#114 – Why is metabolic health fundamental to every aspect of women’s health? (Dr. Kimon Angelides & Dr. Lauren Kelley-Chew)

Women’s health encompasses a wide range of conditions and seasons in life, and metabolic health is part of all of them. Levels Head of Clinical Product, Dr. Lauren Kelley-Chew sat down with Executive Chairman and CEO of FemTec Health, Dr. Kimon Angelides to talk about the connection between the two. They talked about a holistic approach to healthcare, how healthcare has historically overlooked women’s health, and how metabolic health influences every area of women’s health.

03:55 – Looking for a holistic approach

The healthcare system only offers fragmented care to women during various stages of their life, and FemTec is proposing a more holistic one-stop solution.

So with women’s health, the reason I got into it is I saw that the market was so fragmented that there were a lot of point solutions in infertility, some point solutions in pregnancy, some point solutions in maternity and menopause. And goodness, that’s just not how someone carries on with their life. And that was number one. And number two, they were not coordinated. So once a woman gets pregnant, then do they have to actually find another provider or another service, whether it’s a digital service? That seemed absurd. And then the very last thing that I didn’t want to do, whether it was the Y chromosome speaking, is that I saw all of these companies were around the reproductive machinery of a woman. And I said that, reproductive machinery. That really didn’t create the sort of the whole holistic ecosystem around a woman. So that’s the journey and that’s what we wanted to build and that’s what we wanted to provide, a complete ecosystem of products and services at all stages, for women.

05:48 – Invisible diseases

Many neglected diseases are more common among women and less likely to be diagnosed by doctors who don’t believe their female patients.

When I was really looking at, in digestive, I was looking at, I guess you would call [it] invisible and neglected and stigmatized diseases. Predominantly, they were really sort of manifested by women. They were the chronic fatigue syndromes, the lupuses, the fibromyalgias. And it’s very often that most physicians, primary or otherwise, actually even GIs on the irritable bowel syndrome dismiss it as it’s all in your head. And so a large proportion are actually put on anti-antidepressants and a variety of different things. They have a real physiological substrate. So that really was the entry point. I saw these women who had invisible diseases. They say, “Well, you look okay on the outside,” but no one really knew they were suffering on the inside.

08:49 – Distinct differences

Healthcare and medicine has historically underserved women and underdiagnosed immune conditions more commonly manifested by women because the foundation of medicine is predicated upon the male body.

If you take a look at just the statistics, the epidemiology, the prevalence among immune conditions is much higher in women. That obviously tells you something about the underlying sort of immune system. Not worse or not better, it’s just different in terms of how they reacted. And then you have things, for example, like endometriosis that most Y chromosomes really couldn’t possibly experience or understand. PCOS and other types of things, the frequency of UTIs, for example, and things like that, or bacterial vaginosis, some simpler things, but more common. They’re just distinct differences that I don’t think medicine has particularly caterd to. And so I think this is a great opportunity to bring this to light.

27:12 – Breaking down sexual taboos

Being able to talk about sexual wellness as a part of women’s health is essential to treating the whole patient.

One thing I think, which is important, is I think there’s a new revolution in terms of… Just like we talked about IBS and things in digestive, there’s a new revolution in getting rid of the taboo and sexual wellness. Call it sexual wellness. It’s gone from what I think a lot of folks might have thought was, quote, pornographic or whatever. It is to really getting to a place, I think not quite there yet in terms of being clinically significant. And there’s just not a lot of outcome studies so far on that. But I think it’s an important component. And I think obviously, there’s a lot of physiology with it. There’s a lot of things that are associated with it. So I think it’s moved that direction.

28:19 – Sexual wellness and productivity

Sexual wellness has been proven to actually support productivity, which means providing quality care for women is crucial to building a successful business.

It really is part of the human experience. I’ll tell you one of the interesting things and I firmly believe it, but I think this would be really, a very high mark for an employer. There is indeed a very extensive literature in terms of sexual wellness, for example, and productivity at work. And that’s one of the things that’s really important yeah, for absenteeism and productivity. And so it’s a correct sell, to be honest with you. It’s a hard one to sell because it’s still taboo in that environment where you would say, listen, sexual wellness is a really important aspect to increase productivity. But there is good physiological, there’s good literature, scientific literature, peer-reviewed literature, that actually speaks to that. But it’s a hard one to introduce.

31:30 – Metabolic health is fundamental

A woman’s metabolic health impacts everything from heart rate to ovulation to sleep, making it a core part of healthcare.

We’ve got a device that will measure heart variability, it’ll measure temperature, we’re using it for ovulation right now, ovulation frequency, and sleep patterns. When you think about it, what could be more fundamental than all of those, for example, than metabolic health? You’ve got nutrition on one layer, you’ve got sleep patterns and you’ve got actually fertility here. Metabolic is, I think, fundamental to each and every one of those. So it’s super important. Those are some of the things that we’d like to obviously partner and get done because that’s a fundamental physiological parameter that needs to be integrated.

35:40 – Skin health and metabolic control

Insulin spikes directly affect hormonal levels, which directly impact skin health. The connection between metabolic health and skin is undeniable and ripe for more research.

Skin health is really a big one because you know what happens in people, not only women who have really high A1Cs, like 14 and 15, their skin gets glycosylated, the skin, the whole texture. So skin health really changes a great deal. That’ll be another one. And I think, as you probably know in terms of the physiology, when you get spikes, you get changes in the hormonal level as well. I don’t know specifically, but I think they’re going to drop out of this and I think it’s going to be really important to find out how metabolic control can control skin health, for example, and other types of things. I think that’s an exciting area, actually.

38:02 – Beauty as an entry point to healthcare

Self-perception and confidence is a path to igniting interest in routines and products that support overall health.

First of all, I’m a big believer in that beauty, and not just cosmetics, not just this transactional stuff, is really a continuum of who you are and how you perceive yourself in terms of your wellness and or your illness. And our perception of beauty, it shouldn’t be and oftentimes it is in terms of shapes and size and all that. Actually, if you take a look at our branding and stuff, it’s an expanding of the microbiome and they’re different shapes and they’re different oblongs and obtuse and things like this. And so it shouldn’t be body shape. But in terms of, and there’s some good clinical evidence, in terms of how people perceive themselves, in terms of whether they’re well or not, I think there’s a continuum. So I think there’s a great opportunity, just like you said, that it’s a great entry point in terms of engaging and motivating people, not only on the routine side, but also on how they actually feel about themselves.

45:30 – Researching IVF data

IVF is demanding both on families and on employer-sponsored healthcare plans, prompting more research to determine how to reduce failure rates.

We have another study with another institution, which will be announced, that’s looking at IVF. One of the concerns, obviously it’s a big concern, is that multiple attempts at IVF are not only really very difficult for the family, they’re extremely difficult for the family. So that’s why we do have some behavioral health to be able to help for those failures. But they’re also very costly for an employer. And so the question there is that what are some of the markers and some of the things that we might be able to do to reduce the risk of failure? What can you do to help? What is some of the background? So we have a couple of studies going on right now.

49:23 – Metabolic control is fundamental to reproductive health

Since we know metabolic health and reproductive health are intertwined, the next step is understanding how controlling one influences the other.

How could it not help? You have to ask that question. I mean, why wouldn’t you want to understand the metabolic control during pregnancy, for example, or even during an IVF? Why wouldn’t you want to? Again, I think it’s so fundamental that why wouldn’t it impact actual fertility? Why wouldn’t it impact pregnancy? Why wouldn’t it impact lactation? It absolutely has to, and it does. So, it’s fundamental.

Dr. Kimon Angelides (00:06):

When you think about it, what could be more fundamental than metabolic health? You’ve got nutrition on one layer, you’ve got sleep patterns and you’ve got actually fertility here. Metabolic is. I think, fundamental to each and every one of those. So it’s super important. Those are some of the things that we’d like to obviously partner and get done because that’s a fundamental physiological parameter that needs to be integrated.

Ben Grynol (00:39):

I’m Ben Grynol part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And this is your front row seat to everything we do. This is A Whole New Level.

Ben Grynol (00:51):

When it comes to our members, well, the majority of them are women, specifically women between the ages of 30 to 60. And while that’s a pretty broad range, there are so many different topics pertaining to women’s health at different ages. And so Dr. Lauren Kelley-Chew, head of clinical product at Levels, she sat down with Kimon Angelides. Kimon is no stranger to entrepreneurship. He’s a multi-time founder, recently of Livongo. And he started a company in 2020 called FemTec, very much focused on women’s health and aggregating many services, many products that can help women at different stages of life. So Lord, and Kimon sat down and discussed women’s health, as it pertains to things like metabolic syndrome. It’s a great conversation and here’s where they kick things off.

Dr. Lauren Kelley-Chew (02:03):

I’m really excited to have this conversation because I think there’s such a need for the work that you’re doing, actually at all of the companies that you’ve built. I have a lot of admiration for the areas that you go into, which I think are often areas that have such great need, but that there’s been hesitancy for people to enter, for example, digestive disease. But before we get into that, maybe you could just share your background what your journey to FemTec was like, and we’ll start there.

Dr. Kimon Angelides (02:31):

Yeah. Well, thank you by the way for that. Yeah. So the journey of that lonely Y chromosome to FemTec is an interesting one in that respect. But I’ve actually always been interested, and I think looked at the importance of really what I would call three things. And the first is really continuity of care. And so much of what we have now in healthcare, whether it’s digital or virtual, or whether it’s in the clinic essentially has really been fragmented. And so I’ve been really, a big proponent of trying to promote continuity of care. And that’s, like I had diabetes clinics, which originally were bricks and sticks facilities, where we actually coordinated the care for people who had diabetes so they didn’t have to go to five different places. And the same thing if you take a look at digestive, really the continuity of care, because there’s so many different types of services that folks need who have a digestive condition and the variability of the conditions are so great that it really does require a lot of services.

Dr. Kimon Angelides (03:28):

And then when you take a look at women’s health, and the reason we got into women’s health originally, when I went into Vivante, and before that Livongo, before when I went into it, I was really interested in trying to understand and use digital methods to track very subtle immune conditions or conditions that were really very subtle, and IBS being one of them of course. They don’t have well described symptomology, well symptomology they do, but in terms of diagnostics. So with women’s health, the reason I got into it is I saw that the market was so fragmented that there were a lot of point solutions in infertility, some point solutions and in pregnancy, some point solutions in maternity and menopause. And goodness, that’s just not how someone carries on with their life. And that was number one.

Dr. Kimon Angelides (04:16):

And number two, they were not coordinated. So once a woman gets pregnant, then do they have to actually find another provider or another service, whether it’s a digital service, that seemed absurd. And then the very last thing that I didn’t want to do, whether it was the Y chromosome speaking, is that I saw all of these companies were around the reproductive machinery of a woman. And I said that, reproductive machinery. That really didn’t create the sort of the whole holistic ecosystem around a woman. So that’s the journey and that’s what we wanted to build and that’s what we wanted to provide, a complete ecosystem of products and services at all stages, for women.

Dr. Lauren Kelley-Chew (04:56):

It’s an amazing journey. And for people listening who don’t know IBS, for example, is really one of the most common digestive diseases. It affects, you correct me here because my data’s probably a little bit old, but up to one in five people.

Dr. Kimon Angelides (05:08):

Yep.

Dr. Lauren Kelley-Chew (05:08):

But nobody talks about it. And I think there’s a real corollary there with what you’re talking about on the women’s health side. Even in fertility, you figure a condition like PCOS again, up to one in five women are potentially even above that, but very little conversation. What was the first moment where you realized that you wanted to work on women’s health rather than for example, going deeper into digestive disease? And I know Vivante continues, but in terms of your personal commitment in time.

Dr. Kimon Angelides (05:36):

Yeah. Well Vivante, actually 7Wire who invested, really one of our first investors in Livongo it thought also Vivante. So I guess they like the company, they like our company. So we’ve got a good [inaudible 00:05:49] basis. I think the realization is when I was really looking at, in digestive and I was looking at, I guess you would call invisible and neglected and stigmatized diseases. Predominantly, they were really sort of manifested by women. They were the chronic fatigue syndromes, the lupuses, the fibromyalgias. And it’s very often that most physicians, primary or otherwise, actually even GIs on the irritable bowel syndrome dismiss it as it’s all in your head. And so a large proportion are actually put on anti-antidepressants and a variety of different things. They have a real physiological substrate. So that’s really was the entry point.

Dr. Kimon Angelides (06:27):

I saw these women who had invisible diseases. They say, “Well, you look okay on the outside,” but no one really knew they were suffering on the inside. And so when I looked at women’s health, I saw the same thing. First of all, they’re so busy. I don’t know how they do it. I really don’t. Honestly, I’m an older person now. And the demands on women are just so incredible with care taking, families, being professionals, doing all of this. So having to go to five different places to get nutritional support or gynecology support or going diagnostics, I said, this is absurd. And then the second thing, as a physician, you for example, understand that almost most of what we know is crazy. Most of what we know actually came from men’s health. And so the physiology doesn’t translate.

Dr. Kimon Angelides (07:20):

The last thing I’ll say on this is that when we started to look at really what are the differences, if you take a look at the genetic level, we’re all the same genetically in that respect. It’s how we express our genes, number one. But then also if you take a look at the microbiome, what lives on a woman on the skin and the hair and the vaginal microbiome are completely different. And so there really are unique fingerprints on the physiology that I think we really haven’t taken advantage of in terms of delivering the types of products and services that really are specific. So that really excited me, to be able to have that continuity and develop some things that were really specific for women’s physiology. The biology speaks and so that really is important to me.

Dr. Lauren Kelley-Chew (08:10):

I so appreciate that. And just as an example of what you’re describing, I remember in medical school, when we were learning about the symptoms of a heart attack and there were the conventional and unconventional symptoms, and it ends up that actually the unconventional symptoms are the symptoms that oftentimes women experience. And so there’s just this whole terminology around what is normal and abnormal, that was really based on medical research based on men. And even within that men of a narrow racial background, I think if I’m correct, it tended to be white men from certain places, and that just doesn’t reflect the entirety of the world. And certainly it doesn’t capture the female body fully.

Dr. Kimon Angelides (08:48):

Well, totally. If you take a look at just the statistics, the epidemiology, the prevalence among immune conditions is much higher in women, and obviously, tells you something about the underlying sort of immune system. Not worse or not better, it’s just different, in terms of how they reacted. And then you have things, for example, like endometriosis that most Y chromosomes really couldn’t possibly experience or understand. PCOS and other types of things, the frequency of UTIs, for example, and things like that, or bacterial vaginosis, some simpler things, but more common. They’re just distinct differences that I don’t think [inaudible 00:09:29] particularly cater to. And so I think this is a great opportunity to bring this to light.

Dr. Lauren Kelley-Chew (09:35):

I completely agree. So let’s talk about FemTec. You mentioned wanting to have a solution for a woman’s life journey without necessarily being centered completely around fertility or around reproduction. Where do you start, in terms of where your solution starts in a woman’s experience?

Dr. Kimon Angelides (09:52):

Yeah. Well, thanks, that’s a great question. And we’ve thought a lot about how we do this. And again, it’s not unlike really some of what you would call chronic conditions. So we didn’t really want everything centered around the reproductive capacity, because there are other things. If you take a look at sort of this large sphere, there are things like behavioral economics really, which do impact. There’s a stress factor associated with that. And there really is a gender difference with respect to even how behavioral economics and how people manage their sort of life. There’s the caretaker voyage too. So that has to be put into the mix because these are all things that are stress inducers, for example, that are also influenced by the hormonal balances that go through suit too. So it’s a complex system that really requires complex things.

Dr. Kimon Angelides (10:39):

And it can’t be just binned along, oh, menstrual activity, for example, reproductive activity, pregnancy, not pregnant. And so that’s how we did it. So we constructed things, at least to start with, what we call journeys. We could get rid of sort of the age difference. A lot of the solutions that are out there, like fertility, they’re only good for people between this age and this age, and they don’t really consider women who might be 40 or 50 plus for example. So a couple of them, like sexual wellness is one. That doesn’t have really age group. And depending upon where that transition is, or any of the transitions, age transitions, there’s something along that journey at different needs at different stages, of course, that might be. Hormonal balance. We call it hormone balance for example, and that’s really different in terms of the adolescence versus someone who’s in perimenopause.

Dr. Kimon Angelides (11:31):

And so we’ve constructed these journeys so that they actually have the tools and the support or the ecosystem that supports them. So it’s like a sliding scale if you will. And depending upon the vaginal microbiome or depending upon their diagnostics, whether they have AMH, anti-mullerian hormone or FSH, LH, we can actually create this ecosystem of products.

Dr. Kimon Angelides (11:51):

So we have probiotics, we have vitamins, we have supplements that we’ve made that actually match the biology of the woman at that state. Again, it might not be age dependent. And then we have the services that support that, for example. And so they can easily go from one transition to another, for example, through those, depending upon that flexible ecosystem. So that’s what we did. We made it journeys, we’ve got wellness, we’ve got reproductive, we’ve got sexual wellness, we have UTI and vaginal health. We have beauty, and I’ll explain that in a minute because beauty is a really important component here for us as part of the wellness journey. And then we just put everything underneath that essentially, so that we could support them at any particular stage that they were at. So that’s how we did it.

Dr. Lauren Kelley-Chew (12:36):

Really interesting. And it sounds like then people start with a diagnostic. Tell me what’s the initial experience of a new user.

Dr. Kimon Angelides (12:45):

Well, some of the things that we have, here’s the underlying things. We have diagnostics and the diagnostics come in different flavors, if you will. We do microbiome. So we’ll do a vaginal swab from microbiome, or we’ll even do a skin microbiome. And so that comes into your box, in your kit, which is really, if you take a look at, they’re bold and they’re bright and they’re really sort of cheerful. And we have UTI OTC and over the counter UTI, we have bacterial vaginosis. But we do have a microbiome kit. And then we have about 40 different types of individual kits and five prepackaged kits. So for example, there’s STI kits, there’s a wellness kit, there’s a fertility, reproductive or hormonal balance I should say. That’s an entry point with respect to questions.

Dr. Kimon Angelides (13:32):

We understand where you are. We get questions and we configure your box such that you’ll get a vaginal microbiome. Vaginal microbiome goes to the lab and we don’t overburden you with all of this bacterial stuff. Really, the key items are some of the pathogens that might be there. And then you really want to know what are some of the factors that might lead you and the vaginal microbiome for STIs, even endometriosis, PCOS, preterm labor. That gives you a pretty good indication, really where you are, and then even does change during menses. So diagnostics is one.

Dr. Kimon Angelides (14:04):

We have a telemedicine network. The telemedicine network can do the same things, but that telemedicine network is different in the sense that it’s curated for women’s health. We have 900 physicians who are not OBs, but understand women’s health to the extent that they understand what supplements might be better. We have a nutritional network registered dietician of about 1,600 dieticians that provide actually evidence-based diets. That’s a company that we just acquired out of Mass General and Harvard that have 60 different conditions along that course. And then we have our products and we have our products.

Dr. Kimon Angelides (14:42):

So last thing I’ll say on this is that for example, once we know, and the vaginal microbiome, we know what that the ecosystem or that community group is, then we provide probiotics to make sure that we either maintain or restore the normal flora. For example, when you get dysbiosis, oftentimes bacterial vaginosis comes in. Instead of using antibiotics, then we have probiotics that are patented, that will actually come in and restore that normal flora. So those are the types of things, diagnostics and the products to match that, plus telemedicine and nutritional type of support together with that.

Dr. Lauren Kelley-Chew (15:18):

It really does add a whole layer, multiple layers actually of care that I know from my own experience are not typically available. I’m curious in terms of people finding FemTec and deciding to enter that care pathway either as a supplement to, or maybe even, and I’d be curious, as a replacement to their traditional care, is there an event or something that tends to be the moment when the women say, “The conventional system is not working and I’m going to look for something else,” how do people find FemTec and start using it?

Dr. Kimon Angelides (15:51):

Yeah, great question. So there are a couple of things. First of all, we’re looking and we’re working actually in the D2C, the direct to consumer market, and that’s been facilitated by some of the acquisitions that we’ve made, Birchbox being one of them, the subscription service.

Dr. Lauren Kelley-Chew (16:08):

Congratulations.

Dr. Kimon Angelides (16:10):

And that’s where beauty comes in and I’ll get to that in a minute. And the second one is another company called Liquid Grids, which really has a curated network of women in various condition, specific types of things and groups. And so we’ve been able to market and direct to consumer there. It’s priced at 99 or around 99. And as it turns out, actually many of the things that are in there essentially, some of them actually can be paid on an HSA, health savings account. So there’s not a lot of out of pocket in that respect.

Dr. Kimon Angelides (16:41):

Some of the things we are trying to get reimbursed right now in the test. So ultimately, there might be some cash pay and we find that many women want this kind of concierge service because they can get scripts included in that, antibiotics. So the price point is not so high such that it’s not affordable with a minor co-pay or something on HSA. So that’s on the direct to consumer. The B2B, that’s an area that we’ve worked in, our team has worked in with employers and health plans. And most of the services, other than the supplements, which can be paid off on HSA, are really covered under reimbursements. And so they’re typical services that are already covered and like the other business, like I did with little Livongo and Vivante, they’ll be covered services under those payers, under those health plans. That’s how it’ll be paid for.

Dr. Lauren Kelley-Chew (17:34):

It’s a really interesting model, and I think actually very compelling because I think I remember you and I spoke about this in the past. But I really think it’s been very hard for these digital disease management companies to find business models that work, where you’re having to create evidence, not just that there’s clinical efficacy, but also that there’s cost savings. Often, if you want to establish a new type of contract with a payer or to get it covered even as part of an employee benefit. And so I think it’s really a nice solution that you’re creating a portfolio essentially, of solutions, services, products for women that payers have already said, “We believe these are valuable and we will cover them.” But you’re changing the way that women can find them.

Dr. Kimon Angelides (18:13):

Well, you’re absolutely right, actually. They can find us because we’re just beginning campaigns to be able to advertise it. That’s on the D2T. So they’ll see a lot more of us with respect to marketing on the outside as a direct to consumer. But really the key, and you know this, that when you go into an employer, assured they want their employees to be healthy. But because they pay for most of the healthcare, they really want to get a return on their investment. And one of the things that we’ve done, I think right here, and that’s from years of experience, we have a large team of data scientists, about 25, almost 30 data scientists. We’re right now analyzing claims from 44 million women over a six year period, to be able to understand what are some of the markers that proceed serious disease so that we can intervene, using predictive analytics so that we can come into an employer and say, “Look, here are the potentially high cost items that you’ll see, but here are the current items that you’re paying for right now.”

Dr. Kimon Angelides (19:19):

They don’t want to pay anything extra for our service, no matter how good it is. And these digital health startups think that generally. They’ll come in and they say that an employer or your solution is so wonderful, we’ll pay extra. They don’t want to pay extra for it. So you have to figure out, and that’s why we’re really data sensitive is really where you can come in, understand what the cost structure is, know what your intervention is, so that you can save the money and go ahead and do it and take the risk. We spend a lot of time doing that and that’s the only way it really gets by.

Dr. Lauren Kelley-Chew (19:50):

A very wise investment because I think oftentimes when people are thinking about companies like yours or any of these, like I say, disease management companies, it’s hard to imagine the number of haircuts that happen in between, for example, even getting that enterprise contract with an employer and the number of users. And then if you’re right, if you’re sharing risk, it’s not even the number of users you have, it’s the number who have had clinical efficacy or whatever the other outcome is that you’re tracking. And it goes from, we just contract with a 20,000 employee company to we have 400 users, that we can prove benefit. And that’s where the money’s coming from. It’s an incredibly hard thing to do.

Dr. Kimon Angelides (20:25):

It is. You’re absolutely right. So I’ll use the analogy. You really have to have the plane already built before you go into one of these employers. And you’re right, it’s a statistical argument to look at the employer. So you need to know what the data looks like when you’re going in. And if there really aren’t a lot of high costs, it’s hard for us to provide value to an employer that A, doesn’t pay very much for their benefits. And so you might have a great contract with an employer who’s well known, but they don’t pay very much. So there’s no point in doing that, because you’ll never get there.

Dr. Kimon Angelides (20:59):

Versus an employer who really is concerned about their employees and will let you essentially do what you think you need to do on the intervention. And so you have to be really very selective in that respect and you have to be armed with data before you go in and you can’t collect it as you go on. So you know what it’s like. And you can spend a couple of years and you can see that here at the end and you really haven’t really moved the needle a lot.

Dr. Lauren Kelley-Chew (21:23):

Exactly. I’m curious, because I haven’t been in this world in quite this way in a few years, have you found that employers have gotten increasingly more savvy in terms of how to analyze and assess all these potential digital health solutions? And I compare that to payers where, of course, as you know, payers have entire actuarial teams. They’re very sophisticated in their understanding of risk. That’s their bread and butter, is understanding risk. But at least a few years ago, I think employers, especially for solutions, for conditions like digestive disease, where there wasn’t as much of an understanding or acknowledgement of what the real toll is, has that changed where there’s just a lot more understanding of what matters when selecting a solution?

Dr. Kimon Angelides (22:07):

Yeah. That’s a great question. You understand that. You understand that a lot. So first of all, I think employers are benefit folks nowadays. I started in this area, back in 2004, with diabetes. They’re a lot more savvy. Just because there’s a lot more point solutions there. They don’t necessarily understand the medicine or the clinical, and then I’ll get to that, why digestive is one of them. But they understand that they do need to do something, to be able to provide a good service to their employees. The health plan doesn’t always do that. They’ll come with some programs. But it is really incumbent upon them. And some of the employers are pretty savvy because they do have actuarials, either they partner with some of their brokers. And so that’s why we as a company, for example, have to be pretty savvy because we have to have all that actuarial analysis because someone’s going to do it anyway. So we better do it right. We better go in there, so we know what we’re talking about because the most sophisticated ones are going to be ready, employers.

Dr. Kimon Angelides (23:09):

So I think that’s really large part that the employers really have gotten a lot more savvy. Like you say, the health plans, this is what they do for bread and butter. And again, if you’re not prepared to go toe to toe with it on the same set of data, then it’s going to be a hard sell. It’s going to be a hard sell to come back essentially and give them what their return is.

Dr. Kimon Angelides (23:30):

But as you know, as a physician, again, here’s the key. The key is you need to know some medicine. You can’t do this as a tech play. You know this really well because digestive disease, it took at least a couple of years to be able to educate people. They just didn’t know. How could this be a problem? And so you got a couple of years. Women’s health is a little bit different, but it takes a couple of years and you need to understand what the clinical pain points are really. And so you need to be savvy as a company and understanding what really the medicine is before you can really do anything. The numbers don’t mean anything if you don’t know anything about the medicine. Right?

Dr. Lauren Kelley-Chew (24:13):

Completely. Completely. It’s interesting actually that, as you were saying that I was thinking to myself, this is an interesting example of, I believe that in general, HR and people organizations at employers still tend to be female heavy in terms of the composition of those teams. So this is actually an instance where you’re selling to people who really understand the pain points potentially. And of course, every woman’s experience is different in terms of interaction with the healthcare system. But that’s actually a pretty unique thing. And the reason that I was thinking of it is because that was some of my experience with IBS, is it is so common that when you’re trying to sell a solution for that, it may be that it’s not on the top five priority list for a company, but the person that you’re selling to very well may have IBS.

Dr. Kimon Angelides (25:03):

100%. 100%. You hit it exactly right. And that’s where you click, by the way, because it becomes a personal experience. And that’s part of the education. The other four don’t get it, but that one does out of the five. But you’re 100% in our particular case, look, we’re dealing with 50% or even 70% of the population and an employer who would be female. What’s odd, of course, would be me as a guy, and I’ll say this right off, I don’t understand it all. I don’t. There’s no way I can. And I don’t understand how certain things feel. I can understand it from a clinical point of view and I can understand it, and that’s why in essence, we have a all female team because they understand it. They teach me, but I still can’t understand it because I can’t experience it. So I think that’s where we’re really on par with some of these employers and the benefits is that they understand each other and they understand where the things that need to be shored up as well. So that’s where we’re at on that.

Dr. Lauren Kelley-Chew (26:06):

I appreciate you saying that because I think it is so true that you can’t really understand an experience unless you are having that experience. And has it been uncomfortable at times, I guess to be leading in this space as a man? How has that played out? I’m curious.

Dr. Kimon Angelides (26:22):

Actually, let’s put it this way, I’m led by the women in the company. So I’m just the facilitator to bring everybody together. So I think that’s my role. I enjoy it thoroughly. It’s challenging at times, no question about that, there’s no question about that. But to be quite frank, actually I do get frustrated sometimes because I can’t understand it because I haven’t experienced it. And I’m an experimentalist or experiential type of individual. So I can only abstractly, like doing a bench experiment. And is it uncomfortable? I think I’m way past anything uncomfortable. I’ve seen a lot, by the way. I’ve seen tremendous amounts, things I can’t understand, but I think generationally, they probably fit in the right context.

Dr. Kimon Angelides (27:12):

One thing I think, which is important and is I think there’s a new revolution in terms of… Just like we talked about IBS and things in digestive, there’s a new revolution in getting rid of the taboo and sexual wellness. Call it sexual wellness. It’s gone from what I think a lot of folks might have thought was, quote, pornographic or whatever it is to really getting to a place, I think not quite there yet in terms of being clinically significant. And there’s just not a lot of outcome studies so far on that. But I think it’s an important component. And I think obviously, there’s a lot of physiology with it. There’s a lot of things that are associated with it. So I think it’s moved that direction. And so that’s something that is new to me too.

Dr. Lauren Kelley-Chew (27:56):

Yeah. It’s such an important area and I think there’s been an overall acceptance across multiple fields, that this is a core piece of the human experience and it impacts everyone in some way, in so many ways. And I so appreciate that you’re pulling these things into the dialogue because like you say, it takes years to turn the tide and you have to start somewhere.

Dr. Kimon Angelides (28:19):

Well, well said you said it really is part of the human experience. I’ll tell you one of the interesting things and I firmly believe it, but I think this would be really, a very high mark for an employer. There is indeed a very extensive literature in terms of sexual wellness, for example, and productivity at work. And that’s one of the things that’s really important yeah, for absenteeism and productivity. And so it’s a correct sell, to be honest with you. It’s a hard one to sell because it’s still taboo in that environment where you would say, listen, sexual wellness is a really important aspect to increase the productivity. But there is good physiological, there’s good literature, scientific literature, peer reviewed literature, that actually speaks to that. But it’s a hard one to introduce.

Dr. Lauren Kelley-Chew (29:05):

It is. And I would think that there’s also a lot of interesting interconnections here to other areas of health that are known to be important, for example, loneliness. And that’s not to say that loneliness is necessarily completely connected. But in any individual’s experience, there’s a lot of crossover in terms of mental health, sexual health, just everything is interconnected. And I think, like I said, I hope that there’s an increasing awareness that is the case. And even at Levels, not to plug Levels, but our feeling is that metabolic health, it links to mood, it links to everything.

Dr. Kimon Angelides (29:36):

Well you’re on the right path though, too. I think that’s a great example what I think Levels has done here too. I think it’s really a good example. Look, continuous glucose monitoring, and we were actually with some of the Dexcom and then you met some of the original users of that. It was actually only applied to what you would call chronic disease. And when you think about it, by the way, and you know this better than I do, when you start to think about it, why would it only be disease?

Dr. Kimon Angelides (30:04):

Well, I guess because people with diabetes needed to control their blood sugar. But isn’t actually metabolic control fundamentally what we do in our physiology all the time. It gets converted through all of this and this is what we do to make ATP and to do all the things that we do. And so why wouldn’t we want to monitor this? Why wouldn’t we want to monitor other sort of electrolytes? So I think it’s like a fundamental principle. So I think what you’re doing at Levels is bringing it into the mainstream of that rest of the 90% of the folks who really need to benefit as part of their daily lives. So I think it’s important.

Dr. Lauren Kelley-Chew (30:41):

I agree. I’m very biased because this is where all my energy and time goes. But I agree. And I’m curious, is there an overlap of metabolic health in terms of FemTec right now in the solutions that you’re offering?

Dr. Kimon Angelides (30:54):

Yeah, to be quite honest with you, this is really important. It’s really important, it’s fundamental. And so I’ll put it in the context of the way we’re thinking. First of all, if you think about the products that we have, our supplements, vitamins, probiotics, and all that, think about it, the company that we’ve acquired, that’s joining us that is actually using evidence based nutrition that have outcomes, clinical outcomes for 60 different conditions, including PCOS, reproduction, all those types of things. That’s obviously important when you’re not well and when regular meds don’t work.

Dr. Kimon Angelides (31:28):

And then when you think about, we’ve got devices/ we’ve got a device that will measure heart variability, it’ll measure temperature, we’re using it for ovulation right now, ovulation frequency, and sleep patterns. When you think about it, what could be more fundamental than all of those, for example, than metabolic health. You’ve got nutrition on one layer, you’ve got sleep patterns and you’ve got actually fertility here. Metabolic is, I think, fundamental to each and every one of those. So it’s super important. Those are some of the things that we’d like to obviously partner and get done because that’s a fundamental physiological parameter that needs to be integrated.

Dr. Lauren Kelley-Chew (32:07):

I agree. And that’s a lot of where I spend my time at Levels is just thinking about what this interplay is between what we would think of as conventional clinical conditions and these underlying metrics of health that really are the foundation, I think of all of this. And you mentioned microbiome. I’m curious, how does that work? Is that something that people do when they first join, when they feel like it, throughout their experience? And how does that intersect with them, the products that they choose to select?

Dr. Kimon Angelides (32:37):

Yeah. So they can do it throughout each of these voyages. But let me give you one really good example. For some folks, for some women for example, who might have recurrent UTIs, there’s a very distinct fingerprint, if you will, for that dysbiosis of the microbiome, the vaginal microbiome. Okay? And so we’ve developed certain formulas, proprietary formulas, with ingredients, if you will, and strains that have been clinically shown to be able to stop and or reduce that recurrent UTI. So you can restore that so that you have a vaginal microbiome that is more resistant rather than having to think about doing something else and using antibiotics.

Dr. Kimon Angelides (33:22):

Same thing with bacterial vaginosis. And that really is a dysbiosis, there’s a particular strain that keeps the vaginal pH at four and a half, as you know. It produces lactic acid. When that one gets out of whack, all the other bacteria, because they like the higher pH, start to grow. And there you go, you start to have that issue. And so we have a formulation that actually will restore that ecosystem and start producing lactic acid by the symbiotic bacteria there. So that’s why we would do a microbiome test essentially, and then match the therapy. We can always go to antibiotics, but to match the therapy, to restore the normal ecosystem.

Dr. Kimon Angelides (34:04):

Yeah. But getting back to metabolic, for example, I think it’s fundamental and I think what you’re doing is extremely important because… And using this type of technology, by the way, here’s where I think it’s going to ultimately be super important. You’re going to get a big enough, it’s like having millions and millions and billions and billions of [inaudible 00:34:24] out there. When you can start to apply AI and machine learning, as an example, to find out what are really the outliers when in the metabolic and to find out what are some of the biometric signals that you would’ve never seen before if you had done spot testing.

Dr. Kimon Angelides (34:40):

So I think what you’re going to see is you’re going to figure out some metabolic variability by this large statistical and that’s going to be extremely valuable because you’re going to provide really good places to intervene. So I think that’s super exciting on that 90% who already haven’t been diagnosed with heart disease.

Dr. Lauren Kelley-Chew (34:59):

I completely agree. And are there specific areas when it comes to metabolic health and women’s health? We’ve talked a little bit about PCOS. Are there other areas where you suspect there’s a lot of improvement to be had from understanding someone’s blood sugar control and then modifying it?

Dr. Kimon Angelides (35:15):

So PCOS is probably the easiest because there’s insulin resistance that comes there. But I guess the long and short of it is that we really don’t know enough about the patterns, I guess. I think the next one would be cardiovascular. Cardiovascular disease is pretty obvious and kidney disease and things like that, kidney conditions.

Dr. Kimon Angelides (35:34):

And there’s a literature out there because we’ve looked at it, two things, and I’ll tell you the corner cases. Skin health is really a big one because you know what happens in people, not only women who have really high A1Cs, like 14 and 15, their skin gets glycosylated, the skin, the whole texture, so skin health really changes a great deal. That’ll be another one. And I think, as you probably know in terms of the physiology, when you get spikes, you get changes in the hormonal level as well. I don’t know specifically, but I think they’re going to drop out of this and I think it’s going to be really important to find out how metabolic control can control skin health, for example, and other types of things. I think that’s an exciting area, actually.

Dr. Lauren Kelley-Chew (36:18):

I do too. And I think what you said about meeting large scale populations to study this in where we can move past, just saying someone does or doesn’t have PCOS. For example, to say, actually, like you said, when you spike your blood sugar, maybe that was linked to a cortisol spike, and that then impacted your sleep. These things are much more nuanced than I think our current medical terminology can capture.

Dr. Kimon Angelides (36:40):

Totally. That’s a great example about cortisol spike and sleep. And you’ll be able to pick that up and be able to look at sleep and things. And so there’s some very specific areas you’ll pick up and I think that’ll improve the general health. I don’t think it’s entirely, and you know this better than I do of course, I don’t think it’s really entirely about glucose control. It’s really what your metabolic system looks like relative to all the other types of things that are going on, physiologically.

Dr. Lauren Kelley-Chew (37:08):

I agree. And your comment about skin is so interesting. One, because I think the physiology is so interesting and two, because oftentimes, beauty and some of these more aesthetic pieces of the underlying health condition are actually, I think what can get people motivated to start to make changes. So they’re really important. And not to say that beauty in general isn’t important, depending on what any one person prioritizes, but I think it’s such a powerful way to create behavior change sometimes. And I’m curious, you’ve mentioned beauty a couple times in this conversation, and it sounds like you mentioned the acquisition of Birchbox. I’m curious what FemTec is doing in relation to beauty?

Dr. Kimon Angelides (37:48):

Some people in the healthcare area said, “Well, why would you want to buy a subscription in terms of beauty?” It’s been fascinating and it’s been incredibly rewarding and fun. It’s just been amazing eyeopener. I wanted to do two things on this. First of all, I’m a big believer in that beauty, and not just cosmetics, not just this transactional stuff, is really a continuum of who you are and how you perceive yourself in terms of your wellness and or your illness. And our perception of beauty, it shouldn’t be and oftentimes it is in terms of shapes and size and all that, and actually, if you take a look at our branding and stuff, it’s an expanding of the microbiome and they’re different shapes and they’re different oblongs and opportunities and things like this. And so it shouldn’t be body shape.

Dr. Kimon Angelides (38:35):

But in terms of, and there’s some good clinical evidence, in terms of how people perceive themselves, in terms of whether they’re well or not, I think there’s a continuum. So I think there’s a great opportunity, just like you said, that it’s a great entry point in terms of engaging and motivating people, not only on the routine side, but also on how they actually feel about themselves.

Dr. Kimon Angelides (38:57):

And we did a survey in the Birchbox, we have it. And almost routinely people said, “Why do you put on cosmetics?” And then they routinely said, “I feel really good. I feel confident. I feel proud of myself. I felt I have more self-esteem.” And that’s a great entry point for healthcare, honestly. When you take someone, for example, who might not be, well, one of the first things you do, you need to get them back to a place where they actually feel good about themselves. You can’t operationalize that. So that’s why we purchased it and that’s why we acquired. And that’s what we’re trying to change, essentially, bring in the beauty into healthcare and a little bit more healthcare into the beauty aspect to make that continuum.

Dr. Lauren Kelley-Chew (39:37):

This is really a full circle moment for me because years ago, when Birchbox first started, I was working for a venture capital firm and it was a seed firm and, actually pre-seed. And we were looking at Birchbox and I remember going to their very, very early website, and we were just thinking to ourselves, okay, $30… I think it was $30 a month for a box of beauty products. And that idea of a subscription, curated subscription box, was still very new actually. And I remember trying to figure out the business model and whether people would pay. And so to hear that now you’ve acquired it and you’re really using it to put towards health when thought about in a very holistic way and really as an accelerator for people to start on their health journey, it’s really exciting for me. I’m really excited to see what you do with it.

Dr. Kimon Angelides (40:19):

Well, it’s fun. We have over 200,000 women that we’re providing products to every month. So that’s been really good too, because it gives us an opportunity to listen. We haven’t always listened probably in the best way. We’ve made mistakes, but I think we’re getting better at that. To be able to use that community, they’re engaged to be able to start giving them products that actually work. That’s the one thing that I saw in this market, that there are a lot of cosmetic products. If you go to the store, Sephora, Alta and those types of things, they’re just overwhelming number of products. But because we’ve been focusing on healthcare… Just like you know, you have to be outcome driven. We don’t want to sell products that we don’t think are going to work. And so we’ve changed the model such that we’re really going to be insistent on products that actually work for you as an individual and work on your biology. So to me, that’s really exciting to be able to bring really good products to women that actually have outcomes.

Dr. Lauren Kelley-Chew (41:23):

I agree. And it sounds like you’re really… Your product offering is really expansive. It’s very impressive. And many of these are synergistic with each other, like you said. I’m not sure exactly how the tracks work, but I would imagine that someone could be on a, let’s call it PCOS track and also on a beauty track.

Dr. Kimon Angelides (41:39):

Totally.

Dr. Lauren Kelley-Chew (41:40):

And those two actually play off each other really well.

Dr. Kimon Angelides (41:43):

Totally. Honestly, there are folks, women, for example, that have PCOS who wouldn’t know that they have PCOS because normally some people associated PCOS actually with clinical obesity, for example. But that’s not always the case actually. And so by and large, we’ve heard from a lot of women who have PCOS that the beauty aspect is really an important aspect. And so you hit it exactly correct. Exactly correct. And so I hope we can make inroads there because I think it’s an important problem. And I think, well deserving sort of community there.

Dr. Lauren Kelley-Chew (42:24):

I agree. And I think there’s so much emotional energy for women and I’m sure for men too, but not being a man, I haven’t experienced that. But collective emotion, energy that goes into all of these things that we’ve discussed. And yet, there’s not really a very public dialogue about it. And to your point, there hasn’t been much resourcing. And even when you look at venture funding for, I guess, what we traditionally call women’s health or FemTec, it’s been very little and it’s rapidly increased in the last couple years, but it still makes up a tiny percentage overall funding. Especially when you take out things that are related to cancers and specifically breast cancer, it gets even more, a much, much smaller piece of the puzzle. So I think it’s so important and I’m so glad that you’re bringing it to the forefront.

Dr. Kimon Angelides (43:05):

Well, thank you. Like any of the things it’s true, I have a really a great team. I have a really great women backed team. Ultimately, we will bring on a woman CEO for the reasons I explained. I can’t get it, and I think this area deserves a spokesperson who really can use this podium and this platform. But our team is really, and not to brag too much, our team has really done a marvelous job. Look, we started this in May of 2020. We started in 2020. I was able to bring on some extremely talented women from some really great places. They’ve done a tremendous job. You’ve been in startups and you are now. It oscillates between moments of incredible joy and chaos. And you set these deadlines and you get these deadlines because you’ve got to launch. And then you say, “How am I possibly going to make this?” But guess what? You do.

Dr. Lauren Kelley-Chew (44:07):

Yep. It’s interesting because I was listening to a podcast recently about running, and I think this was what Ryan Hall said, the famous American marathoner. He said, “Everyone always says it’s a marathon, not a sprint. But what people don’t understand is that oftentimes, at any given mile of a marathon, it actually is at sprint pace.” And that really spoke to me in terms of startup life, because it is a marathon and a sprint, especially in healthcare. But every mile is its own sprint. I’m sure you’ve experienced that as well. And I’m curious on that note, and also this is just thinking in terms of potential partnership or ways that we can collaborate, do you have a research arm or an area of the company that’s focused on doing, like you were mentioning, some of those larger scale data science efforts?

Dr. Kimon Angelides (44:52):

Yeah, we do actually. So we do have a large data science team that’s doing this. But we do actually have two IRBs there, approved IRBs. We’re doing a study right now in the large population. And that’s partly where Liquid Grids has really been, or that community’s been really good because they have curated communities of women like cardiovascular, PCOS. They have cancer, they have a variety of things. So we’re doing a plus and minus HRT study to take a look at some menopausal interventions right now. And certainly, looking at the microbiome of plus minus HRT so that we can apply a certain map.

Dr. Kimon Angelides (45:30):

And we have another study with another institution, which will be announced, that’s looking at IVF. One of the concerns, obviously it’s a big concern, is that multiple attempts at IVF are not only really very difficult for the family, they’re extremely difficult for the family. So that’s why we do have some behavioral health to be able to help for those failures. But they’re also very costly for an employer. And so the question there is that what are some of the markers and some of the things that we might be able to do to reduce the risk of failure. What can you do to help? What is sort of some of the backgrounds? So we have a couple of studies going on right now. And so to get those, that type of data, that’s what we’re doing.

Dr. Lauren Kelley-Chew (46:13):

Amazing, amazing. These are all areas that have not gotten a lot of funding and that are so important. And luckily, increasingly being recognized as employers, and like you said, by employers, and I think the impetus for that is money and cost. But that’s okay because they deserve attention. And from my perspective, whether that comes because employers want a reduced overall cost or whether that comes because of some other forcing function, at least it’s getting studied.

Dr. Kimon Angelides (46:40):

Yeah. And so listen, with Levels and metabolic control as well, it’s, again, coming into an employer for example, and you know this from digestive, I mean it coming to an employer and said, well, listen, I want to do metabolic control. Well, why? Where is next? What does that really mean? And so you craft actually the offering and the argument, if you will, and the offering around that. And so there’s some education. And so when we come in, in terms of partnering and things with metabolic and potentially with Levels, what we’d want to do essentially is make part of as a whole package. We understand that it’s a continuum, essentially. They should look at this because it’s really important. Well, yeah, here’s a specific problem we’re applying it to, but just here’s all the other mass where it could be applied to as well.

Dr. Kimon Angelides (47:27):

I think that’s the objective is how do you bring a solution like yours essentially to an employer, to a health plan. And I think the first vehicle is really to show the importance of it, to show that it actually can hit the larger population. It’s like doing digestive. If 50 or 60% of the population, you need to educate the employers in terms of the importance of it. That’s where I think a partnership is meaningful where women’s health is a big category. It shouldn’t be refused actually, women’s health. It shouldn’t be.

Dr. Lauren Kelley-Chew (48:02):

No, it shouldn’t be. And I think my numbers here are probably dated. But I remember looking at this a while ago, in terms of most expensive acknowledged conditions by employers, in terms of how they do their accounting of cost. And on the women’s health side, it was basically pregnancy, was the expense. And like you said, that really just captures a fraction of any woman’s experience. And it’s pretty amazing that it’s taken this long. And I so appreciate your work on it, like I’ve said many times, because this is not only my experience, but also the experience of many of my close friends and family. And like you said, they’re families. I have many friends right now who are doing IVF and it’s incredibly hard on everybody.

Dr. Kimon Angelides (48:42):

It’s really hard. I think you mentioned this as well. So I think there’s so many just different areas that need to be touched. That’s certainly an important one, I think as well. So anyway.

Dr. Lauren Kelley-Chew (48:54):

Yep. Yep. And I would, of course, be interested in terms of how metabolic control and metabolic health plays into success rates and some of them. There’s significant reason to think that lowering insulin resistance, improving glucose control improves outcomes and improves fertility in general. But it would be nice to prove that in a real world, setting at scale.

Dr. Kimon Angelides (49:19):

Yeah. First of all, in finishing up on this, is that, how could it not help? You have to ask that question. I mean, why wouldn’t you want to understand the metabolic control during pregnancy, for example, or even during an IVF? Why wouldn’t you want to? Again, I think it’s so fundamental that why wouldn’t it impact actually fertility? Why wouldn’t it impact pregnancy? Why wouldn’t it impact lactation? It absolutely has to, and it does. So it’s fundamental.

Dr. Lauren Kelley-Chew (49:51):

I agree. I agree. And this is probably a good to be continued moment because I would love to chat more about potential collaborations, ways we can partner. I think what we’re doing is very synergistic. And even from a pure science perspective, there’s so much to be learned and it’s important. It’s critical, really.

Dr. Kimon Angelides (50:08):

Yeah. I think we need to bring your solution in. I think we need to do this. I think we need to make sure it’s part of all of the journeys, for example, fertility, just general wellness, things, for example, along any of these pathways, for example. I think it’s really fundamental. So I think to be continued is really our next steps and they will be continued.