods, eat what you love and see what happens.

Dr. Casey Means: So just what is what you’ve been eating, been doing to your glucose. And so I think that’s pretty fascinating the first week is just like try not to modify the diet and just eat what you normally eat and make some observations there. Then moving into the second and third week, it’s really about experimentation. So what happens when you’ve had a good night of sleep versus a bad night of sleep? What happens when you do yoga versus high intensity interval training? What happens if you add a lot of fat to your carbohydrates versus no fat? What happens if you take berberine? What happens if you take an apple cider vinegar shot before your meal, which in many studies has been shown to lower glycemic responses. Like what happens if you had cinnamon to your oatmeal instead of no cinnamon, which cinnamon is shown to be an insulin synthesizer, try these different things. And also I really suggest try, you know, walking after meals and see what that does. And that’s really just like exploratory, and we have some challenges that we can, you know, guide people with too sort of help them create these experiments for themselves. And really just start to see how these other factors are impacting the response.

Dr. Casey Means: And then fourth week I would really move into optimization phase. So take what you’ve learned from your experiences and just try and keep it flat and stable. So that’s really the time to see how much you can move the needle with everything that you’ve learned.

Melanie Avalon: So if listeners do it for the month and how does it work if they want to keep getting more sensors, is it starting over again? Like you still have, the account, is like the price the same. How does that work if they do want to use it indefinitely?

Dr. Casey Means: Yeah. Yeah. So right now we’re really set up mostly for this one month program, but people can subscribe if they want to. And we do have a very large number of people who want to subscribe, the main issue there is really is price point. You know, the hardware right now is still quite expensive. And the thing is, is that is going to change, I think, rapidly in the next six months to 18 months, there’s a lot of hardware companies coming down the pipeline and people really innovating for new hardware. And I think we’re going to see a huge drop in the prices as this technology becomes more and more widely adopted, especially by a wider market. So as those, those prices change for hardware, it’s going to be much more amenable to a subscription type product where people can use it long term.

Dr. Casey Means: So that’s the main barrier now, but if people do want to subscribe, we can do that for people for essentially it’s half the cost of the first month, because there’s, you know, they don’t have to go through the physician consultation again. And we will just essentially ship them two new sensors for the month to continue working with the app and with the program. But I think over time we’re going to see it could be, you know, people being able to use this more for like six months year, as long as they want, as long as it’s valuable for them as the prices come down.

Melanie Avalon: Awesome. Kind of sounds like the trend with blood glucose strips or testing keto strips, even though this is a slightly higher price point than that’ll have to keep our fingers crossed that it keeps dropping. So within the app, because there are different scores that it gives you because I got a lot of questions about, you know, can the everyday person interpret the data? Like how will we know what this all means? So what are the different scores that the app gives you? And like what user data can you input? Cause I know you can like log your meals and things like that. So, just like within the world of the app, how does it help users to, you know, learn the, the most that they can from, from their CGM data?

Dr. Casey Means: Yeah. Yeah. So in terms of data that you’re inputting, so obviously you’ve got the continuous glucose data stream and then people are logging their food in the app manually. And we try to make this as easy as possible with just like a really quick photo of your food and you can go back and, you know, annotate it later and put in the ingredients and then people can import their data through Apple Health Kit or Google fit to start getting their, you know, activity, sleep, heart rate data in there so that they can start correlating that with their glucose. So, that’s the data input. And then in terms of the interpretation, that’s really what we’re trying to make easy for people. So it’s tough to know whether going from, you know, 80 to 1 26 after a meal, what is the impact of that? You know, it’s tough to know.

Dr. Casey Means: And so we’ve created two scoring systems to make it easier for people. So one is what’s called the zone score and one is called the metabolic fitness score. So the zone score is a score that’s graded from zero to 10 and basically tells you how good or bad your meal was metabolically for you. So a 10 is like a perfect score. And a zero is, you know, a failing grade. This takes into account a lot of different aspects of the response to the meal. So things like, how long were you elevated? How high did you go? How far did you rise from baseline? Where did you start out? Like, what was your, what was your glucose before you started? And just taking into account? A lot of these different factors that we know are important for health and then turning them into the like one very simple composite metric with the zone score.

Dr. Casey Means: And what’s really cool about the zone score is that it doesn’t just take into account the food you ate, but also anything that you did around that meal. So clearly if you eat a meal and then take a walk, both of those things are going to impact the glucose outcome. So it’s not just a meal score. It’s actually what happened in that zone. And then there’s some neat comparison features where you can compare zones. So you could do, you know, oatmeal followed by a 30 minute walk. And that zone score may have gotten like a seven and then oatmeal followed by no walk. And that zone score may have gotten a five. And then you could do like oatmeal followed by gave a really stressful talk to my company like high stress. And that may have gotten a two.

Dr. Casey Means: And then you can graph those really nicely to basically show your, you know, show, okay, so this plus walk was the best. This plus no walk was worse and this plus stress was absolutely the worst. So that starts helping people guide them towards that metabolic toolbox and what metabolic awareness then the metabolic fitness score is a longer term metric. So this is actually looking at your whole day and giving you a percentage out of a hundred of where you stand metabolically. So this is taking into account, you know, the, the more longer term metrics throughout the day.

Dr. Casey Means: Like how many spikes did you have? What, you know, which is a term called glycemic variability. What were your averages throughout the day? You know, how much glucose exposure basically did you have, how quickly did you recover from, you know, your glucose spikes and, and that’s more of that, that longer term metric that tells you a little bit more about like where you’re standing, you know, not just how, what a meal did to you, but like how you might be standing like overall in your metabolic health. And so those are the two main scores we use to try and really make it easy for people to understand.

Melanie Avalon: So is that metabolic score? Is it based on what you were saying earlier in the show about the ranges of like 70 to 120 and like 92% of the population and being at certain amount, what is it based on?

Dr. Casey Means: So our sort of optimal range that we tell people in the app is 70 to 110. So the more people stay within that range, the closer they’re going to be to a hundred on their metabolic fitness score, but even within 70 to 110 people can be super stable and low or they can be like super up and down. So you still might not a hundred percent on your metabolic fitness score if you’re like going up and down all the time, even within the healthiest range. So, you know, or might people might be living in the higher end of that range versus the lower end of that range. So all of those things are taken into account to give this, this score. And it’s a score that’s under, you know, constant evolution. We are, you know, growing our know user base, we’re in a beta program right now. We’ve had about a thousand people go through the program, but certainly refining the score as we learn more from the data. So.

Melanie Avalon: Yeah, that’s the amazing thing about, you know, apps that they can constantly be updating and constantly making them, you know, adjusting from, you know, user data and all of that. That’s actually one thing. Do you anticipate having an update because right now, well, I guess it might be different too, if you use the other CGM. The, is it Dexcom? Dexcom? Yeah. Dexcom. Cause right now it’s like you scan with the Freestyle Libre app and then it pulls the information to Levels. Do you anticipate making it a one stop shop with like direct from the Levels app?

Dr. Casey Means: Yes. That is definitely the goal. And we’re, you know, we’re moving in that direction as rapidly as we can.

Melanie Avalon: I have some other just random, rapid fire questions. I know we’re running up on time. So one is, do you think there will be a development? Cause right now, at least with the Freestyle Libre and I don’t know how the Dexcom, how often you have to scan it, but it stores data for eight hours. So you do have to scan at least every eight hours. If you want to have the full picture, do you think they’ll make updates in the future where it’ll store 24 hours?

Dr. Casey Means: Actually, what is so exciting is that, so both companies, Abbott and Dexcom now made Bluetooth sensors. So these are going to actually send the data without having to scan it with your smartphone, which means that that eight hours is going to become obsolete because it’s going to be sending the data all the time. So the Abbot just released, what’s called Freestyle Libre two. It was just FDA approved and is making its way to pharmacies in the US. And that is Bluetooth. And so it’s going to send every 15 minutes that data to the phone and the Dexcom G6, which is the, the current model that’s widely used from Dexcom right now is already Bluetooth enabled. So, that’s sending the data every five minutes to your phone. So that’s very, very exciting because you know, it can be tough sometimes to remember to scan every eight hours.

Dr. Casey Means: You know, usually in the beginning of the program, people are scanning like every five minutes and you don’t just want to see that data constantly, but with the Bluetooth capability, it’s just coming automatically, no scanning required, and you’re going to have that higher fidelity data stream as well. Cause there’s going to be no gaps. So yeah. And just to clarify where people are listening. So with the non Bluetooth enabled older sensors, you have to hold up your phone to the sensor to transmit the data it’s called NFC near field communication. So you actually have to like have it close by.

Dr. Casey Means: And, you know, since the sensor only stores eight hours of data, if you like, wait nine hours to scan, you might lose an hour of data. So that technology has just been in advancing rapidly. And so we’re excited about the Dexcom offering coming up very, very soon with us, meaning that we’re going to be able to, you know, prescribe and send Dexcoms to individuals because you’ve got that Bluetooth capability. And you also have a really nice feature on the Dexcom that gets back to the accuracy question, which is a calibration feature. So you can do a finger prick home and actually calibrate your sensor to make sure they’re as accurate as possible.

Melanie Avalon: Oh, that’s interesting. Yeah. Because right now with the eight hours, cause I usually sleep longer than eight hours. So it’s like, I like wake up in the middle of the night and scan, which is messes with my, I don’t have my blue light blocking glasses on, in the middle of the night. So I know my centers are going to want to know is the Bluetooth the problem with EMFs? Is there an option still to do it the old school.

Dr. Casey Means: Way? That is such a great question. I don’t know the answer to that. Like if you can disable the Bluetooth and do near full communication, I’ll look into that.

Melanie Avalon: Or if it’s only Bluetooth, like can it be put into maybe like airplane mode?

Dr. Casey Means: Like I see. Yeah. Like not have it transmitting and then just downloading all the data every certain, you know, I don’t know. And I will, I got to look into that. That’s a great question.

Melanie Avalon: Cause I know they’re going to want to know and then, oh, okay. So there’s one like sort of larger general question that I meant to ask way earlier, but could you just briefly explain the difference between blood glucose levels, HbA1C and fructosamine which I feel like doctors don’t usually test fructosamine, but it seems that apparently that might be the perhaps a more accurate indicator of your blood sugar load.

Dr. Casey Means: So blood glucose values is just like, you can imagine like the level of circulating glucose in your circulatory system. You know, when you eat carbohydrates, glucose is, you digest the carbohydrates in it enters through your gut lining into the bloodstream and you get this, this glucose surge. And that glucose level, the body tries to keep it in a very stable range, as much as it can. It doesn’t want it to get too low. It doesn’t want get too high and we really need it to stay within a fairly, narrow range for just optimal functioning of the body. And then we talked earlier about the different ranges for glucose levels and you know, the ones that you’re going to hear about most clinically is under a hundred milligrams per deciliter for a fasting glucose being considered quote unquote nondiabetic normal.

Dr. Casey Means: So, so that’s, that’s just circulating glucose. Hemoglobin A1C is a longer term assessment of your average glucose level. So this is actually taking blood and they can test in a lab. This can’t be done at home, but can be done in a lab. How much of the hemoglobin in your red blood cells has sugar stuck to it? So, that’s glycated hemoglobin. Hemoglobin is, you know, the oxygen carrying molecule in the red blood cells. And since red blood cells last about 90 days in the bloodstream before they’re recycled, this can tell us essentially a 90 day average of our or glucose levels, which is in some ways helpful because you know, you can get a sense of like generally where your average glucose levels were. But what it doesn’t tell us is how much like ups and downs you had. So it totally misses like the whole glycemic variability part of things.

Dr. Casey Means: And, you know, your average glucose might have been 110 throughout the month, 110 milligrams per deciliter, which might, you know, lead to a certain A1C level. But is that because you stayed right at 110 the whole time, or is that because you were going up to one 50 and crashing to 60 and 70 all throughout the month and those two things are going to be very different health, you know, statuses, you don’t want that up and down swing. You want the stability. So, the helpful metrics or sort of general long term averages for your glucose, but missing quite a bit in terms of the granularity of the ups and downs and of course missing the biofeedback element, because it’s not going to help you really figure out what in your diet was. The thing that was the problem.

Dr. Casey Means: And then serum fructosamine is kind of similar to hemoglobin A1C, in the sense that it’s a glycated protein that can also enable assessment of long term glycemic control in patients with diabetes. And this is measured in relation to serum albumin levels because reduction in serum albumin will lower a fructosamine value. So that’s a test that’s like not frequently used, but I have seen very few doctors order this test, hemoglobin A1C is much more sort of mainstream. I’d say.

Melanie Avalon: I read. It was potentially more beneficial because like hemoglobin A1C, there could be false. I don’t know, it could be false positive or false negative. Like sometimes people on lower carp diet, perhaps their red blood cells were living longer. So they were showing higher levels of glycation, but it was because they weren’t dying earlier. And so fructosamine might be more appropriate.

Dr. Casey Means: There’s a lot of issues with hemoglobin A1C. One is like just the, missing sort of the variability component. It’s just really telling you more averages. And the other is what you just as said, which is that people have a lot of variability in their red blood cell lifetimes. It can be 90 days is about on average, but it could be 90 to 120 days. And hemoglobin A1C tends to pick up more preferentially what the most recent glucose was. So like closer to the time of the test. So, you know, it might be skewed higher or lower based on what happened really close to the test and not necessarily be like the best snapshot of the full picture. So I think we’re going to definitely move into a world where dynamic tests like wearing a CGM for a week actually will end up becoming diagnostic tools because you can just get so, so much more information about someone’s just like baseline metabolic health based on seeing what’s happening to the glucose over time.

Dr. Casey Means: Like what their one week average is what, what their area of the curve is after their meals. And this is stuff that’s really interesting. Michael Schneider, the head of genetics at Stanford, he has published a paper a year or two ago called gluco types, which was like different types of people basically based on their continuous glucose monitoring curve and their risk for future issues. So I think we are hopefully going to see a movement towards tests like that, that are, that are more dynamic and more accurate in terms of predicting the future for people. But for now what we’ve got is A1C, fructosamine which is much less used fasting glucose, and then the results of an oral glucose tolerance test, which is like I mentioned before the chugging, the glucose, and then looking at the 75 grams of glucose and then looking at the blood glucose at 30 minutes an hour and two hours after that. And those three things, fast A1C and oral glucose tolerance tests are the three standardized criteria for diagnosing diabetes in the US.

Melanie Avalon: Yeah, that was actually a question from a listener. She wanted to know if there was the potential, but in the future instead of an oral glucose test, maybe for pregnant women, if they could do CGMs, do you think that might all be in the future of like the medical system?

Dr. Casey Means: I very much hoped so, and it’s something that I’m personally, you know, pushing for, because one, I think, especially with gestational diabetes, you know, diagnostics, like we probably should not be having pregnant woman chug 75 grams of glucose with some of them have like artificial dyes in them and it’s just, it’s just yucky. But also it’s just, it’s just a single, you know, shot. Like it, it could be different on a Monday versus Tuesday versus a Wednesday based on hormone levels and how much sleep they got and how much stress they had in the parking lot before the test. And so it’s just, you know, I don’t think it’s probably capturing all the nuances of someone’s current health. And I would really love to see us to be able to clinically validate the results you’re seeing on a CGM and how those correlate with these other diagnostic tests. So we can start moving towards like this more nuanced diagnostics with CGM. I think it would be really positive for people.

Melanie Avalon: That’s so exciting. Yeah. She literally said, can MD please petition insurance companies with this rationale.

Dr. Casey Means: I’m on it, I’m on it. And you can imagine like, yeah, for, for like the, the average person walking around with maybe a normal A1C, like totally normal, their doctor says they’re normal, but then they would put on a CGM and their doctor might see huge variability and like big spikes after meals. But, they just haven’t gotten to that point where they’ve the insulin resistance has tipped over into just like really high, average glucose levels. But like that person you could potentially capture them and, and find out that they’re at risk so much earlier than just waiting for their A1C or their fasting glucose to rise. So what I’m most interested in, like, how can we capture more of the at risk population through these other aspects of glucose that we know are clinically important, like glycemic variability in A1C that we’re just ignoring right now. And maybe we could intervene so much earlier for these people who are certainly on the spectrum of moving in the wrong direction of metabolic health, but they’re lab tests that we standardly order just aren’t showing it yet.

Melanie Avalon: Yeah. This is so incredible. And I know like, you know, all of that is like on the doctor petitioning side of things, but I think what you’re doing, bringing it into like the popular vernacular and like making it a thing I think is so huge for the movement of making forward progress, just in general, on the health side of things with patients, as well as the general public, like you’re doing so, so thank you so much. I’m so grateful for your company. I’m so grateful. This conversation was incredible, really amazing. And so right now Levels is on a wait list, which is it still like around 40,000 or so

Dr. Casey Means: It is yes. And you know, so right now you can sign up for the wait list on the website levelshealth.com and we’re in a close beta program. So we’re working through the wait lists as quickly as we can, but yeah, we, we’re hoping to, you know, just really grow and scale our operations in the next coming months so that we can, we can just get everyone access to this product who wants it.

Melanie Avalon: So the show notes for today’s episode will be at melanieavalon.com/levels. But if you are interested in getting on board with this, you can go to mealnieavalon.com/levelsCGM. And that will actually, I think it’ll like put you to the front of the wait list.

Dr. Casey Means: Yeah so it lets you skip the 40,000 person wait list.

Melanie Avalon: Very exciting.

Dr. Casey Means: Yeah. So as opposed to waiting a long time, you can get to the front of the line. So excited to do that for your listeners.

Melanie Avalon: Thank you so much. I really, really appreciate that. And I know my listeners will as well. And so that brings me to the last question that I ask every single guest on this podcast, which relates to that. And it’s just because I’m realizing every single day how important mindset is surrounding everything. So, what is something that you’re grateful for?

Dr. Casey Means: I am so grateful that I actually got to spend the last five weeks. I live in Portland, Oregon, but I got to spend the last five weeks in rural Pennsylvania in Honesdale with my partner’s family. We actually left Oregon because of the wildfire smoke last month and flew out there. And it was just so wonderful and peaceful that we stayed for five weeks. So his poor family, but it was really, I live really in an urban environment here in Portland. And I was in a cabin looking out over a valley of leaves changing and it really helped me incorporate health behaviors, you know, into my daily life in, in a way that was, I think even better than I do here in Portland. So I was sleeping on a sleeping porch. So I was actually breathing fresh air all night. I woke up to seeing leaves.

Dr. Casey Means: I woke up to the sunshine and could not look at my phone for the first half hour of the day, because I was just like, there’s so much beauty to see. I was able to like, you know, brush my teeth, standing outside, looking at the leaves and like just everything on the property. Like you kind of have to walk a lot more. And so I was moving a lot more throughout the day. I was, you know, less artificial light sleeping with this fresh air. I also just read that book. You mentioned this on one on your previous episodes, the James Nester book Breath. And I loved it. So I was doing a lot of the breath stuff while sleeping outside and I think it like totally changed my dreams and like I was dreaming more and like, it just was kind of like everything related to stress, sleep, exercise, and food.

Dr. Casey Means: They’re very, very healthy, have a beautiful organic garden in their house. Like it was just like everything was, and I was working remotely from there, from this deck being outside, so like all aspects of just sort of like health behaviors were just easy. And I was also just around family, which was wonderful, like just people that were just so loving.

Dr. Casey Means: And so it just was such a reminder of like how much our environment shapes our health and you know, to really just like seek out environments that are going to encourage your best self and your best behavior for doing those behaviors every day that are going to generate, you know, the conditions in the body that are associated with feeling great and doing good work. And so I’m just so grateful for that time. Sorry, long answer to that, but it was just, it was really special and I really made me reflect on, on how much our lived environment and our surroundings like have an impact on, on the way we live.

Melanie Avalon: I love it so much. That’s why I love asking that question at the end. I think it’s like my favorite question, every episode, because it’s just so wonderful to hear and just puts a smile on my face and so, so important. So, thank you. This has been so amazing. I can’t wait to share it. My listeners are going to love it. Friends, get a CGM. It’s going to you away what you can learn. And I’m really excited to see the updates in the future and where this all goes. Because thank you. You’re doing really incredible work. So thank you.

Dr. Casey Means: Thank you Melanie. You are also doing incredible work and it was so great to chat with you and thank you so much for having me on. Thanks

Melanie Avalon: Casey. Thank you so much for listening to the Melanie Avalon Biohacking podcast. For more information, you can check out my book, What Win Wine, Lose Weight and Feel Great with paleo style meals, intermittent fasting and wine as well as my blog, melanieavalon.com. Feel free to contact me at [email protected] and always remember you got this.