#182 – Epidemic levels of metabolic dysfunction with Dr. Casey Means

A health system that prevents sickness versus promoting health. A food industry suffering from a lack of regulation. Farming practices that promote unhealthy byproducts. In America, it’s no wonder that we are suffering from a health epidemic. It’s easy to get overwhelmed by the health challenges facing us in the United States. But Dr. Casey Means of Levels sees a light at the end of the tunnel. The solution is monitoring our glucose levels so that we can remain metabolically fit and stave off chronic health conditions. Levels Health is looking to accomplish this task by making modern biowearables available to all. Listen in to hear Dr. Means chat with host Geoffrey Woo on the Health Via Modern Nutrition podcast.

• Check out Levels
• Follow Levels on LinkedIn or Twitter
• Connect with Dr. Casey Means on LinkedIn or Twitter
• Check out Health Via Modern Nutrition
• Connect with Geoffrey Woo on Twitter

1:17 – Our genes are a blueprint

Dr. Means was always fascinated by how the human body works. She also came into medicine at a time of personalized genetics and how each person’s health is determined by the interaction between the genetic blueprint, environmental exposure, and daily choices regarding food, rest, and physical activities.

“My interest in going into healthcare and medicine really started in high school. I’ve always been fascinated by how the human body works and how to achieve optimal health. And I was at Stanford as an undergrad, right at the height of the human genome project, and when direct to consumer genetics were really starting to come online. The beauty of coming to medicine during that time was that we were really thinking about the interaction between the environment and genetic expression. Our genes are a blueprint, but health is really the interaction between that blueprint and our environmental exposures. And that is what really determines our outcomes. So in many ways, being in this milieu of personalized genetics and genetic testing as I came into medicine, it was a very empowering perspective. Because nothing is deterministic, we’re not fated to have certain outcomes. It’s really the interaction between our everyday choices, exposures, and inputs in that gene that really determined health.”

3:02 – We can’t operate on the immune system

Chronic inflammation is the root cause of all diseases, but we take medicines and get surgeries because we cannot treat our immune system.

“I was becoming more and more aware of how we’re understanding that inflammation is at the root cause of so many conditions. Not just ENT conditions, but also many of the chronic conditions that are plaguing our country today, things like heart disease, stroke, Alzheimer’s dementia, obesity, diabetes. We know that a lot of the inputs, the environmental inputs and exposures that our body has, the food we eat, the amount of stress we’re under, how much or how little sleep we’re getting, the environmental toxins we’re exposed to in our food, water, and air, the amount of sleep we’re getting – all of these things can generate chronic inflammation. So, of course we can prescribe steroids. Of course we can go to the operating room and bust a hole in the sinus and suck the pus out. But that doesn’t actually change the underlying core physiology of inflammation because you can’t operate on the immune system.”

3:37 – The role of dysregulated blood sugar

At the heart of most diseases is one major culprit: inflammation caused by metabolic dysfunction, which is a product of out-of-whack blood sugar regulation.

“That was really the big transition for me, becoming obsessively interested in understanding the root causes of these core pathways that lead to so many diseases and then how to mitigate those in hopes of keeping people out of the operating room and keeping people off chronic medications. And what we know is that one of the key fundamental triggers of inflammation in the body is dysregulated blood sugar and metabolic dysfunction. And unfortunately, our modern society makes it extremely difficult to escape metabolic dysfunction. It’s thought that about 88% of American adults have metabolic dysfunction. And this underlies nearly all of the chronic conditions that we’re seeing today in our country. And nine of the ten leading causes of death in the US are exacerbated by high blood sugar or metabolic dysfunction.”

4:29 – How to move away from reactive whack-a-mole medicine

According to Dr. Means, our current medical system is reactive. We are treating conditions in isolation, losing the focus on the links between those conditions and our overall health.

“So that really was kind of my journey from the early stages of my career and interests of personalized medicine and the interaction between environment and our body, and then really thinking through more deeply how do we attack, as physicians and as a healthcare system, the core fundamental physiologic pathways that are leading to multifarious conditions? So we can move away from the reactive whack-a-mole type medicine that we’re practicing right now, where we consider every single disease as a different isolated entity and treat accordingly, and actually focus on really high-value medicine, where we focus on the links between diseases, the core physiology. And since so many of those core linking physiologies like metabolic dysfunction, insulin resistance, chronic inflammation – since these are fundamentally rooted in the choices that we make every day, day in and day out with regards to food, sleep, stress, exercise, movement, it really comes down to how do we inspire people to make smart, personalized choices, day in and day out.”

11:11 – The USA is the sickest western nation – despite spending $4 trillion on healthcare

In the US we are super focused on reactionary medicine and not on proactive health. From our unregulated food marketing system to our bad cultural norms regarding nutrition, the result is an undeniable health crisis.

“Dr. Mark Hyman, in his book Food Fix, talks about really how we’ve gotten to our problems today. And then Dr. Lustig, who wrote The Hacking of the American Mind, which talks about how we’ve gotten to this place where we’re super focused on reactionary medicine, not about proactive health. And some of the things that are talked about in both of these books really get into all the wide array of issues around the web of why we are just the sickest Western nation, why we’re spending $4 trillion on healthcare, and why our life expectancy is going down. And briefly, these things range from cultural norms regarding nutrition and what is comfort food and that sort of socialization of unhealthy foods. We have relentless food marketing and advertising. We have a very unregulated food marketing system, one of the only countries that actually still advertise this to children with unhealthy ultra-processed foods. We’ve got a food system that focuses on super addictive foods that take you to your bolus point – so actually hijack our reward circuitry in the brain to make things as addictive or more addictive than drugs of abuse.”

12:21 – Bad systems and lack of knowledge are wreaking havoc

Our farms produce disease causing proteins, our medical system promotes drugs, and our digital world promotes a sedentary lifestyle. Worst of all, we don’t have the information to help us take the right decisions.

“We’ve got a public policy system that actually financially incentivizes and bolsters the production and purchasing of disease causing protein foods. So our farm bills spend hundreds of millions of dollars on promoting the production of food that directly causes disease, like corn, wheat, and soy that are largely turned into animal feed or refined seed oils. And then we’ve also got our healthcare economics that we talked about and very much a fee-for-service system that promotes a bias towards action – drugs, and surgery. And we’ve got a built environment and a culture that highly promotes sedentary behavior. We’ve also got a digital world that keeps us really trapped in artificial light and using our devices. Staying sedentary creates a system of low-grade chronic stress of pings and messages. The last thing I would mention is that we don’t really have any good feedback on our daily choices in terms of knowing what’s good or bad for us. Nutrition is very much an open-loop system. We make choices, but we don’t actually know how they’re affecting us for very long periods of time. We might get a fasting glucose test once a year or a cholesterol test once a year, but that makes it very difficult to actually think back and say, what were the foods that were actually causing the problem?”

18:01 – Metabolic health can prevent chronic illness

When we don’t metabolize energy properly it leads to cell and tissue dysfunction, and symptoms of chronic illnesses soon follow. By inspiring people to make healthy choices, we can reduce illnesses and bring down healthcare costs.

“I think if we made our country metabolically healthy, inspired people to make choices that generated metabolic health, and improve metabolic health, we’d see our healthcare costs plummet to a mere fraction of what they are today. We would see a happier, healthier, more emotionally regulated, fitter, more productive society. And we’d see a fraction of the very painful chronic conditions that we see today. So why is this the case? What are the mechanisms? So fundamentally our metabolism is how we produce energy from our food and our environment. So we make this energy by converting sugar and fat into something we can actually use, namely things like ATP, which is like the currency that our cells can actually use. And we have trillions of cells in our body. And the sheer reality is that every single one needs energy to function. And when there’s an energetic deficit, when they’re not using energy properly, what happens is cells dysfunction, then tissues dysfunction, and then symptoms arise, and then disease arises. But really a lot of that comes down to the cells not having the energy to work. So the metabolic process of energy production is a core fundamental pathway of every cell in the body. And when we don’t do it well, we see diseases.”

21:57 – How too much energy is leading to energy deficiency

We are eating a hundred times more sugar and carbohydrates than we did a 100 years ago. Our body cannot process the excess energy and is breaking down at the cellular level.

“We are eating probably around a hundred times more refined sugar and carbohydrates than we were a hundred years ago. The average American was eating a pound or two of refined sugar per year about a hundred years ago. And we’re eating on average 150 pounds now. Our poor little bodies have to process every single one of those molecules and our hormones have to be released to help process that. And we can’t do it. So we’re breaking down. And the irony is that we have too much energetic substrate in the body, but we actually have an energy deficit in our cells. And so tissue is breaking down. You can imagine, if this is happening in every cell type in the body, any symptom could emerge. If there’s an energy deficit in the brain, it could look like Alzheimer’s dementia. It could look like brain fog. It could look like chronic fatigue. It could look like chronic pain. It could look like depression. It could look like anxiety. All of these conditions are related to dysregulated blood sugar.”

30:54 – Avoiding glucose is not the answer

The answer is being metabolically healthy is making the right choices that are customized for each person. It’s not about not eating glucose. It’s about getting all the right micronutrients to maintain a healthy microbiome.

“Some of the key things that go into a glucose readout in terms of behaviors or potential inputs is the amount of sleep we’re getting, the amount of stress we’re under, the food we’re choosing to eat, the combinations of how we’re pairing food, the time when we’re eating food per day, how much physical activity we’re doing each day, and how sedentary or how much we’re moving our major muscle groups. Not only if we’re doing it, but how frequently during the day we’re doing it. So those are some choice-based things. It’s also critically related to the microbiome. The microbiome makes metabolic byproducts that are critical to our metabolic health. It’s our micronutrient status. Every single cell in the body is just filled with cellular machinery that requires micronutrient building blocks to both be built and to function. These micronutrients like vitamins and minerals and Omega-three fats are all either building blocks, structural elements, or locks and keys to make these things function. We’re just this big, very complex machine. We talk a lot about macros, but micronutrients like manganese, zinc, magnesium, vitamin C, B vitamins, carnitine, are all critical for these processes to work. So I think that where it starts feeling a little like, Oh, if you just keep glucose down, if you just don’t eat glucose, you’re going to be healthy. That’s not true. It is one aspect of a very complex set of physiology.”

39:30 – Personalized data on a silver platter

Our current system is not set up to support people to make healthy choices. It’s not easy to follow a prescribed diet and lifestyle. That’s why Levels is working creating digital technology that can help and support people hold themselves accountable and make more informed choices.

“I think it comes back to a lot of the systems issues. I think it also comes down to the fact that maybe there’s just a lack of faith that at scale, we can bind together and really do this and change things, which I think is a flawed way of looking at things. I think this is a time for us to be really creative as a healthcare community and as a society. Yes, it is true that most diets fail. It is true that when a doctor recommends a dietary intervention, it very rarely is followed sustainably by a patient. We are not tapping into smart, personalized tools that we have available to really drive behavior change. And this is what Levels is all about. We are focused on utilizing digital technology to help people hack those behavior change loops that make it fun and engaging and satisfying to actually do these things that many people consider hard. People think it’s hard to give up sugar. People think it’s hard to improve your diet, but when you’re really engaged with a digital product that actually is handing to you on a silver platter your current data, and then telling you all these different ways that you can improve it and supporting you in that, I think it just a creative way to approach it, but we’re not really thinking that way. Yes, many people fail at improving their metabolic health and dieting, but there are so many technologies, especially in the digital health world that are helping people make really big changes and make people more aware of their health. So how can we think bigger? I think that’s where we need to go.”

49:57 – Why we should start studying healthy people

Typically doctors study sick people. But Dr. Means thinks that by studying healthy people, we can understand what healthy base levels look like and how we can help everyone reach them.

“What we need is for researchers to be studying healthy non-diabetic individuals, the healthiest in the population, and looking at 24-hour CGM glucose profiles. What’s happening after meals? What is the average? What is the fasting? What is the area under the curve after meals? Mapping that on to underlying metabolic bone biomarkers. How does this type of curve relate to fasting insulin levels? How does this type of curve relate to our triglycerides and other metabolic markers? So we can start to understand how these CGM data sets actually map on to underlying metabolic health and then start to do some clinical research showing, okay, if you can keep within these ranges, what are the actual clinical outcomes? And if we improve our CGM metrics, how does that actually improve our clinical outcomes? That is where I think the next five years of research are going to be at, five to ten years in terms of really longevity-focused position research. And I am super excited to see this happen and be a part of it.”

58:56 – CGM as a personal toolbox for optimizing health

With bio wearables, people know at all times where they are with their health and fitness. There are no more surprises at the doctor’s office – the power is with the people.

“I think that a lot of people are moving in the direction of a more personalized approach to diagnostics. And there is a lot of interest in the medical community and bio wearables, things like Whoop and Oura and Eight Sleep and Levels and Apple Watch and all of these biometric trackers. Imagine if we were able to see our glucose 24 hours a day, understand how food and lifestyle activities were affecting our glucose, see what our glycaemic variability is every day and learn how to improve it, see what our fasting glucose every day and learn how to improve it, see how different foods are affecting our post-meal response and learn how to improve it, see how stress exercise, too little sleep is affecting our glucose and figure out how to optimize those. You would never in your entire life have to walk into the doctor’s office again and get a surprise about your metabolic health. If you’re doing this and tracking it, it changes the whole dynamic with healthcare. You’re never going to walk into the doctor’s office and have them drop a bomb on you about your metabolic health, because you know and you have tools, you have a toolbox to optimize it.”

1:18:11 – Our body is a slave to glucose

In the US, we are not metabolically flexible. When your body is flooded by excess glucose, it can’t train itself how to burn fat.

“Metabolic flexibility is the ability to use fat or glucose based on different substrate availability. We are not very metabolically flexible in our country because we’ve been only creating conditions where our body uses glucose, never really having an opportunity to use fat, which is why most people in America are fat. We think about metabolic fitness like it’s just like lifting weights day after day. We’ll start to see muscles grow over the course of weeks and months. Similar to this, if you work these pathways, and by pathways I mean keeping glucose down, burning through your glucose when you’re working out, and then having to actually flip on the switches for fatty acid oxidation in the mitochondria. Over time, those pathways, those receptors, those channels, it all becomes stronger. And maybe it just becomes second nature, so to speak, in ourselves, to be able to do this. So it’s fitness. It’s adaptations. This requires doing it over and over. It’s not going to be easy the first day that you do it when your body is a slave to glucose. I think it’s great to know that when you’re hungry, maybe during a workout or in the morning or whatever, and you’re like, Oh my God, I’m hypoglycemic, I’m so hungry. You look at your glucose and you’re like, oh. I’m actually like firmly in the eighties or the nineties. I’m not actually hypoglycemic.”

Geoffrey Woo: [00:00:00] Hello, ladies and gentlemen, this is Geoff with The Healthy Via Modern Nutrition podcast, the HVMN podcast. And I’m super excited to welcome Dr. Casey Means. So she’s a co-founder of one of what I would say, one of the most exciting companies in the metabolic health space, is a company called Levels. And they’re really mainstreaming a really interesting technology that we’ve talked about on this program before, which is continuous glucose monitoring.

But I think the larger picture to me is that in the future, there will be a real-time dashboard of key metabolic markers, key health markers, and I really see Levels enabling that future for all of us. So, Casey, welcome to the program. Great to talk to

you.

Dr. Casey Means: [00:00:48] Thank you so much for having me, Geoff, thrilled to

be here.

Geoffrey Woo: [00:00:51] Yeah. So. Clearly a lot of overlapping interests. And before we go down the Levels rabbit hole and the future of continuous biomarker tracking, starting with glucose, we always like to start from the beginning. So you’re a practicing clinician, a Stanford trained doctor. What was little Casey like? How did you decide to venture into the medical

realm?

Dr. Casey Means: [00:01:13] Oh man. Little Casey was a fiery ball of energy. So you know, my interest in going into healthcare and medicine really started, it started really in high school. I’ve always been fascinated by how the human body works and how to achieve sort of optimal health. And I was at Stanford as an undergrad, right at the height of the human genome project, and when direct consumer genetics were really starting to come online.

So sort of early 2000s, mid 2000s. So the beauty of coming to medicine during that time was that we were really thinking about the interaction between the environment and genetic expression. You know, our genes are a blueprint, but health is really the interaction between that blueprint and our environmental exposures.

And that is what really determines our outcomes. So in many ways, being in this mileu of personalized genetics and genetic testing, as I came into medicine, it was a very empowering perspective because it’s, nothing is deterministic. You know, we’re not fated of certain outcomes. It’s really the interaction between our everyday choices, exposures and inputs in that gene that really determined health.

So, you know, flash forward, I did my medical school training also at Stanford. And then I went on to head and neck surgery residency. And in my surgical residency, I was treating and operating on diseases of the ear, nose and throat. And I was struck by how so many conditions I was treating were fundamentally rooted in chronic inflammation.

It was all this, it was sinusitis, laryngitis, thyroiditis, all the itises, which in medicine is a suffix, that means inflammation. And it caused me to step back and say, you know, Why is there so much chronic inflammation at play? And why are we just reaching for our prescription pads for all these heavy duty steroids to quell the immune system, instead of asking what’s causing inflammation and what’s the root cause?

I was becoming more and more aware of how we’re understanding that inflammation is at the root cause of so many conditions, not just ENT conditions, but also many of the chronic conditions that are plaguing our country today. Things like heart disease, stroke, Alzheimer’s, dementia, obesity, diabetes. And, you know, we know that a lot of the inputs, again, the environmental inputs and exposures that our body has.

So the food we eat, the amount of stress we’re under, how much or how little sleep we’re getting, the environmental toxins we’re exposed to in our food, water, and air, the amount of sleep we’re getting, all of these things can generate chronic inflammation. So, you know, of course we can prescribe steroids.

Of course, we can go to the operating room and bust a hole in the sinus and suck the pus out, but that doesn’t actually change the underlying core physiology of inflammation, because you can’t operate on the immune system. And so that was really at the big transition for me, was becoming kind of obsessive, really interested in understanding the root causes of these core pathways,

that lead to so many diseases. And then how to mitigate those in hopes of keeping people, you know, out of the operating room, and keeping people off chronic medications. And what we know is that one of the key fundamental triggers of inflammation in the body is dysregulated blood sugar and metabolic dysfunction.

And unfortunately our modern society makes it extremely difficult to escape metabolic dysfunction. It’s thought that about 88% of American adults have metabolic dysfunction. And this underlies nearly all of the chronic conditions that we’re seeing today in our country. And nine of the 10 leading causes of death in us are exacerbated by high blood sugar or metabolic dysfunction.

So that really was kind of my journey from, you know, this early stages of my career and interests of personalized medicine and the interaction between environment and, you know our body, and then really thinking through more deeply, how do we attack as physicians and as a healthcare system, the core fundamental physiologic pathways that are leading to multifarious conditions.

So we can move away from the reactive whack-a-mole type medicine that we’re practicing right now, where we consider every single disease that’s different, isolated entity and treat accordingly, and actually focus on really high value medicine, where we focus on the links between diseases, the core physiology. And since so many of those

core linking physiologies like metabolic dysfunction, insulin resistance, chronic inflammation. Since these are fundamentally rooted in the choices that we make every day, day in and day out with regards to food, sleep, stress, exercise, movement, it really comes down to how do we inspire people to make smart, personalized choices, day in and day out, that create conditions in the body that optimize these pathways.

So that’s kind of my journey and how, you know, I went from sort of, I would say mainstream conventional medicine to really focusing on directly empowering individuals with personal health information to make better choices to improve

fundamental health.

Geoffrey Woo: [00:05:46] Hey guys, this is Geoff Woo  interrupting my podcast for a special offer.

A special announcement for you. As you might know, HVMN just launched the new Keto Food Bar, and they’re yummy, they’re delicious, and I want to make a special personal offer for you to give you a discount to get those into your hands. So for a limited time only, use the discount code Geoff 10. That’s G E O F F, number one, number zero, Geoff 10 for a 10% discount on the keto food bar on H V M N.com. We got Mexican hot chocolate, one of my personal favorites. We got vanilla shortbread. We got chocolate chunk. And of course we got the everything bagel, which is legit, savory garlicky oniony, and these have become staples in my own personal life.

I like to eat this with a cup of coffee for breakfast. I’ve been using the Mexican hot chocolate and vanilla as grab and go bars when I’m biking, out on the town, when it’s not easy for me to eat healthy, eat keto. So these are certified organic. They actually are honey. They aren’t these weird synthetic artificial tasting bars, you might see that are keto compliant, but have a bunch of fake IMOs and things that actually spike glycemic response.

And of course, while they’re also certified organic and they actually taste good, these have been tested on continuous glucose monitors. So they actually have flat glycemic response on your blood sugar. So essentially it’s a fasting mimick, but we’re still delivering almost 300 calories of healthy fat, and 12 grams of healthy protein

and grassfed collagen. These are legit. I’m so excited for you to try them and use my personal discount code, Geoff 10 to get a special 10% discount. So check it out and enjoy and back. I think I have the privilege of speaking with a lot of doctors that are forward thinking like yourself, but it feels like for, you know, 90% of the doctors, they’re mainly functioning as technicians who are kind of caught up in the healthcare infrastructure.

And I’m just curious to get your take on this. Is there some structural issues with how healthcare is done in America, where people would just avoid like the primal root causes that you’re trying to tackle here with metabolic health, versus which I think are just like, just much more hotfixes, right?

Like grabbing that script, grabbing that shortcut, you know. Is it because there’s just like so much pressure to pay off medical school debt? Is it just because it’s so much easier to just get paid by payers to just write that script? Like, what is that diagnosis here? And second part is obviously like, I think most, 90% of the people that I think go into medicine want to help people, but like what made you take that extra leap forward and be like, Hey, I’m going to put myself out of like the norm of being a day-to-day standard hospitalitist or a day-to-day practitioner, and get into,

I would say like a health technology, broader platform with something like Levels.

Dr. Casey Means: [00:08:54] I think the question here is really like, how did we get here, and why are we practicing in a way that is unfortunately very focused on just, you know, avoidance of death and managing disease rather than proactively making people well.

So I think there’s a lot of reasons. And a lot of it comes down to the fact of really healthcare economics. For the past 60 or 70 years, we’ve had a system that really focuses on fragmenting the body. We look at things in very individual systems, and we have a medical billing system that is based on codes. And fundamentally codes are a huge problem in terms of why we’ve gotten to where we are, because to bill something and to make money for a service in healthcare,

you have to code it and label it and then submit a claim for that. So what that means is that you are basically creating these minutia, little micro diagnoses about all these different things and they’re considered sort of separate things. And so we’re focusing on the downstream effects of physiologic processes,

as opposed to the physiologic processes themselves. You cannot code for metabolic dysfunction. You cannot code for chronic inflammation and you, but you can code for, you know, a very specific type of psoriasis. And so what happens is we focus on these downstream manifestations of chronic processes as opposed to the actual processes themselves.

And that leads to this very siloed system where we’re very fragmented, we’re a very highly specialized system and we’re not focusing on core fundamental health. And we also, you know, there’s a mis-incentive here. So if in a fee for service system where you get paid for doing something, paid for treating. Pharmaceutical companies make money by selling prescriptions, hospitals make money by selling surgeries.

Then a very, very healthy patient is a very, very bad customer. And certainly, I don’t think this type of malaligned incentives makes it into the actual daily thought process of a doctor, but the reality is systems do actually drive behavior. And so, you know, when our livelihood is dependent on treating patients who are sick, it creates a very backwards incentive structure for making people investing

in high value interventions that may be low costs, that keep both very, very healthy, and very much out of the pharmacies, out of the hospitals, out of the operating rooms. So I think that two people describe this better than almost anyone. And one is Dr. Mark Hyman, his book Food Fix talks about really how we’ve gotten to our problems today.

And then Dr. Lustig, who wrote The Hacking Of The American Mind, which talks about how we’ve gotten to this place, where we’re super focused on reactionary medicine, not about proactive health. And some of the things that are talked about in both of these books really get into all the sort of like wide array of sort of issues around the web of why we are just the sickest, you know, Western nation, why we’re spending $4 trillion on healthcare.

And we, our life expectancy is going down. And briefly, these things range from one, just cultural norms regarding nutrition and what is comfort food, and that sort of socialization of unhealthy foods. We have relentless food marketing and advertising. We have a very unregulated food marketing system, that is one of the only countries that actually still advertizes to children with unhealthy ultra-processed foods.

We’ve got the food system that focuses on, you know, super addictive foods that take you to your bolus point. So actually hijack our reward circuitry in the brain to make things as addictive or more addictive than drugs of abuse. We’ve got a public policy system that actually financially incentivizes and bolsters the production and purchasing of disease supporting foods.

So our farm bills spend hundreds of millions of dollars on promoting the production of food that directly causes disease. So corn, wheat, soy that are largely turned into animal feed or refined seed oils. And then we’ve also got, you know, our health care economics that we talked about and very much a fee for service system that promotes doing, a bias towards action, drugs and surgery.

And we’ve got a built environment and a culture that highly promotes sedentary behavior. We’ve also got a digital world that keeps us really trapped in artificial light and using our devices. Staying sedentary creates a system of low grade chronic stress of like pings and messages. And we, the last thing I would mention is that we don’t really have any good feedback on

our daily choices in terms of knowing what’s good or bad for us. Nutrition is very much an open loop system. We make choices, but we don’t actually know how they’re affecting us for very long periods of time. You know, we might get a fasting glucose test once a year or a cholesterol test once a year, but that makes it very difficult to actually think back and say, what were the foods that were actually causing the problem.

So lack of, sort of immediate feedback on things, very important, environmental inputs, like nutrition, I think is also a problem. So those are some of the factors at play. And, you know, I think there’s a lot of hope. There’s a lot of people thinking about how to change the system to make it healthier.

We’re moving towards a value-based care system that’s going to pay for outcomes over cost. So outcomes will be a part of how we get paid. So I think that’s going to change the incentive system a bit. But yeah, highly recommend those two books I mentioned for any listeners. And it’s a complex issue of how we kind of

got here.

Geoffrey Woo: [00:14:00] A hundred percent.

And I like to always start talking from an infrastructural or an incentives perspective because I very much like the quote, show me, then send us and I’ll show you the results. Because I think there are more, I will say, extreme or more conspiracy, tinfoil hats wearing people in the community here who are like, Oh, this is like some kind of new world order to like make people sick for profit.

I don’t think it’s to that extreme where there’s, like crazy conspiracies. I think everyone’s trying to do their best, but because the game is so localized in terms of incentives, right? Like we want to optimize doctors for this kind of outcome, but now we’re paying them by scripts and codes, as you were mentioning.

Well, like it’s, everyone needs to pay their bills at some point. So it’s like, okay, it’s not unexpected that they would go for insulin or a surgery versus nutrition counseling, which is so much more labor intensive and so much less reimbursed by the payer or the healthcare provider insurance company. So I think it’s like refreshing to hear that.

I think it’s, I mean, it’s like, it’s like a very clearly articulated perspective. I think it’s, I haven’t, I’ve talked to many doctors on this issue and I think you’ve just summarized situation very, very nicely. So kudos to your very, very clear thinking on the space. So. Let’s go into the mechanism.

So I think that’s where our bread and butter is. And let’s start from the basics here. So it looked like as you were on the front lines, on the surgery side, you wanted to solve a more primal root cause. What caused you to go down the metabolic health path? And then why was blood glucose the key thing to focus on?

And let’s talk about the mechanisms. Like how does high blood glucose or high variance or these big, like standard deviation spikes and drops. What is that basic biological explanation of why this is bad for inflammation and some of these downstream killers of Americans, right? Like I think when you talk about cardiovascular disease, cancer and the cognitive impairment, right?

Like those are like the basic, like three of the top five killers of Americans today. Why do these all have metabolic roots, or what is the theory and what is the hypothesis that these have some sort of metabolic implication?

Dr. Casey Means: [00:16:04] Yeah. So two questions there. I think the first one is really like, what was the big drive to like jump ship from surgery and then go towards trying to fix metabolic health.

And then what are the why? Why is this such an important pathway to devote time and energy to? So in terms of the first question, the decision of leaving surgery to sort of start a mission of eradicating metabolic dysfunction in this country, really came from stepping back and reflecting and sort of looking at my life and realizing, you know, we have one life. I have

one shot here. And I love being a physician. I love medicine. I love science. How do I want to most serve the world? Like what are, how am I going to most serve and utilize my experiences, my thoughts, what I’ve synthesized throughout these experiences to create a better world. You can do that through surgery.

Surgery is a beautiful art. There’s surgery. There’s a place for surgery in the world. But in terms of scaling solutions that are going to improve health, wellbeing, happiness in the world, the, surgery is not going to do that. Surgery is a very high touch one-to-one interaction. It’s highly reactive and it doesn’t empower people.

It’s reactive. It’s a doctor doing something to the patient. And I think people are happy and thrive more when they feel like they have agency over their lives and control and direction in this life. And so I wanted to make sure that how I was helping people, was in empowering them, not just doing to them.

And then in terms of metabolic health, this one for me was such an important nut to crack as a physician, and to scale solutions to fix this because of how pervasive it is, one. How much it’s related to the many of the chronic health conditions we’re seeing, two. And three, because it’s readily fixable.

It’s reversible. It is, there’s hope in it. It’s not like it’s a one-way street. So for those three reasons, it was just like, this is what we have to, this is what we have to solve. I think if we made our country metabolically healthy, inspired people to make choices that generated metabolic health and improve metabolic health, we’d see our healthcare costs plummet to a mere fraction of what they are today.

We would see a happier, healthier, more emotionally regulated, fitter, more productive society. And we’d see a fraction of the very painful chronic conditions that we see today. So why is this the case? What are the mechanisms? So fundamentally our metabolism is how we produce energy from our food and our environment.

So we make this energy by converting sugar and fat into something we can actually use, namely things like ATP, which is like the currency that our cells can actually use. And we have trillions of cells in our body. And the sheer reality is that every single one needs energy to function. And when there’s an energetic deficit, when they’re not using energy properly, what happens is cells dysfunction, then tissues dysfunction, and then symptoms arise, and then disease arises.

But really a lot of that comes down to the cells don’t have the energy to work. So the metabolic process of energy production is a core fundamental pathway of every cell in the body. And when we don’t do it well, we see disease emerge. When we do see it working well, when we have the energetic capacity to meet the stressors and the demands of our lives, we thrive, we see stable energy.

We see vigor, we see mental clarity. We see athletic endurance, we see stable mood. We see good memory. We see healthy skin. We see all the things we want. And we see of course the avoidance of future chronic disease. So it’s really at the nexus of current performance and then avoidance of future issues.

And when we take, when we eat carbohydrates that are converted to glucose, our bodies. As I’m sure many of your listeners know, they have to release a lot of insulin to get that glucose, to be taken into the cells. And over time, if we eat in such a way that our glucose is persistently high in the bloodstream, our body has to pump out more and more of this insulin into our bloodstream,

to drive that sugar into cells. And over time, the cells become a little fed up. They’re like, Oh my God, there’s so much sugar coming in here. We have to process all of this in the mitochondria, and we can’t do it. So the cells become resistant to that insulin, and block the glucose from coming in.

And that’s the process of insulin resistance. And over time, the pancreas pumps out more insulin to try and overcompensate. And so now you have high insulin, you have high glucose. And this leads to a number of problems. So when insulin is high because it’s a signal that the body has enough glucose for energy, it says we don’t need fat for energy.

We’ve got tons of glucose around. So it blocks us from efficiently burning fat for fuel. And so what happens is we end up storing fat, storing glucose as fat, and we become fat. So insulin resistance is very tied in with why we have a chronic obesity epidemic in our country. We have 74% of Americans that are overweight and obese, you know. And the other thing that, so that’s insulin being high, blocking fat oxidation.

And the second thing is that glucose alone in the bloodstream causes problems in its own right. Hyperglycemia, high blood sugar drives chronic inflammation. It drives oxidative stress, and it drives glycation. So these are three processes that are really problematic for ourselves. Inflammation, of course, being upregulation of the immune system, releases inflammatory cytokines, that over time can be damaging to the body when they’re unregulated. Oxidative stress, being the production of too many free radicals, these reactive species in the bodies with unpaired electrons that can go around.

And basically that unpaired electron will bind with proteins and fat and DNA, and cause dysfunction. And then glycation, being the formation of advanced glycation end products, which is where too much glucose in the bloodstream literally goes around and sticks to things, sticks to proteins like collagen, causes change in the actual shape of these structures in the body.

And that causes dysfunction. So you’ve got the insulin pathway that’s problematic. You’ve got the glucose pathway via these three other pathways that are, is problematic. And all of this fundamentally comes down to the fact that we are overloading our body with this substrate glucose, and it has these downstream effects.

We are eating probably around a hundred times more refined sugar and carbohydrates than we were a hundred years ago. The average American was eating like a pound or two maybe, of refined sugar per year, about a hundred years ago. And we’re eating on average, 150 pounds now. Our poor little bodies have to process every single one of those molecules, and our hormones have to be released to help process that.

And we can’t do it. So we’re breaking down. And the irony is that we have too much energetic substrate in the body, but we actually have an energy deficit in ourselves. And so tissue is breaking down. And you can imagine, if this is happening in every cell type in the body, any symptom could emerge. If there’s an energy deficit in the brain, it could look like Alzheimer’s dementia.

It could look like brain fog. It could look like chronic fatigue. It could look like chronic pain. It could look like depression. It could look like anxiety, all conditions related to dysregulated blood sugar. Is this happening in the ovary? It could look like polycystic ovarian syndrome, insulin resistance of the ovaries, the leading cause of infertility in our country.

It’s happening in the blood vessels. It could look like heart disease. If it’s happening in the penis, it looks like a erectile dysfunction, which is at this point, thought to be a key indicator of metabolic dysfunction, erectile dysfunction. So you know, any, you know, name any system in the body, and I can tell you, you know, the way that it’s related to dysregulated glucose and metabolic dysfunction, because we’re dealing with these core fundamental, energetic pathways.

And one of the key ones that is interesting right now and is so prescient is that this also happens in our immune cells. It happens when our immune cells are exposed to too much blood sugar, they become dysfunctional. And so we are seeing right now with COVID that one of the key indicators of worse COVID mortality or morbidity is underlying blood sugar dysregulation, metabolic disease or obesity.

And this is not a surprise really, at all. We’ve known for a long time that dysregulated blood sugar, impairs immune function, and COVID is just highlighting that for us. So, you know, of course, social distancing, hand sanitizers, masks, these are things that prevent us from being exposed to the virus. But I think really more of a focus on actually improving our own biologic resilience to the virus, and help people understand that

it is very simple to control blood sugar. And it could be one of the best, highest value things we could do to improve our biologic resilience to the virus. So that’s sort of the web and the world of why metabolic dysfunction is such a key thing to focus on. And again, it’s so hopeful because we can actually do something about it rapidly.

Virta Health, a company that’s actually approaching diabetes through a really novel platform, they’ve shown that in 10 weeks, they can take people with full fledged diabetes and get them to a non-diabetic blood sugar level. 10 weeks.

Geoffrey Woo: [00:24:39] And essentially they’re administrating ketogenic

diet.

Dr. Casey Means: [00:24:42] Right. Exactly.

It’s simple, and coaching.

Geoffrey Woo: [00:24:44] Yeah. It’s like, ketogenic diet and coaching and like accountability.

Dr. Casey Means: [00:24:47] Exactly.

Geoffrey Woo: [00:24:47] And yeah, that, that’s like a credit for them like showing that this digital therapeutic or just lifestyle intervention is just as powerful, if not more powerful than insulin and Metformin, which is

awesome.

Dr. Casey Means: [00:24:59] Absolutely, like reduce the substrate in the body, which is AKA refined carbs and glucose, reduce the influx of that. That’s one side of things. The second side is building a body that processes glucose effectively. So that’s a little bit more complicated. That’s keeping our micronutrient status on point, keeping our microbiome on point, making sure we have the building blocks in the body to actually process glucose effectively.

That’s keeping our cortisol and our stress down, getting enough sleep so that our hormonal milieu is effective for metabolism. So it’s two-sided, sort of building our body with healthy habits, and then also reducing the substrate going in of glucose. And together, anyone can improve their metabolic function.

So, but that’s sort of, that’s why I decided to focus on this issue, because it’s just high value. It’s high leverage, it’s achievable. We have digital tools that can help people do it. And that to me, made it very easy to walk in and leave surgery, and focus on this. And I’m very glad that

I did.

Geoffrey Woo: [00:25:55] Awesome. Yeah. There’s a lot to unpack there. I mean, like, just from a historic perspective, interesting to talk about the evolution of food system and how and why sugar was so prized in the 1800s. Right. I think literally if you think about history, humans enslaved other humans to produce more sugar, right.

That was like a big part of the slave trade. And it was just like, interesting to realize that it was such a addictive, tasty commodity that we had to be, you know, one of like, I guess, like one of the worst travails of human cultural evolution was, you know, it’s like a lot of people that like manufactured sugar essentially.

So I think it’s interesting from a historical cultural perspective. And then going all the way until now, which is interesting from a COVID perspective. I almost want to unpack each of these things and talk about them a little bit more detail. I mean, just from a historical perspective, I think the reason why I think what you guys are doing at Levels is so interesting is that we need to evolve the nutrition food production system.

And I think the mission of HVMN is to modernize and almost like bring ancestral best practice in, in a lens of science. Right. So I think that’s just like, okay, let’s actually have foods that make sense. And then to it, what I always believed was important was the closed loop, as you talked about the open loop of just having. Like the thing with food, because it’s so continuous, such a every day, multiple times a day practice, it’s hard to track whether each individual dose does anything to you.

But over time, I think just given the way our systems are set up, you maybe have a snapshot checkpoint every year, if you’re like on top of your stuff, right? Like realistically, I think a lot of people aren’t even seeing their doctor once a year and getting their bloods done. So I think where Levels I think is part of that future is that you are enabling people to actually be accountable, actually be metrics driven on their day-to-day metabolic health, which I think is so powerful in terms of just that feedback loop.

I think let’s just admit what is true, which humans are very bad at long-term planning. Like we’re not very intuitive of our long-term chronic health. If you’re giving people a number that’s like, Hey, this bar or this drink or this meal was really, really bad for your glycemic response. Therefore, leading to all the different downstream, like kind of end points that you were just mentioning. Hey, you can actually do something immediately the next day or the next night,

and correct that. I think that is very, very powerful. So I think, I think one of the interesting things is that when someone says this solves everything like, oftentimes it leads to like this person’s full of shit. Because like, it’s like if it does everything it’s like too good to be true. But I think if you actually tie it into the metabolism, because metabolism, as you’re mentioning every single cell in our body must generate ATP from some substrate.

Like it is like, yes, it does everything because it is essential. It is essential to everything. So I think that’s like that kind of a funny conversation where it’s like, okay, If this has implications potentially towards Alzheimer’s, diabetes, cancer, that’s literally, and overweight obesity. That’s literally like some of the top five, 10 killers of Americans.

Right. It’s like it almost does everything. And how do you address that? Or is that something like, yes, it is so central and that’s why it’s so high leverage. Like we need to be educating people more. Or do you feel sometimes defensive about the fact that if something is quote unquote too good to be true?

Does that feel weird to you? Because I think that’s just like an interesting conversation, I think within the nutrition blogosphere. And I think a lot of our listeners are, I think have seen really, really good personal results here. And as people are advocating and bringing people into this community, into this lifestyle, lower carbohydrate consumption, sometimes, like, I don’t want our movement to look like,

kind of like zealots where it’s like, you have like the crazy vegan people or the crazy carnivore people that seem a little bit too religious, versus like, Hey, this is based on sensible, rational, like constrained claims rather than like, Hey, this is like the new best religion. How do you try to balance that?

Do you find that there is like a tension

there?

Dr. Casey Means: [00:29:57] It’s a great question. So I think that, so I’d step back and say eating low carb or reducing glucose intake is definitely not the panacea for good health. Like there’s no question that doing that behavior is not going to generate good health. It is necessary, but not sufficient for that.

So I don’t see, I see glucose and the power of glucose is that it’s a readout that has many different inputs that are all important for generating holistic good health. So what goes into what your glucose is doing? You know, if you have a continuous glucose monitor on, you’re essentially seeing this little movie, this line of what’s happening with your glucose all day. That is not the result of just whether you had a cookie or not a cookie, refined carbs or not.

It is a result of so many complex physiologic processes that are driven by many of the different behaviors and the micro choices we make thousands of times a day. So some of the key things that go into a glucose readout in terms of behaviors or potential inputs is the amount of sleep we’re getting,

the amount of stress we’re under, the food we’re choosing to eat, the combinations, how we’re pairing food, the time when we’re eating food per day. So sleep, stress, food, how much physical activity we’re doing each day, how sedentary we are, how much we’re moving our major muscle groups. Not only if we’re doing it, but how frequently during the day we’re doing it.

So those are some choice-based things. It’s also critically related to the microbiome. The microbiome makes metabolic byproducts that are critical to our metabolic health. It’s our micronutrient status. Every single cell in the body is just filled with cellular machinery that requires micronutrient building blocks to both be built and to function. These micronutrients like vitamins and minerals and Omega three fats and things like this.

These are all like either building blocks, structural elements or locks and keys to make these things function. We’re just this big, very complex machine. So micronutrients, we talk a lot about macros, but micronutrients things like manganese, zinc, magnesium, vitamin C, B vitamins, carnitine. These are all critical for these processes to work.

So I think that where it starts feeling a little, potentially like, I don’t want to say like Charlataney or something like that is when we say like, Oh, if you just keep glucose down, if you just don’t eat glucose, you’re going to be healthy. That’s not true. It is one aspect of a very complex set of physiology.

But what I love about tracking glucose is that it becomes the centralizing force that around which revolves so many of the things we have to do each day in order to be healthy. So that’s sort of how I would simply put that. And so, yeah, I’ll pause there, but yeah, that’s kind of how one way to sort of frame that.

Geoffrey Woo: [00:32:37] Yeah, because I think that. I’m exactly in the same, I think position as you are in the sense that in terms of something that’s like very non-controversial and a very low hanging fruit, reducing refined carbohydrate intake is very, very easy to accomplish. But then I think it’s like, how do you balance the nuance in terms of, if you’re looking to be an elite athlete, some carbohydrates that’s fast, transport might be useful. If you’re having higher exercise load, how are you balancing that all out?

And especially at least from the HVMN context, I know that a lot of elite athletes and elite military operators are trying to look at CGMs as a performance tool. Those use cases are very, very different than someone who’s overweight looking to lose weight, versus someone that’s healthy and just looking to optimize longevity.

And I think we, as a community, need to give people a very easy entry point to enter the community. Which is like, Hey, just reduce carbohydrate intake, like cut out sugar, cut out candy bars, cut out like Coca-Cola, but also very quickly educate people on like the broad system where these are all inputs and sugar in very select use cases can be beneficial for a specific end point, right?

If this is like, you know, like trying to win an Olympic gold medal, or you’re doing very heavy powerlifting or, you know, doing something that’s very energy, anaerobic, intensive, sugar might be a useful substrate for you. And I think it’s hopefully elevating the conversation where there’s no like evil or not evil substrate.

These are just all chemicals in foods. Right. And like they’re all useful to solve different problems. And I would say that a lot of the problems that we have as a society have solved is curing famine. You know, one of my favorite observations that if you look at what killed people in the 19th century, it was famine. It was famine and war.

Right. What’s killing people today is all the chronic diseases that we just talked about. So I think we essentially solved the famine condition. Of course, like we have to say there’s certain third world countries that people are still starving, but that’s mainly a transportation and like economics question rather than like a capacity question, right.

There are literally enough shelf-stable carbohydrates, everywhere to feed everyone. It’s a little bit of a distribution problem, but I think that in turn has reflected an issue in our food system. For now, the problem is over consumption, all these energy overabundance issues that are creating all these chronic disease conditions.

So again, I think there is like that very short, easy, clean story, but hopefully we can move that conversation towards a little bit of a nuance. I think another conversation, or maybe if we shift topics here, is COVID, right. And I think it is weird to me that our public health policy officials don’t ever talk about health and lifestyle interventions.

And it’s like, I think you say exactly right, which is that of course, do all the social distancing, all the standard policy that is very commonly disseminated by our public health, public officials. When they talk about improving metabolic health, just giving it a little bit more sunlight and improving vitamin D status, which also has very, very high correlation or association with negative or positive outcomes with COVID.

It’s interesting that all the lifestyle stuff is omitted from discussion, even though these are very, very cheap, very, very like easy low-hanging fruit. I’m curious to dive into that topic and get your thoughts there. Are our public health policy officials saying that if we talk about lifestyle stuff, it just feels too hokey.

Like why don’t they tell people, Hey, doing a little bit exercise, improving metabolic health, getting some sun, improve vitamin D status. That like people, I would say in that, like the lifestyle or like the nutrition community talk about this. And I think there’s definitely just like a huge, almost conspiratorial, like tone because our public health officials just omit like 90% of what people can do to like actually improve their metabolic

health.

Dr. Casey Means: [00:36:31] Yeah. You bring up great points and it is, I think for us in this sort of nutrition focused community, it is like sort of wildly perplexing to sort of step back and think, it’s been almost 10 months since this virus started. And I have not seen a sort of governing medical body come out and put down a hard line on, Hey, every person in America, we need to be.

Taking personal accountability for our daily choices to improve our metabolic health. And we need to do it for ourselves, our families and our community. Not even just asking people to sort of step up a little bit with their choices that are evidence-based for improving metabolic health rapidly, but also changing the systems in a creative way to make this easier.

I mean, what if every McDonald’s all of a sudden, you know, what if we subsidized foods differently in our country, rapidly changed it so that we were increasing production of healthy foods that we know have compounds that are associated with improved outcomes with COVID, things like selenium and zinc.

And like you said, vitamin D. Why aren’t we thinking that way?

Geoffrey Woo: [00:37:31] And like, yeah, like, and these are not like we need a bajillion dollars, like to make these things happen, right? Like.

Dr. Casey Means: [00:37:37] We spent literally trillions of dollars on COVID at this point. Like I kind of step back and think like, you know, Hey, I mean, we could have probably sent, you know, organic low carb, daily harvest harvest bowls

to you know, this direct to consumer frozen food company that creates all organic vegetable filled delicious foods, to every single American, you know, for weeks, that it probably would have cost less than what we’ve spent. You know, we could be creating absolutely wide access to coaching.

We could be increasing distribution and access to continuous glucose monitors. So, you know, if glucose is the key driver of worst COVID outcomes. And we know that that is not just for diabetic individuals. The research actually shows that even in non-diabetic individuals, if you present to the hospital with a higher than normal glucose levels, even in the absence of a prior diagnosis of diabetes, significantly higher likelihood of dying in the hospital from COVID.

This is a research that came out in November. So it’s not just diabetic individuals, it’s even non-diabetic individuals. And when we look at prediabetics in this country, which is about a hundred million Americans, 90% of people with prediabetes don’t know they have pre-diabetes. So we are just walking around clueless to a biomarker that is readily trackable.

There is technology that is pretty cheap to check this continuously, continuous glucose monitors. We have companies like Levels that actually interpret that data for people and help them improve their metrics rapidly. And we’re not a part of the conversation. I actually published a paper in the journal Metabolism in April that reviewed the first hundred or so papers on metabolic health

and COVID, saying, you know, calling for this type of action. And we haven’t seen really any of it come to fruition. If we really wanted to see positive movement in this pandemic, every billboard in America would have five tips for reducing your blood glucose levels, and educating people on why it’s important, but we are not seeing that.

And I think it comes back to a lot of the systems issues. I think it also comes down to the fact that maybe there’s just a lack of faith that at scale, we can bind together and really do this and change things, which I think is a flawed way of looking at things. I think this is a time for us to be really creative as a healthcare community and as a society, you know?

Yes, it is true that most diets fail. It is true that when a doctor recommends a dietary intervention, it very rarely is followed sustainably by a patient. There have been, but that is in part because we are not tapping into, you know, smart, personalized tools that we have available to really drive behavior change.

And this is what Levels is all about. Like we are focused on utilizing digital technology to help people hack those behavior change loops that make it fun and engaging and satisfying to actually do these things that many people consider hard. People think it’s hard to give up sugar. People think it’s hard to improve your diet, but when you’re, you know, having really engaged with a digital product that actually is handing to you on a silver platter, your current data, and then telling you, you know, all these different ways that you can improve it and supporting you in that, I think it just, it’s a creative way to approach it. But we’re not really thinking that way.

Like how, yes. You know, many people fail at improving their metabolic health and dieting, but there are so many technologies, especially in the digital health world that are helping people make really big changes and make people more aware of their health. So how can we think bigger? I think that’s where we need to go.

And we actually have to think this way because everyone thinks, Oh, when the vaccine comes, everything’s going to be better. But the reality is we are still a biochemically fragile society that does not have the bioenergetic or the molecular capacity to deal with threats and to deal with stressors, and stressors,. Being things like a virus, infection, lack of sleep, et cetera.

We are not biochemically resilient as a society. And that’s for all the reasons that we’ve talked about so far. We are in many ways, broken machines. And so the next pandemic that comes down the line, the next flu season that comes down the line, the same thing’s going to happen. And we’re going to be like, Oh my gosh, I can’t believe how bad this is.

When in fact the real pandemic that we are fighting right now is metabolic disease. And yet we’re not talking about it. So even with the flu, even with influenza, which kills, I think around 50 to 70,000 people per year, so not insignificant. People who have blood sugar dysregulation are five times more likely to end up on a ventilator or die from the flu.

Okay. So this is not like COVID is the first disease to discriminate against people with metabolic disease. They all do. People with diabetes, a cause of death is opportunistic bacterial infections. You know, this is why people get infections in their feet that can cause systemic infections and lead to death. Bacteria and viruses prey on people with metabolic dysfunction.

So this is not a COVID thing. It will always be a thing. So as long as, until we focus really on the metabolic health, in a creative, new way with different incentives, different behavior change approaches, I think we’re just going to continue to, you know, stumble along in a very victim focused mindset.

That is not good for anyone.

Geoffrey Woo: [00:42:43] Yup. Yeah. I think that’s a good astute point, which is that even the vaccine, which is, I think a huge medical innovation, you know, I think it’s going to do a lot of good and save a lot of lives. It’s still just a band-aid, right. We’re not solving again, the root primal cause in terms of just improving metabolic, overall resiliency of our population.

So I know our audience is pretty quantitative. So what are these benchmarks or thresholds for fasting blood glucose that you’re kind of categorizing for what people should be targeting for maximum resiliency? Obviously I think some of the main line numbers, over a hundred milligrams per deciliter, fasting is considered pre-diabetic. If you’re passing 120 or 130,

that’s considered full blown type two diabetic. As you’re parsing out the data, what are the thresholds or the segments that you’re seeing in terms of, if people are looking to improve their metabolic health, what should

their targets be?

Dr. Casey Means: [00:43:36] Yeah. So all the things I’m about to say are based on my personal review of the literature and not actually evidence-based recommendations that are being like, promoted in clinical practice.Cool. Not medical

Geoffrey Woo: [00:43:50] Cool. Not medical advice, just like scientific interpretation.

Dr. Casey Means: [00:43:52] Yeah.

Geoffrey Woo: [00:43:53] Don’t, don’t make us in trouble.

Dr. Casey Means: [00:43:56] Yeah. So, but I think it’s important to dig deeper into the research and I’m really thrilled to share some of it with people because I think it’s really interesting.

So I’ll talk about fasting glucose and I’ll talk about post-meal glucose. So standard criteria for glucose levels based on ADA guidelines is that normal quote unquote normal fasting glucose means a value under a hundred milligrams per deciliter, after not consuming calories for eight hours. So you walk into the doctor’s office, you get your fasting glucose checked once a year.

If it’s 99, they tell you that you’re normal. So this does not necessarily tell us what is optimal. Okay. So I consider an optimal fasting glucose range to actually be between 72 and 85 milligrams per deciliter. So quite a bit lower than. Just all comers under a hundred. And that’s based on a number of research studies that show that as fasting glucose increases, even when it’s in the normal range, there’s an increased risk of health problems like diabetes and heart disease.

So a couple of studies to mention. So first was a study where men whose fasting glucose was greater than 85 milligrams per deciliter had a significantly higher mortality rate from cardiovascular disease than men with blood sugars, less than 85. So that was like just sort of a dichotomy, above 85, higher risk of cardiovascular mortality, lower than 85.

All with normal blood sugar quote unquote, but a big difference there. The second is that people with fasting glucose levels in the high normal range, they consider this in the study to be 95 to 99 milligrams per deciliter, had significantly increased cardiovascular disease risk when compared to people whose levels remained below 80.

Okay. So 95 to 99, higher risk. Below 80, much lower risk. We also said that children with fasting glucose levels between 86 and 99 milligrams per deciliter have double the risk of developing prediabetes and type two diabetes as adults, when compared with children, whose levels are less than 86. So this is fascinating.

You know, we’ve got this whole box of normal, but 86 to 99, twice the risk of developing diabetes and obesity than if they kept it below 86. So why in God’s name, would we tell people to shoot for 99 when we should be telling people to shoot for less than 86? I mean, there’s, I got a bunch of these, but like, you know, people with fasting glucose between

91 and 99, were found to have a three fold higher increase in the risk of type two diabetes compared with people who had levels less than 83. So there’s a lot of these studies look at core tiles or Quintiles of like in these different categories, within normal, what’s the increase odds ratio. And it’s just, it’s literally every study that has looked at this, and there are about six, and I’m happy to send these to you in the show notes.

So, because of all that, I kind of put that all together and said, yes, certainly not shooting for the nineties. 70 to 85 is really where we want to be. That’s my personal opinion. Now let’s talk about postprandial, like post-meal glucose levels. So according to the International Diabetes Federation guidelines, they say that non-diabetic people should have a glucose level, no higher than 140 milligrams per deciliter, after meals.

And that glucose should return to pre-meal levels within two to three hours. So basically it’s saying don’t go above 140 and get down to your pre-meal levels within two to three hours. So that’s IDF. The American Diabetes Association has guidelines for diagnosing diabetes. And this is done through an oral glucose tolerance test where people slammed this disgusting drink called Glucola, which is 75 grams of oral glucose.

And they drink that and then they check their blood sugars. Yeah, it’s, it’s just, it’s so gross. And it’s like a lot of sugar, sugar with no protein or fat or fiber in there. So it’s really just like hitting you straight with glucose. And if glucose levels are less than 140 at two hours after the drink.

So it could go up to 250 during the test, but if it’s below 140 at the two hour time point, then the individual is considered normal. Okay. So this to me feels way, way too lenient, because there’s actually been like many, many studies where they’ve actually just slapped continuous glucose monitors on healthy young non-diabetic people and looked at their glucose levels throughout 24 hour periods.

And they find that actually post-meal glucose tends to be based on the study between about a 99 and 135. Like that’s where the majority, the vast majority of healthy non-diabetic people will be, and that they will peak between 46 minutes to an hour and then come, come quickly back down to normal. So the idea that we should be going like way up above 140, and then coming back to 140 by two hours, like, no, we should probably be going up to like 99 or like low hundreds and coming back within like an hour and a half.

And so based on all this kind of research, my personal recommendation is that, I always shoot for a post-meal glucose less than 110, ideally less than a hundred. Definitely, no more than a 30 milligram per deciliter increase from my pre-meal levels, and should absolutely return to baseline within two hours.

If you’re not returning to baseline within two hours, that’s a sign that you might be insulin resistant. Because like you’re not actually getting the glucose up into the cells. And I will say that’s sort of my review of the literature. If you look, there’s a few other physicians who have written about this, you know, on their own blogs or in podcasts.

And I’ve kind of tried to compile everyone that I’ve sort of seen what they said and the people who have written about this and are very much, I would say in somewhat concordance with what I’m saying is Peter Tia, Mark Hyman, Dr. Sara Gottfried, Chris Kresser and Dr. Molly Maloo, for all metabolic health experts.

I think Dr. Tia says that he aims to keep his glucose around an average of 90 milligrams per deciliter, and never wants to go really more than 10 above that. So that’s like basically staying between 90 and a hundred. Sara Gottfried talks about wanting to keep her glucose for her patients between 70 and 85, and keeping average glucose around about like 95, 97.

And then I think Dr. Hyman says that our fasting glucose should always be below 80 and never rise above 110 or 120 on the post-meal check. So kind of in that same web of what I’m talking about. And I think we’re already in the same literature. So that’s probably why, but what we need is for researchers to be studying healthy non-diabetic individuals, the healthiest in the population and looking at 24 hour CGM glucose profiles. What’s happening after meals?

What is the average? What is the fasting? What is the area under the curve after meals? Mapping that on to underlying metabolic biomarkers? So like, how does this type of curve relate to fasting insulin levels? How does this type of curve relate to our triglycerides and other metabolic markers? So we can start to understand how these CGM data sets actually map on to underlying metabolic health, and then start to do some clinical research showing, Okay, if you can keep within these ranges, what are the actual clinical outcomes?

And if we improve our CGM metrics, how does that actually improve our clinical outcomes? That is where I think the next five years of research is going to be at, five to 10 years, in terms of really longevity focused physician research. And I am super excited to see this happen and be a part of it. You know, Levels is investing.

We just closed our seed round of funding. And we’re investing a lot of money in supporting clinical researchers who want to answer these questions, because we are dealing with a country that is 88% metabolically dysfunctional. We have 128 million Americans who have prediabetes or diabetes. We have 74% of Americans who are overweight or obese.

And we actually do not know as physicians what to recommend people to keep their blood glucose at. That is absolutely

crazy.

Geo ****[00:51:16] Yeah. And I think you’re hitting something that’s spot on that I think is non-obvious for a lot of lay listeners or folks who just haven’t studied, what are the benchmarks? So I spend a lot of time with high performance athletes and performance coaches, and they almost throw away the recommendations of like the bars that you get from quest or lab Corp in terms of like their biomarker values of like, what is a good fasting glucose or what is a good insulin status, because where is that data from?

It’s literally 25 to 74, 75 percentile of the average American person, which as we just realize is like basically metabolically dysfunctional. So if we’re benchmarking on the norm, which is like sick, then like what are we even targeting? So I think that is something interesting where in the elite, at least what I’ve observed, in the elite performance space, they literally are trying to like set like actual biomarkers that are relevant to the high performance community, because that’s just basically different from like the average American, which is sick and overweight and obese.

Like the average American’s probably again, it’s hitting metabolic dysfunction. Probably pre-diabetic and probably has an extra 50 pounds on them. And like, that is not the target that we should be aiming for. So in some sense, why are the constraints so loose? Is it because the traditional medicine, medical infrastructure can’t optimize everyone?

Is it just like, okay, if we’re just trying to like max every one to like 110 after a postprandial glucose, that’s like impossible. We’ve given up. So we’re going to like, let people just get up to 140 or surpass it. Do you think it’s less sophistication or is it, you think that the folks that, the powers may be, understand that they should be targeting a higher threshold, but because it’s so far from what they think is practical that they’ve given up and they’re like, Hey, if you’re just like, not clearly screwed up, like you’re okay.

Like have we just given up in terms of like the standards. Or is it like, Hey, we need people like ourselves and in the work you’re doing like, Hey, this is not that. Like, we can all do it. Like, do we just need like more leaders inspiring and challenging the

norms here?

Dr. Casey Means: [00:53:23] Yes, for sure. But I think a lot of the ways we’ve got into these more lenient numbers just has to do with the way that biomedical research is designed and implemented.

So if we look at something like the history of how a diagnostic tests like hemoglobin A1C came about, it actually sheds some light onto this. So hemoglobin A1C is a blood test that you can get that tells you about your sort of 90 day average for your glucose levels. But it’s not a great test for a lot of reasons.

It’s dependent on the lifespan of your red blood cells. That’s looking at how much sugar is stuck to your red blood cells, basically. So that’s variable between people. You might have a decent hemoglobin A1C, like a non-diabetic, but that actually tells you nothing about how much you were going up or down, in terms of variability during those three months. And glycemic variability, how much spikes and dips we have in our glucose is a key predictor of health outcomes.

We do not want mountains and valleys. You want flat and stable for our glucose. And hemoglobin A1C doesn’t tell us anything about that. So you could have someone you can imagine who, let’s say their average glucose is a hundred, and then their A1C reflects that. They could just be always around a hundred all the time.

Or they could be someone who goes from 150 to 75 to 150 to 75. The average might be the same, but that person with the big spikes and depth is going to be much less healthy.

Geoffrey Woo: [00:54:33] Yes. So why is that

problematic? If you’re recovering quickly, you know, one person, Hey, like, you know, my HD one, like my hemoglobin A1C is fine.

Why is the spike problematic? Why is having hyperglycemia problematic on

these bursts?

Dr. Casey Means: [00:54:48] Yeah, so that spike is a signal to the body to release insulin. And so every time you spike, your pancreas is having to create and secrete insulin, which then helps, makes you, you know, allows you to take that glucose out of the bloodstream into the cell.

So there’s a hormonal cascade that is ultimately going to, if happening over and over and over again, generate insulin resistance, like we talked about before. And that’s going to create problems with baseline hyperinsulinemia, and the cells basically not being able to take up glucose as effectively, and over time, will just make your baseline glucose levels rise

if you spike

too much. That’s number one. The second is that when you spike high, which the average American is spiking high all the time, because the vast majority of our calories come from refined carbohydrates and sugars. And we have been told to snack all the, you know, have six meals a day, small meals, but these are high carbohydrates.

So we’re basically spiking your insulin all day. So with these spikes and dips, in that high insulin state, we are never giving our bodies the opportunity to be in a low insulin state, which is where fat burning happens. So that’s problem number two. The third problem is that a big spike will lead to a big insulin response, which will then sometimes overcompensate. You’ll actually suck too much glucose out of the bloodstream and have what’s called reactive hypoglycemia, where you go up, but you crash down. And reactive hypoglycemia, when you get low after a big high, because it’s basically an exaggerated insulin response.

What happens in that time of reactive hypoglycemia, we see a lot of the subjective pain points of life. We’ll see anxiety. You could have a post, like a slump, like your energy is low at that time. How people often, you know, they’ll eat a big meal and then feel like really tired afterwards. It’s actually been associated. A big spike and then dip has been associated with reduced acute memory recall, like fact recall.

And so they’ve done tests with people where they like put their glucose really high. And have them try and remember words and things like this verbal memory, and they do worse. So the reactive hypoglycemia, we want to avoid that. A lot of these sort of like ups and downs in our day, mood, lability, energy lability, et cetera, memory liberality, like actually I think is just directly related to our blood sugar going all over the place.

So stable blood sugar is in many ways, promotes a stable life, subjective experience of life. And then the last thing is that that spike in its own right, can cause glucose related physiology, the inflammation, the oxidative stress, the glycation. So you do not want to spike. You want to stay as flat and stable as possible.

And you know, hemoglobin A1C doesn’t capture any of that. And we categorize people into these thresholds of hemoglobin A1C. So like less than 5.7% of what your hemoglobin in your red blood cells being glycated as normal, like 5.7 to 6.4, pre-diabetic 6.5, and above diabetic. And that wasn’t because like we were being lenient when we made these, you know, when the scientific community made these categories. It’s that we’re dealing with population health.

We’re not dealing with individuals in our research. And they basically found that like, Okay, below this level of A1C, we see a certain amount of clinical outcomes. The clinical outcomes, bad clinical outcomes go up between 5.7 and 6.4. And they go way up after 6.5. So that’s what we’re going to categorize people.

And I think the original research in A1C was actually done in diabetic retinopathy. So how much people developed retinopathy, which is small vessel disease of the retina and the eye, one of the leading cause of preventable blindness in the world. So I believe that was the clinical outcome they were looking at in the 70s and 80s when they were doing this research.

Geoffrey Woo: [00:58:00] Pretty advanced those

days.

So I think it is pretty interesting that you’re benchmarking on some blindness, which is like a very severe end point of diabetes. So like you theoretically should be much, much more constrained if you just want general metabolic health, like even getting seven it’s like, Whoa, like you’re going, that’s, that’s blindness.

That’s like amputation

levels.

Dr. Casey Means: [00:58:18] There’s a great book by Todd Rose. He’s a Harvard professor who wrote The End Of Average, that talks a lot about how our sort of the way we do research and the way we lump things and the way we approach bell curves. What happens is that you end up basically doing some bad research, like by trying to optimize for the average within different groups, you actually lose a lot of people.

It’s very interesting. And I, you know, I think there was no, there’s no malintent here. It’s really just trying to be efficient in our system and capture, you know, help, you know, capture people into groups so we can triage and allocate resources effectively, but it’s not working. It’s not working. And we are extremely metabolic dysfunctional.

And you know, I think that a lot of people are moving in this direction of more a personalized approach to diagnostics, and the interest in the medical community in bio wearables, things like Woop and Aura and Eight Sleep and Levels and Apple watch, and all of these biometric trackers is that. You know, imagine if we were able to do see our glucose 24 hours a day, understand how food and lifestyle activities were affecting our glucose.

See what our glycaemic variability is every day and learn how to improve it. See what our fasting glucose every day, learn how to improve it. See how different foods are affecting our post-meal response. Learn how to improve it. See how stress, exercise, too little sleep is affecting our glucose.

Figure out how to optimize those. You would never in your entire life, have to walk into the doctor’s office again and get a surprise about your metabolic health. If you’re doing this and track it, it changes the whole dynamic with healthcare. You’re never going to walk into the doctor’s office and have them drop a bomb on you about your metabolic health, because you know, and you have tools, you have a toolbox to optimize it.

And the interesting thing is, is that for each person, it’s going to be a different plan based on their biochemical reality. So, you know, you and I could eat the exact same banana and have wildly different glucose responses because we have different microbiome and we have different insulin sensitivity.

So what might be a great metabolic choice for you, that’s going to drive pretty low insulin response, might be a terrible one for me. And so, you know, in that situation where you’re going to the doctor and let’s say, they do say you have a problem and they say, Hey, you need to eat healthier and exercise more.

What in the heck does that mean? It’s actually not a great. You know, kudos to doctors who say that to their patients and who even in any way, promote lifestyle and dietary improvements. But we know now that it really needs to be more personalized than that. And so seeing your own data, seeing how individual foods are affecting you, how stress affects your glucose, not just some blanket statement.

I think that’s where we’re moving, and it’s incredibly empowering to individuals. It changes the dynamic with the healthcare system and kind of takes us to, in some ways like a post-marketing economy where it doesn’t really matter what the tribalistic voices in the nutrition health care space say like, you have to be vegan,

you have to be carnivore, you have to be keto, you have to be paleo, you have to be low carb. It doesn’t matter anymore because it’s, you’re seeing exactly how those different things are affecting your body. Like Quaker Oats. It’s gonna be a long time before they’re required to not put on their packaging

that they’re not heart-healthy, which they’re not. But currently Quaker Oats say heart healthy, high fiber, whole grain food. Well, the majority of our customers who eat instant oatmeal or oatmeal, see a gigantic glucose spike, and that glycemic variability we know is associated with endothelial dysfunction and poor cardio-metabolic outcomes.

So people are doing that day in and day out. It is unequivocally unhealthy for them if they’re having a huge spike after it. And so I think we’re going to see that we move towards, like I said a post-marketing kind of type of environment where it’s, you don’t have to take at face value a lot of these claims that are being made because you actually can just see how it affects you.

And in a lot of ways that makes life easier and it makes it more peaceful, because as opposed to constant trial and error, and trust and shame around making bad decisions, and just yo-yoing ,and just all of this misattribution that we do in our lives, and just like the very lagging indicators we have for knowing whether the choices we’re making are actually affecting us positively.

We instantly see if we’re making good choices. We instantly see how we should move forward. And that takes a lot of emotionality, it breaks a lot of the neurologic feedback loops that can be maladaptive in behavior change. So like you were talking about earlier, the more we can link an action with a reaction in a one-to-one relationship and in a short period of time, the more we overcome these profound, you know, dopaminergic reward pathways that are kind of being hijacked by our modern system and the general confusion

that exists in the nutritional world

right now.

Geoffrey Woo: [01:02:47] Yeah. Let’s, let’s just like shift topics and just talk about Levels specifically and why the CGM and how you guys are making it so much more accessible. I know that just through the course of our podcasts, we’ve experimented a lot with CGMs, but it’s always been pretty bootleg in terms of getting access to these devices.

And I think one of the things that I was so excited about and full disclosure, I’m a tiny little investor and big fan of what you guys are doing. We should just talk about why and how you guys are just elevating the space. And just, I think that the forefront of changing this game and as a part of, you know, helping make this accessible to more people, I know that one of the biggest questions that I had gotten over the years is what’s the best way to get a CGM.

Can I talk, do you have a doctor you can refer that might prescribe this to me and. It’s always been like, I have some doctor friends, but they’re like not set up to do telehealth. They’re not set up to like onboard like 500,000 people just like paying them just to get a CGM that might not be diabetic.

They just want to be optimizing. And you guys are essentially solving that problem. So one, we have a special offer for our atrium and podcast listeners. So I know you guys are like, just crushing it because about what, like over 60,000 people on the wait list. So for folks that are listening on this program, this conversation with Dr.

Means, we have a special link levels.link/html levels. L E V E L S dot L I N K slash H V M N, will skip you to the front of the line. So Dr. Casey and her team can help you out here. So one, check that link out we’ll have in the show notes, but two. Like, what was the world like before Levels? I mean, essentially my experience was either finding kind of off-shelf

e-bay kind of bootleg access to CGMs or to getting like a very like forward thinking doctor to basically prescribe this to you because it’s considered a medical device in the United States. So. What have you guys built that makes this much, much easier for everyone to actually tap into.

Dr. Casey Means: [01:04:56] So I think a lot of people have had experiences like yours, where they’re just like, how in the world do I get someone to prescribe this to me?

And the reason for that is because continuous glucose monitors, they’ve been around for like over a decade. And they are FDA approved for type, for management of type one and type two diabetes. So these have been game changing for the diabetic community, as opposed to just pricking your finger three or four times a day, to get some information about your glucose so that you can manage your medications.

This for, you know, allows for this like movie, as opposed to a snapshot of your glucose, and just gives you so much more insight, but still is mainly indicated for diabetics, for medication management. So like how to dose insulin and things like that. It was never really meant or thought to be a behavior change tool.

Like how could this data stream actually inform our choices and reinforce feedback loops that are positive. So Levels brings this technology, this hardware to the mainstream and create software that helps people really be empowered to understand their current level of metabolic health, and then make choices to improve it.

So we basically take out the guesswork of what’s the perfect diet for you, and empower people with this real-time continuous metabolic data to understand how food’s affecting your body. So the way we built that is that our members of the program, they engage in what’s called a metabolic awareness journey. It’s one month.

And that involves three things. It involves a telemedicine consultation. So we have a telemedicine network where people are evaluated with a verybrief consultation online, filling in some answers, written answers to questions. That’s reviewed by a doctor in their state. And if they are approved for continuous glucose monitor, then our partner pharmacy sends them two continuous glucose monitors in a Levels box with performance covers that, and that gets sent to their door.

And then they get access to the Levels app which interprets all the data and helps you make better decisions. The sensors each last on the arm for 14 days. So you get two sensors, which makes up the month. And these sensors take a glucose reading every 15 minutes automatically. You don’t have to do anything.

And then you just scan your phone to your sensor and it pulls in all those every 15 minute glucose readings. And so you can kind of think of it like a Fitbit or a Whoop for glucose. And you know, what it does is it creates that closed loop biofeedback, and helps you all move towards that flat and stable glucose level that we know is associated with current and future wellness.

And so the way we recommend people approach the month is the first month, the first week of the program, just like, do all your normal stuff, eat what you’re normally eating. And kind of just like, see how your normal diet is affecting you. Some people like to just jump into trying to optimize, but it’s kind of interesting to see like how everything you’ve been doing has been affecting you.

We talked about oatmeal and how that’s been a big surprise for a lot of people. People who every morning at 11:00 AM reach for their second cup of coffee, because they think they’re tired because of lack of coffee or not enough sleep. And they see that their oatmeals spike their glucose to like 200, crash down to 50.

And that’s when they feel tired. And then all of a sudden they switched to like, you know, eggs and avocado and their energy is completely stable in the morning. So you just start to see those surprises that are fascinating. You also start to see like hidden things that have been totally screwing you without knowing it.

So like the ketchups, the salad dressings, the sugar that’s hidden in bread. And it just, it’s everywhere. There’s like, you know, 56 different names for sugar. They’re hidden all throughout these products that have no need for sugar. I mean, it’s literally filling our peanut butter. It’s crazy.

You have to be like a hunter, sleuth in the grocery store to avoid added sugar and, or like order your ketchup on Amazon, through Primal Kitchen, which is what I do because there’s not a single ketchup in Whole Foods that doesn’t have added sugar. And so you start just like seeing surprises. So that’s week one. Week two, and three, we help people through like a bunch of challenges and explorations to help them understand how to build their metabolic toolbox.

So like, What is less sleep versus more sleep due to your glucose? What does deep breathing when you’re stressed, due to your glucose, compared with just like letting the stress take you and kind of engaging with it. How does walking after meals for 20 minutes change your glucose response? How does pairing vinegar or cinnamon, substances known to be insulin sensitizers,

how do those impact your post-meal glucose spike? You know, doing a lot of these different trials to start building out your metabolic awareness and your metabolic toolbox. And then week four. I think it’s fun to really try and optimize. So like put everything you’ve learned into like keeping your glucose as flat and stable.

And then at the end of the month, people get like a really beautiful, detailed report of kind of everything they did and how things improved, you know, their time and range over the course of four weeks, their average glucose, their post-meal responses. And the app is really cool. It has a lot of cool features that are fun to play with.

There’s a compare feature where you can like do different trials of different things and see how they affect you. So someone, an awesome customer basically tried like four or five different sports bars that they were eating around their workouts, and saw exactly how each sports bar was affecting them, and then could graph it all on one graph really easily in the app.

And he found that like a Cliff Bar, like put them up to over 200 on their glucose, and a number of the bars shot them up. But there were a few bars.

Geoffrey Woo: [01:09:50] Yeah, Cliff Bar.

Dr. Casey Means: [01:09:51] We had someone

do, another athlete who has been drinking Gatorade for years. And they did Gatorade and they did the, ElemenTea sports drink, which has no sugar, but still has like a lot of electrolytes and whatnot. And the ElemenTea you like was completely flat. The Gatorade again, put them to 200, like this is, yes.

We all agree you want to replete your glycogen in your muscles so you can build strength, dah, dah, dah, like, but that is a. No human body needs to be up at 200 to replenish glycogen. I’d suggest you probably need like the mild little bump in your glucose to like fully replete your glycogen. We only have like four grams of sugar in our entire bloodstream.

We do not need 37 grams of sugar from a Gatorade. And to see that and realize that, Oh my God, this thing that I thought was fueling me is actually causing all this collateral damage and is totally unnecessary, has been a game changer for a lot of the athletes in our program. So that’s a compare feature.

There’s also an activity catalog that shows you all your scores. We score meals. We don’t just tell people like, you know, raw number of glucose data, but we actually give them a letter grade or a grade one through 10 on each of their meals, which takes into account a number of these metrics about a glucose curve, like area under the curve, and change from baseline, and puts them into one simple metric to understand.

So you’re like, This dinner was a 10, this dinner was a three. And you can start to understand like what’s affecting you. So that’s some of the stuff that, you know, people will find in the app. And you know, I’m biased, but I think it’s so much fun. I’ve been wearing it for 18 months and my life has certainly changed.

Geoffrey Woo:Geoffrey Woo: [01:11:22] Yeah. And I think it’s just, it’s super valuable. Even just invest for one month just to get that baseline understanding of yourself. I remember this was probably three, four years ago I was wearing a CGM and I had an overnight flight, like a red-eye flight to, from California to Boston. And then I decided to have just like, uh, uh, like a, like a splurge meal or cheat meal.

I got a double Whopper fries, Coca Cola at the Logan Boston airport. And I was measuring my blood sugar was like literally like 250, something like ridiculously high. I’m like, and again, I think we all intuitively know that that’s probably not the best healthiest meal, but just seeing that number. And you’re like, wow.

This is  bad for my, like my glycaemic response. I think it was compounded by like, not sleeping, pretty high stress from traveling and then just a mega carbohydrate bolus from Coca Cola, fries and a double Whopper. I think that’s like very powerful. Right? Because I think we all know the theoretical, what we know from just like common sense, but just seeing that personal number, your personal number, your personal glycaemic response, I think it’s very, very powerful.

It’s very, very visceral to you. So I think just, even from that level, it’s very, very powerful. And then too, I think like when we were developing our keto food bars, like we were using Levels, we’re using CGMs, the benchmark. And I think I, that feels like that will be the future of nutrition of food where, if these are very quantitative measurable impacts on our physiology, let’s design and build foods and nutrition protocols that actually integrate with on the other side. Like, let’s get that, let’s actually test these things.

So I think like this, I think this is like the combination of like thoughtful produced foods and then actually grading them. And actually how that’s personalized to your personal physiology. I think I’m just curious to hear any interesting, surprising anecdotes in terms of like non-obvious or obvious things that people might’ve, you might’ve picked up from either yourself or from the community of members.

Like there it’s, I just see the very interesting results for like, I think grapes seem very, very, in terms of glycemic response, like blueberries are much better in terms of glycemic response. I think some things that are non-obvious. I know that for certain ethnicities, like white rice seems to do better for some folks than others.

Like there, I mean, this was like a very like well-published Israeli cell paper that showed that like glycemic responses to the same foods is pretty variable across different populations. So anything that’s like, particularly interesting that has been amusing or interesting that might be non-obvious.

Dr. Casey Means: [01:14:09] Oh my gosh.

So many things. Truly I feel like I could talk about this for the next five hours because our, you know, in our customer or our members are posting about this stuff constantly on Twitter and Instagram. And like, just to see what people are learning, and how so much of it both reinforces what’s in the research literature.

But also sometimes it’s a little different than what’s in the research literature. It is like, beyond fascinates me. But some really fun ones that I think are maybe worth mentioning. So I mean, the one about the, like mentioning about the pro athletes and like realizing like what they’re doing to fuel their bodies might be hurting.

That’s been really interesting to me to see how people actually are changing their fueling to optimize recovery and performance. I think also with athletics, we’re seeing this interesting movement, which I know you’ve covered on your blog and in podcasts like carb cycling. And I think you guys have like the best

blog post on carb cycling of any I’ve read. I recommend it to everyone. But this idea of like the low carb athlete and being able to tap into different, energetic, fuel substrates and perform in workouts. And so, you know, with the standard American diet and how we’re eating, we’re basically forcing our bodies to be totally reliant on glucose during athletic performance.

And if we actually can train in a lower glucose state, we can start to adapt to actually use fat for fuel more efficiently during our training. And so actually using CGM as a tool to learn where you’re at in terms of your glucose during training and during, towards, during actual competition can help athletes adapt to being better fat burners, during their  training.

And this has a lot of implications for endurance athletes. And you can imagine if you start to be able to burn fat more efficiently, especially at higher intensities, where we tend to be more glucose burners. If you can shift that more, that fat burning curve to the right, where you’re actually able to burn more fat at higher VO2 max max as heart rates intensities, we open up this whole extra source of energy and become less dependent on exogenous glucose during our training.

So, you know, we have lots of athletes who have used Levels and who are sort of more in the low carb, you know, Geoff Volek, Steve Finney type athletics camp who have really used this to enhance their low carb training. And they still might use glucose on performance days to kind of get an extra bump, but they’ve actually adapted their body to be able to also use fat.

So we’ve got pro runners who are like doing fasted marathons, like 26 miles, even in our own company. Our head of customer success is an incredible athlete, Mike Donato. He’s doing fasted marathons frequently, and you see fascinating data when you’re doing that, but they’ve adapted to become like amazing fat burners.

So that’s one thing I would kind of mention. So training. The second is a lot of people are fascinated by seeing their glucose actually go up on their sensors during high intensity interval training. So in high intensity interval training, we know that like stress of that activity causes the liver to actually quickly dump a lot of glucose into the bloodstream, breakdown glycogen, and produce more glucose put into the bloodstream for the muscles.

So even if you’re fasted, you actually might see a glucose sort of spike while you’re doing high intensity training. And that’s actually not a bad thing. It’s not exogenous glucose that you have to like release insulin and process. It is glucose to feed a need. So there’s an energetic need that you’re meeting and it’s kind of emptying your tank.

It’s emptying your, it’s moving through your stored glucose and glycogen, so that you’re actually, you know, you’re getting closer to fat burning and to these metabolic adaptations, when you see that happen during a high intensity workout. So people are pretty fascinated by that.

Geoffrey Woo: [01:17:25] To interject there, yeah, I think that’s like something that’s like non-obvious. And remember I was doing a seven day water fast and I was exercising through it. And it’s pretty amazing to see that the body’s fairly adaptable in terms of gluconeogenesis and creating glucose from fat. And I was still elevated blood glucose, even when I was exercising like five days into a water fast.

So it is pretty remarkable how adaptable the human body is to generate substrate as needed for different types of demands you’re demanding from the body.

Dr. Casey Means: [01:17:58] It’s so true. And it doesn’t happen overnight, like the body upregulates and down-regulates things. And genetic expression changes as we put these stressors or these new inputs on the body.

So we have to think of it as like, we like to call it metabolic fitness. You know, there’s metabolic flexibility, which is the ability to use fat or glucose based on different substrate availability. We are very not metabolically flexible in our country because we’ve been only sort of creating conditions where our body uses glucose, never really have an opportunity to use fat, which is why most people in America are fat.

And so metabolic fitness, we think about it as like, this is like just like lifting weights day after day. We’ll start to see muscles grow over the course of weeks and months. Similar with this, if you work these pathways, and by pathways, I mean, keeping glucose down, burning through your glucose when you’re working out, and then having to actually flip on the switches for fatty acid oxidation in the mitochondria, over time, those pathways, those receptors, those channels, it all becomes stronger, and then it just becomes

second nature, so to speak, in our cells to be able to do this. So it’s fitness. It is adaptations. This requires doing this sort of like over and over. It’s not going to be easy the first day that you do it when your body is a slave to glucose. So, yeah. So I think it’s great to see that, that feedback.

And also to know that like when you’re hungry, maybe during a workout or in the morning or whatever, and you’re like, Oh my God, I’m hypoglycemic. I’m so hungry. You look at your glucose and you’re like, Oh, I’m actually like firmly in the eighties or the nineties. I’m not actually hypoglycemic. What I am is that I’m not able to use another source of energy.

And I don’t have, I haven’t eaten this morning and I’m not able to burn fat. And so I’m hangry and I’m feeling panicked. And like that just goes away. I  think so many keto people find this, that when you tap into fat burning, this idea that like, Oh my God, I haven’t eaten in a few hours. I need some food.

It just, it actually just disappears because you have this, you know, hundreds of hours worth of energy stored as fat in your body that we’re just not able to

access.

Geoffrey Woo: [01:19:53] SoSo I think that’s good, awesome survey or overview in terms of like some of the insights that Levels can offer. I think, again, it just, these are very powerful. And I think, again, just that personal data is so visceral that even if you’re just like the most disciplined person ever, if it’s not your own numbers, I feel like it’s still a little bit abstract.

And what I found for myself, it’s like, I just want to make infrastructure assistance and make it easy for me to be the way that I want to live or be disciplined. And I think Levels is an awesome tool to do that. And if it just like you get that first month and just to understand like the core, basic, I think it’s so helpful.

I think. It will not surprise me that in five, 10 years, everyone has Levels for like at least a month, just so they can get educated on how their body responds to different stimulus. Right. And I think that would be a good service for all of us to understand like, Hey, you know, these types of foods make me feel this way and also quantitatively benchmark in this way.

So it’s not just like some intuition thing, which is like very hard to control, some placebo effect. You got real numbers. I think even just from that level, I would say that almost everyone can get value. Like literally everyone gets value from something like this. No, I mean, I’m a true believer in terms of just like just the overall space.

And I think that’s part of the reason why I’m excited to talk to you and also, you know, figuring out a way to get early access or skip the wait list for our listeners, because I think it’s super valuable. So again, that link is Levels.Link/H V M N. So as we wrap up here, any like thoughts? I mean, I think just the overall conversation, I think you’re just super well-spoken on the space.

I mean, are you on Twitter, Instagram, where do people follow along? I know that Levels has, it also has a great blog as well. Where do people keep tuning

in?

Dr. Casey Means: [01:21:36] So I think certainly follow us at Levels on Instagram and Twitter. So that’s just @ Levels and just like seeing people’s experiments and what they’re learning, I think is absolutely fascinating.

I am on Twitter and Instagram at Dr. Casey’s Kitchen. So DrCaseysKitchen, and I’m actually I’m plant-based so I, I read a lot about sort of like the intersection between plants and plant carbohydrates and how to optimize that through everything we’ve been talking about to basically get the benefits of plants without the collateral damage of plants, which can be

a lot of high glucose spikes and whatnot. So that’s something I talk a lot about using plant protein and fat and things like that, to really create a good context for glucose processing in the body. Our blog, like you mentioned, LevelsHealth.com/blog is an amazing source of information on all of these topics.

We have incredible guests, physician writers, PhD writers, Dom D’Agostino, Ben Beckman, number of great doctors writing on the blog about really forward-thinking ways to approach this from a systems and personal level, and a lot of member testimonials to kind of see how people have benefited from glucose monitoring technology.

So that’s the way to find us. And I’m, yeah, I’m so glad that you’ve shared the link as well with people that allows people to skip the wait list and join our beta program. And we’d love to hear from anyone,

so.

Geoffrey Woo: [01:22:50] Awesome. Yeah. Excited to get this out there. And I think there’s like a lot of meat for part two.

So if you guys have questions. I think one of the interesting areas to potentially have a potentially a part two is talking about plant-based keto. Because I think that’s definitely an interesting, I would say flash point within the, just overall low carb community, plant-based, carnivore based and that’s my perspective.

I’m pretty agnostic. I think, you know, there’s pros and cons for different approach, including environmental factors and morality factors. I think it’s always like a fun conversation to have. So we’ll save that for part two. So again, Casey, thank you for taking the time to come on our program and talk to you soon.

Dr. Casey Means: [01:23:31] Thanks so much, Geoff.