#59 – Dr. Casey Means

As a former medical student at Stanford, a trainee at Oregon Health & Science University, and a surgeon for more than five years, Dr. Means was treating a lot of medical conditions with steroids, antibiotics and surgery. But something became apparent to Dr. Means: these were all conditions that are inflammatory in nature. Was there a way to be proactive to prevent the onset of disease? Dr. Means thought so. Through Levels Health, a health and wellness company Dr. Means co-founded with Josh Clemente, they empower users through glucose monitoring (CGM) devices so that they can track their glucose levels, which they believe will prevent the worst side effects of insulin resistance. On the Doctor Diet Podcast with Dr. Bret Scher, Dr. Means describes the healthcare system that’s been more reactive than proactive, the importance of CGM, and the effects CGM could have for our health.

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04:01 — From the operating room to the board room

After several years of prescribing medications for the same types of conditions, Dr. Means realized that she, and the healthcare system as a whole, wasn’t dealing with these patients in a proactive manner.

“It’s kind of felt like fighting a battle with the wrong weapons. And so this was quite interesting to me. I started thinking, ‘Why are my patients so inflamed? And why is it that everyone’s got these revved-up immune systems?’ And it was especially interesting to me in light of what I was learning about other chronic conditions. So things like obesity, diabetes, even things like cancer, depression, Alzheimer’s disease, you start reading the literature on these things, and it also stems back to inflammation. And so sort of started putting these Venn diagrams together, thinking, this is fascinating that cytokines like TNF alpha and IL-6, they’re kind of upregulated in all of these diseases. What’s going on here? And what is this threat that all of our bodies, our immune systems are responding to? And ultimately that got me really digging deep, thinking about the root causes of inflammation and I really sort of transitioned from being someone who was very passionate about surgery and about helping people in that way, to someone who really became laser-focused on, how do we keep people out of the operating room?”

08:19 — You eat what you kill

The above is a saying that doctors sometimes use to describe the relationship that exists between the cost of surgeries and the money that, as a result, goes into doctors’ pockets. This t rarely talked-about truth is why new approaches like Levels feel as if they’re disrupting the healthcare space.

“There is sort of this underlying push towards doing this intervention that is both good for the patient, but also extremely lucrative for the system. You know, its surgeries are very high paying high reimbursement, and you know, what doesn’t get much reimbursement is a 30-minute counseling session about diet and lifestyle are really digging into the core. The core realities of a patient’s lives lead to the health behaviors that ultimately underlying chronic disease. So there’s interesting stuff going on there. And so when you come guns blazing saying, hey, you know, I want to spend a bunch of time talking to my chronic sinusitis patients about food sensitivities and about, you know, their exposures and about these things that may be really jacking up their inflammation. I want to talk about food as medicine, and I want to talk about, you know, how certain food compounds may be helpful for their anti-inflammatory effects — there’s not a lot of space or time for that in conventional medicine.”

13:46 — Shifting away from the patient-doctor paradigm

While having conversations with your doctor can be beneficial, Dr. Means said that there needs to be a shift away from this relationship toward one that includes supplemental tools — like Levels — that can help implement diet and lifestyle changes in a patient’s life.

“While patients do enjoy having that conversation with the doctor, when a doctor makes a recommendation about diet and lifestyle, it’s pretty unlikely that it’s actually going to be carried out by a patient. Not to say that it never does, but in terms of the statistics they’re not great. And so you got to think, how can we pair that really powerful conversation with the doctor and the high-level thinking that a doctor can do with tools that a patient can have day in and day out to really personalize and empower that advice and make it actually really practical? So that’s where I see the future of medicine is pairing the wisdom and the real cognitive beauty of the physicians or the healthcare practitioners’ knowledge with tools that make it a day in and day out situation. Because this isn’t about encouraging someone to take a pill. It’s not about encouraging someone to have a procedure. It’s about encouraging someone to make decisions hundreds of times a day that are ultimately gonna move the needle on health.”

18:56 — Continuous glucose monitors as a preventative health tool

Type 1 and Type 2 diabetes aren’t on-off switches that suddenly appear. Rather, these diseases are on a spectrum, Dr. Means said. Patients are likely progressing along this metabolic dysfunction spectrum over the course of years, even decades. Having tools to monitor these levels can help to make active lifestyle changes before it’s too late.

“You can imagine how having this information about glucose far earlier — you know, years and decades before you get that slam of a diagnosis or that fasting glucose in the doctor’s office that finally says we have reached diabetic levels — you can have this way, way before and actually tailor your diet and your lifestyle to minimize the glucose spikes that ultimately start pushing us down the path of insulin resistance towards overt dysfunction. So it’s sort of this beautiful tool that can really prevent us from ever having to walk into the doctor’s office and get a surprise about our metabolic health. And that I think is really empowering. And secondarily, I think it’s an antidote, a welcome antidote to the mass confusion about nutrition that we’re dealing with right now. There’s data that suggests 80% of people are confused about nutrition advice. I feel that in my own practice and in my own social community, nutrition has become essentially tribal warfare, and to be able to cut through some of that noise with an objective data stream that gives us continuous information about our key metabolic biomarker is so exciting.”

24:12 — Pairing subjective experiences with objective data

Tools that monitor glucose levels can help cut through the noise of food marketing and help patients more clearly tailor which foods and habits are right for them – such as whether or not oatmeal is a heart-healthy breakfast choice.

“All of a sudden you put together the subjective experience you’re having with this objective data and realize that this might not be the best choice for you. And so it’s a way to, one, really move past food marketing and understand what foods are actually best for your own physiology. And then, two, to really gain an amazing sense of body awareness by pairing subjective experiences that you’re having throughout the day with objective data. And I think as you do that over and over and over again — and realize how these little things that are happening throughout the day, especially related to cognition, mood, and energy and athletic performance, and sort of our physical vigor and seeing how that relates to your data — I think you really build this beautiful sense of somatic awareness of starting to understand how the choices you’re making are impacting objective metrics and how that’s leading to a subjective experience. And that trifecta is really somatic awareness. And I think digital tools can help us get back in touch with those inner workings of our bodies.

33:57 — Extracting important data through the flurry of raw data

With such immense data at our fingertips — and more to come with the influx of new tools and devices — sourcing good data might be a challenge. But with the right guidance, that data can serve up personalized recommendations that can change health behaviors.

“So of course it could feel very confusing, but my feeling is that the lowest hanging fruit is these four main pillars of food, sleep, exercise, and stress. And that’s where I think software that is overlaid on top of that raw glucose stream and really integrating data sources. So the raw glucose data stream with other data streams, like objective measures of exercise, sleep and stress. So we think about heart rate variability, other noninvasive biomarkers we can track at home — when we start merging some of those data streams, you can actually really start to pick up really interesting trends and help people parse out and weight how these different lifestyle and dietary factors are affecting that glucose readout essentially. So it’s really a multivariate thing, but that’s where I think machine learning AI software is going to revolutionize this and sort of hand to a person on a silver platter. Like, ‘Hey, every time you eat those apples with peanut butter, do you have a 15 point lower glucose response?’ And, ‘Every time that you don’t eat these foods, X, Y, and Z, after 6 p.m., your deep sleep is 20% better.’ That’s where I think we’re going to see people being able to have those actionable insights.”

36:46 — What is the “optimal” blood sugar level?

There’s no clear-cut answer to the above question. But Dr. Means hopes that a shift toward a more proactive healthcare system — along with the research of doctors and researchers — could help provide patients with more understanding of their health goals.

“We know we want to stay below a fasting glucose of 100 to not be labeled pre-diabetic, but that doesn’t actually tell us what to shoot for. What’s going to keep us thriving in our current day-to-day lives and also out of trouble down the road? So this is where we really need to do some research. And I think part of the reason we haven’t done that research is because our medical system is very much a reactive system. We wait until diseases and symptoms have manifested before we intervene. And we are certainly moving more towards prevention efforts with value-based care to really focus on the front end of health. And I think that’s great. But we need to be thinking about glucose when people are not pre-diabetic or diabetic because that’s where we can really move the needle on keeping people out of trouble down the road. And so I think the more CGMs and data we can produce in a non-diabetic population, the more we’re going to start to understand some of these trends.”

41:55 — Glucose levels are an ‘excellent start’ for predicting other health info

Though the research is still in its infancy, having glucose levels at your fingertips could open the door for understanding the short- and long-term effects that increased or decreased levels have on a patient.

“The average person — you walk down the street and ask them to predict what their metabolic health is or the glucose is — no one’s going to have any idea. And you can go from that to essentially being an absolute expert in your glucose very quickly by using CGM. And I think you actually can make some inferences about sort of the underlying downstream stuff by tracking your glucose long-term. So for instance, you might go to a post-meal glucose level of 110, and go up and come immediately back down and then stabilize the rest of the day. Or you might go up to 110 and stay elevated for an hour and then come down. Or you might go up instantly after a meal, or you might actually not peak for an hour after a meal. All of those little, extra pieces of data actually tell us something about our insulin sensitivity and our insulin response. So this is where these labs are really starting to figure out, how do a glucose curve and the patterns within that curve tell us about the bigger picture? So we actually translate that to simple, easy-to-understand information. We’re not there yet, but I think as we do research, pairing insulin levels to glucose curves, we’re going to actually be able to use glucose as a much more viable, predictive marker.”

45:01 — The rise of the popularity of ‘glycaemic variability’

No more pricking your finger dozens of times a day to understand your glucose levels. Instead, Dr. Means predicts that because continuous glycaemic monitors will provide continuous updates, we’ll start to see people paying more attention to how their levels affect their lifestyle.

“I think glycaemic variability is going to be a term that’s going to make its way into the zeitgeist, and we’re going to be talking about it on the tip of our tongues in five years. We haven’t been able to talk about glycemic variability in the past because we haven’t been checking our glucose levels 24 hours a day. We’ve just been pricking our fingers. You cannot assess glycaemic variability by pricking your finger unless you are doing it 50 to 60 times a day, which my business partner has done in the past because he couldn’t get access to a CGM. And so, you can basically graph your own continuous glucose curve if you’re pricking your finger 56 times a day, but no one wants to do that.”

Dr. Brett Scher:  [00:00]                      Welcome back to the Diet Doctor podcast. I’m your host, Dr. Brett Scher. Today I’m joined by Dr. Casey Means. Now, Dr. Means has a pretty unique story on how she got into being on the forefront of metabolic health and continuous glucose monitoring. She actually started as a surgery resident in ear, nose and throat, ENT. And from that realized, as you’re going to hear, that most of what she was treating was probably preventable with proper nutrition and lifestyle, which is pretty different for most surgeons to think. So from there, she went on to get trained in functional medicine, started her own medical practice, focusing on these sort of deeper dives and bigger discussions about what’s at the root cause of inflammatory problems. And now has gone on to be a co-founder and chief medical officer of Levels Health. And through this whole process has really focused on continuous glucose monitors and the amazing amount of data and information we can get from them and how that affects behavioral change, because that’s really what it comes down to. Right? We can develop all the data in the world, but if we’re not using it to motivate ourselves to change our behaviors and to improve our health, then what good is it? Right? So she sees CGMs is such a powerful tool and she clearly has a wealth of information. So we’re going to talk about a lot of the data, a lot of the concepts about CGMs, and sort of bring it back towards how that affects inflammation and metabolic health. And near the end, we get into some, we try to get her in a rapid-fire, but you can see she’s got too much information for rapid fire, but we get into some really practical tips on what you can do, what you can take away of how to use the CGM, how to talk to your doctors about it, and what some of the nuances are that you need to know. So hopefully this will be a great introduction and deep dive at the same time and to continue to continuous glucose monitors and metabolic health, and what it can mean for you.

Dr. Casey Means thank you so much for joining me on the Diet Doctor podcast today.

Casey Means:  [01:59]   Thank you for having me, Dr. Scher, I’m so happy to be here.

Dr. Brett Scherr:  [02:01]                      Yeah. And I want to, there’s a lot I want to get into today with you about metabolic health and CGMs. But first I want to talk about your journey because I find it so interesting. I mean, here you are, a resident in ear nose and throat surgery at a prestigious institution at Stanford University, spending your days in the operating room. And somehow you got from there to focusing on metabolic health and blood sugar and nutrition, because usually when people make that transition, it’s from like internal medicine or endocrinology or some sort of metabolic focused specialty, but yours was totally different. It was from a surgical specialty into metabolic health. So give us a little bit about how you made that kind of unusual transition.

Casey Means:  [02:46]   Yeah, absolutely. So like you said, I was practicing ear nose and throat and I was, had trained fully in the conventional system. You know, I had been an undergrad at Stanford. I had been a medical student at Stanford, and then I had gone to Oregon Health and Science University for my surgical training. And I’m five years in and I’m treating a lot of the same conditions over and over every day. I’m doing chronic sinusitis. I’m doing ear tubes for chronic ear infections, treating Hashimoto’s thyroiditis. I am treating vocal cord granulomas. And what was so interesting to me is that fundamentally all of these conditions are inflammatory in nature. These are all foundationally inflammatory conditions. And that was really interesting to me because the main modalities we are using to treat many of these conditions were steroids, antibiotics, and surgery. And certainly steroids take a big hit on inflammation and the immune system, but you know, surgery isn’t actually really a tool that affects our inflammation or our immune systems. It’s kind of felt like fighting a battle with the wrong weapons. And so this was quite interesting to me. I started thinking, “Why are my patients so inflamed? And why is it that everyone’s got these rubbed up immune systems?” And it was especially interesting to me in light of what I was learning about other chronic conditions. So things like obesity, diabetes, even things like cancer, depression, Alzheimer’s disease. You start reading the literature on these things, and it all also stems back to inflammation. And so sort of started putting these Venn diagrams together thinking, “This is fascinating that cytokines like TNF-alpha, and IL-6, they’re kind of upregulated in all of these diseases. What’s going on here? And what is this threat that all of our bodies, our immune systems are responding to?” And ultimately that got me really digging deep and thinking about the root causes of inflammation and really sort of transitioned from being someone who was very passionate about surgery and about helping people in that way, to someone who really became laser focused on how do we keep people out of the operating room? How do we impact these inflammatory pathways to keep people healthy? And if we can affect those core fundamental underlying physiological perturbations, we might be able to have multifarious benefits on health, not just helping in the ENT condition or depression or Alzheimer’s or heart disease or stroke, but actually kind of help quite a bit with one fell swoop. So that was really a journey for me away from the operating room and into trying to help patients identify the root causes that inflammation affect that. And I think what we’re learning more and more these days is that a lot of that inflammation is stemming from diet and lifestyle. It’s stemming from the exposures that, in the choices that we’re making every single day about what we eat, when we eat, how we respond to stress, the quality and quantity of our sleep, the quality and quantity of our physical activity and exercise, the toxins we’re exposing ourselves to, our micronutrients we’re consuming, all of these things have an impact. And microbiome, of course, how we’re treating our microbiome. All these things translate into our body’s fundamental level of health. And so that became a real focus for me in my career. And I got out of the operating room, opened up really a more metabolic health focused private practice, where I was really digging into the root cause of people’s underlying health conditions, trying to draw lines between a lot of the different seemingly disparate symptoms and conditions they had, and helping them make the behavior change choices that were ultimately going to generate conditions in the body that would generate wide-ranging good health and health improvement. And a key to that was really behavior change. It was, “How do we make these choices every day that are going to lead to conditions in the body that generate health?” And so behavior change became a huge, huge focus for me. And as doctors, we’re actually not really that well trained in being agents of change.

Dr. Brett Scher:  [06:53]                      We’re not.

Casey Means:  [06:55]   It’s not really in our curriculum. And what’s more, you know, as much as we want to be on our patient’s shoulder every day, we’re not there every day. We can’t be there for the hundreds of micro decisions that people make every day. And so I got really fascinated with, “Well, what can we leverage to scale our efforts?” And that led me to digital health and to try to really partner with companies who are thinking innovatively about tools to get people to make the lasting, personalized, sustainable choices that generate health. And so, that’s sort of the core of my focus now, is supporting companies that do that and then practicing and this really high touch clinical practice where I focus on the root cause of health conditions.

Dr. Brett Scher:  [07:38]                      Yeah. So let’s rewind for a second. There’s a lot there to unpack, but so when you’re going through your surgery training, I mean, there’s an old mantra in surgery that there’s no problem you can’t fix by cutting it out. I mean, you can fix anything by cutting it out. So to have sort of the opposite mentality, as you’re still in training is kind of heresy. I mean it’s- Were people looking at you, like you had two heads and sort of thinking you’re a little crazy for your thought process or did people sort of get it and say like, “Yeah, you’re right. There is an underlying problem here we need to address.” What was that like?

Casey Means:  [08:09]   I would say people did not fully get it. I think now a few years out people definitely get it, but at the time, no. It did feel a little bit like heresy. There’s quite a few fun outages in surgery, like “When in doubt, cut it out.” And there’s also one that’s a little darker, which is said sometimes, which is almost embarrassing to share, but it is, “You eat what you kill.” And what that means is that you make money and you generate revenue when you book surgeries. And so there is sort of this underlying push towards doing this intervention that is both good for the patient, but also extremely lucrative for the system. You know it’s, surgeries are very high paying, high reimbursement, and you know, what doesn’t get much reimbursement is a 30 minute counseling session about diet and lifestyle, or really digging into the core realities of our patients’ lives that lead to the health behaviors that ultimately underlie chronic disease. So there’s interesting stuff going on there. And so when you come guns blazing saying, “Hey, you know, I want to spend a bunch of time talking to my chronic sinusitis patients about food sensitivities and about their exposures and about these things that may be really jacking up their inflammation. I want to talk about food as medicine, and I want to talk about how certain food compounds may be helpful for their anti-inflammatory effects.” And that’s just, there’s not a lot of space or time for that in conventional medicine. So that was a little bit tough, but I really blame a lot of the authors in this space for being my motivator. So I was reading Jason Fung. I was reading Obesity Code and The Diabetes Code. I was reading Mark Hyman, The UltraMind Solution and The Blood Sugar Solution. I was reading Joel Fuhrman. I was reading Sara Gottfried. I was reading just all, a lot of people. I was listening to Rhonda Patrick and Peter Attia. And just really once, I think, you start going down that pathway and you’ve got these audio books going on your headphones as you’re walking on, down the hospital wards, it starts to plant a seed that’s really hard to undo, that we need to be thinking bigger about how we’re managing chronic disease. And in the face of sort of the realities, which is that 88% of Americans are metabolically dysfunctional. It was a UNC study two years ago, that 72% of Americans are overweight or obese. There’s 128 million Americans with diabetes or pre-diabetes. And the pre-diabetes there is about 90 million Americans. 90% of which don’t know they’re pre-diabetic. So we’re dealing with like, this is not fringe, it’s astronomical. And pretty much everything I just mentioned is preventable and is driving up our chronic morbidity mortality and our healthcare costs. So, you know, you’ve got these incredible forward thinkers in one ear. You’ve got these stats in the other ear. And it’s really hard to just walk into the operating room with a scalpel, thinking that you’re making an impact at scale. Surgery’s a beautiful art and it’s important, I think, for acute conditions, but for chronic disease management, I don’t think it’s the best tool we’ve got.

Dr. Brett Scher:  [11:23]                      Yeah, I think that’s a great assessment. And especially when you talk about, “You eat what you kill,” actually is a disincentive to getting to the root cause of problems and solving the problems. And whether it’s conscious or not, that’s the way the system is. And so there’s a disincentive there that you went past. I can just see your surgery attendee’s eyes rolling  back into their head if you were talking about these things and wanting to spend more time with your patients. So that’s why I think it’s important for people to understand where you came from, that you had to come from sort of the exact opposite mindset, which just shows how powerful of a motivator it is for you and how much you truly believe in this. And then, so you went and started your own practice and from there and now trying to scale it through technology to use CGMs, to help people understand their glucose and metabolic response to different foods and lifestyle changes. So first, before we get into that, have you always been sort of techie and wanting to get into sort of a technology sector? Is this like totally new for you?

Casey Means:  [12:26]   I would say somewhat yes. So I was so fortunate to be in the Bay area and Silicon Valley at Stanford for my entire medical training, from undergrad to medical school. And there you can’t help but drink the water, drink the Kool-Aid. We can’t say Kool-Aid because that’s full of refined sugar, but drink the water, during the kombucha of digital health and of the real beauty that can come from interdisciplinary collaboration. And so by that, I mean, physicians engaging with business so as to really leverage their efforts. You know, Medicine has so traditionally been, we’ve really glorified this one-to-one interpersonal interaction between the doctor and the patient, which is a beautiful and can be a transcendent relationship. But with the challenges that we’re facing today in healthcare, so much of which are related to chronic disease. And so much of that chronic disease is related to diet and lifestyle and ultimately behavioral choices. I do think that paradigm needs to shift a little bit because the one-to-one conversations are actually not extremely effective at moving the needle on behavior change. There’s been quite a bit of research to support this, to say that while patients do enjoy having that conversation with the doctor. When a doctor makes a recommendation about diet and lifestyle, it’s pretty unlikely that it’s actually going to be carried out by a patient. Not to say that it never does, but in terms of the statistics, they’re not great. And so you got to think, “How can we pair that really powerful conversation with the doctor and the high level thinking that a doctor can do with tools that a patient can have day in and day out to really personalize and empower that advice? And make it actually really practical.” So that’s where I see the future of medicine, is pairing the wisdom and the real cognitive beauty of the physicians,  or the healthcare practitioners’ knowledge with tools that make it a day in and day out situation, because you know, this isn’t about encouraging someone to take a pill. It’s not about encouraging someone to have a procedure. It’s about encouraging someone to make decisions, these hundreds of times a day that are ultimately going to move the needle on health. And what’s so interesting is that the decisions for each person are going to be completely different. What you and I both need to eat for optimal metabolic health may actually be very, very different. And one example of that is that, you know, recent research has suggested that we could eat the exact same meal of carbohydrates, the exact same standardized meal and you and I could have a completely different glucose response to that. Same exact cookie. I could go up to a glucose of 150 milligrams per deciliter. You could stay at 75 milligrams per deciliter. So for one of us, that’s a potentially good metabolic choice. And for one it’s not. So that’s where you can really see how the one-to-one relationship between the doctor and patient without supportive personalized tools can actually fall apart because we need this really personalized direction for each body. So that’s just one example of where tools that can give a little bit more personalized feedback in real time can help be synergistic with the physician interaction and really scale the efforts. So.

Dr. Brett Scher:  [15:43]                      Which is a perfect segue to start talking about CGMs or continuous glucometers, which are probably the best tool we have right now, certainly for blood sugar control, because the others, you know, you do a finger prick a few times a day, which gives you a one point in time measurement, or you get a hemoglobin A1C at a blood test every three months, which gives you a retrospective backward looking three month average of your blood sugar, but a CGM is totally different. So for people who may not know, give us just a brief introduction of what a CGM is and then about how you’re using it to really help patients make decisions.

Casey Means:  [16:24]   Yeah, absolutely. So a continuous glucose monitor, otherwise known as a CGM, is a small wearable device. They can go on the back of the upper arm and they are worn generally for around two weeks at a time. And what they do is they have a small microfilament that goes right under the skin, into the interstitial fluid, which is the fluid between cells, and samples glucose automatically every 15 minutes, 24 hours a day, and then sends that information to a smartphone or a reader. So instead of having to prick your finger, get a drop of blood, use a glucometer and get those readings, maybe three to four times a day on a good day for the average person with diabetes, this is actually giving you dozens and dozens of data points in the background, and you can really see a much more high fidelity, high granularity curve of what’s happening to your glucose in real time. And so the beauty of this is that as opposed to just getting a single snapshot of what’s happening to your glucose levels in response to dietary and lifestyle choices, you’re seeing the really dynamic action of the body, and you’re actually getting much more granularity into your overall metabolic health. So just to step back, this technology has been traditionally used for the treatment, it’s FDA approved, for the treatment of type one and type two diabetes. So this has been a game changer for those populations in making fewer finger pricks and higher data resolution and for allowing people to dose their medications properly and more safely. But what’s really neat to think about is, “Well, how could this technology that’s already existed for over 10 years actually benefit a wider population than just the type one and the type two diabetic community? This is essentially a biofeedback tool that finally for the first time can actually close the loop between any nutritional choice and what’s happening to our health in real time. It’s one of the only continuous biomarkers we can track at home. And fortunately it tracks the core metabolic substrate of our body that has huge implications for health. And what’s more, we know that metabolic disease and metabolic dysfunction. So like overt conditions, like type two diabetes, that these are not, these conditions that one day you don’t have it in one day you do. It’s not like a light switch. These are diseases that are spectrums, where you are likely progressing along this metabolic dysfunction spectrum over the course of years, if not decades, from the repeated choices and exposures that lead us towards insulin resistance. And so you can imagine how having this information about glucose far earlier, you know, years and decades before you get that slam of a diagnosis or that fasting glucose in the doctor’s office that finally says we have reached diabetic levels. You know, you can have this way, way before and actually tailor your diet and your lifestyle to minimize the glucose spikes that ultimately start pushing us down the path of insulin resistance towards overt dysfunction. So it’s sort of this beautiful tool that can really prevent us from ever having to walk into the doctor’s office and get a surprise about our metabolic health. And that I think is really empowering. And secondarily, I think it’s an antidote, a welcome antidote to this, just the mass confusion about nutrition that we’re dealing with right now. There’s data that suggests 80% of people are confused about nutrition advice. And it’s, I mean, I feel that in my own practice and in my own social community, like everyone it’s, you know, nutrition has become essentially tribal warfare and to be able to cut through some of that noise with an objective data stream, that gives us continuous information about our key metabolic biomarker, is so exciting. So that’s really how I use the technology, is in a more mainstream population. So not just for patients with clinically diagnosed metabolic conditions, but in, really, all patients as a precision nutrition and lifestyle tool, and much more as a prevention tool.

Dr. Brett Scher:  [20:32]                      Yeah. And I think that’s definitely where the future is going. I mean, hopefully more mainstream medical practitioners are going to catch on to see the utility of this in the general population, not just people with diagnosed  type two diabetes or type one diabetes. But you know it’s sort of like a catchphrase to say, “Oh, everybody’s individualized. Oh, everybody responds differently.” And while that may be true, there are a certain underlying consistencies that apply to just about everybody. Like not eating too much sugar, not eating overly processed foods. I mean, we can sort of get all that stuff out of the way. And, but then you’re absolutely right. Then there’s a very personalized response that people have to foods. And when we live in a society that puts out a dietary guideline that says, “We all need to eat whole grains and more grains and more fruits,” it becomes confusing. And something like a CGM though, it can be a wonderful tool to show how maybe that’s not the case for everybody. So is that something that you’re finding that these so-called expert recommendations really can get a lot of people into trouble with the CGM? Or do you not see that so much?

Casey Means:  [21:39]   I would say I see that so much. Yes. I think it’s a really great point. So I think there’s two aspects that are very, very helpful. One is certainly the personalized and that really refinement piece that really can take people to the next level of picking the perfect foods for them. But then there’s the much broader brush stroke of just really having this tool of insight and almost recourse to a very loud food marketing environment. So take, for example, something like instant oats. You know, these, if you go look at a box of instant oats at the store, it will say all over it, “Excellent source of whole grains. This is a heart healthy food.” There’s pictures of hearts all over it. “This gives you X grams of whole grains per day, which, you know, this is a good source of fiber.” So it has a lot of very compelling marketing on the package. And so of course the good consumer is going to say, “Well, I’m making a really great choice for my health by buying this food.” And one of the most interesting things we’ve seen in using continuous glucose monitors and a lot of healthy patients is that instant oatmeal for most people that I have seen spikes them into well into what we would call sort of diabetic, or really unhealthy levels. So I’m talking like 170 to 210 with just plain instant oatmeal. What’s more, if you actually go to some of the websites of these companies, they will actually show the instant oatmeal with some brown sugar fruit, a glass of orange juice toast. And so I actually can’t, I fear what that glucose response would be for the average person, but just instant oats alone can send people up to 170, 180. Different between each person. I know some people who haven’t spiked very much on it, but for those people who are spiking that high, they are almost guaranteed, having an astronomical insulin response, they are exposing their whole body to a very large glucose and insulin burden. And if that’s happening every morning, they’re starting their day that way, you’re likely putting yourself on a glucose rollercoaster. That insulin is likely to cause a profound, reactive hypoglycemic dip after breakfast. And so a lot of you will walk around thinking, “Yeah, I always kind of have this mid-morning energy slump,” and “Oh, I’m feeling a little moody today,” and “Oh, you know, my energy is a little off.” And you pair that with this data, showing your wild rollercoaster of your glucose. And all of a sudden you put together the subjective experience you’re having with this objective data and realize that this might not be the best choice for you. And so it’s a way to, I think, one, really move past food marketing and understand what foods are actually best for your own physiology. And then two, to really gain an amazing sense of body awareness by pairing subjective experiences that you’re having throughout the day with objective data. And I think as you do that over and over and over again, and realize how these little things that are happening throughout the day, especially related to cognition, mood, and energy and athletic performance, and sort of our physical vigor and seeing how that relates to your data, I think you really build this beautiful sense of somatic awareness of starting to understand how the choices you’re making are impacting objective metrics and how that’s leading to a subjective experience. And that trifecta is really somatic awareness. And I think digital tools can help us get back in touch with those inner workings of our body. And there’s a really cool term for this called interoception, which is a sense of people understanding and sensing what is going on inside their body. And so an example of this would be heartbeat. Many people have the ability to just sit still and actually really feel their heartbeat. And other people really struggle with that. And the people who are good at that, or who can do that, tend to have much better mental health outcomes, anxiety, and cardiovascular outcomes. It’s good to know what’s going on inside your body. And we live in a culture right now where it’s actually hard to feel what’s going on inside our bodies. There’s a lot of stimuli. There’s hyper palatable foods. We live in a very addictive digital world and we can become, I think, a little bit numb to how we’re feeling and our internal cues. And I think there’s a potential for biofeedback tools, especially ones that are measuring internal biomarkers to get us back into that loop of really correlating these experiences with our objective metrics. So. Yeah. So I’ve definitely, just to circle back to your question, definitely seen that there are foods that are putting people on rollercoasters with their glucose and unquestionably, putting people, if repeated, down the path of insulin resistance that are marketed as healthy. And I like to say to people, a carb in the mouth is not glucose in the bloodstream. It is different, it’s not necessarily a one-to-one relationship. It’s different for every person. And that comes down to our microbiome composition, our insulin sensitivity, how much exercise or sleep we’ve got, and a number of factors, but we really have to know for ourselves what that relationship is. We can’t assume it, we can’t use glycaemic index charts. There’s, it’s more complex, we’re learning it’s much more complex than that. So.

Dr. Brett Scher:  [27:09]                      Yeah, I’m really glad you brought up food marketing, because that is such a problem. Especially if you take an already pretty confused public and then throw them in the midst of very talented marketers, whose goal is not your health, right? Their goal is to sell you product. And when you can get the American Heart Association, Heart seal on Honey Nut Cheerios, or some highly sugary type food source, that’s not actual real food, but to get like a seal of approval and all the marketing just leads to more confusion. So a CGM cuts through all that and gives you the feedback exactly, like you’re saying. But one thing that’s so interesting though is, so how do you correlate saying- Okay, some people are eating oats or eating fruit or eating whole grains, get these huge spikes in their blood sugar, but yet we have observational scientific data that saying eating whole grains and eating whole fruit is healthy in general for people. Like that’s sort of a cognitive dissonance or a disconnect that most doctors might not be able to reconcile. So how could you help doctors or just the general public sort of reconcile those two things?

Casey Means:  [28:18]   It’s a really, really good point. And I think there’s a lot there. So first of all, I think the foods we’re eating today are not necessarily the traditional foods that we have been exposed to throughout history. An apple today is very different than an apple 20, 30, 40 years ago. So that’s just one place to start. You know, the fruit toast level and I think some of these foods that we’re seeing is just, these are sugar bombs. A lot of them. And we’re eating portions that are really high. So I think on the one hand, it’s that. It’s that we’re eating different food and we’re eating really large portions. And we’re also much less physically active than we were historically. So there’s other mitigating factors there with the whole grain piece. I think that’s also a tough one because a lot of whole grains now, we’re seeing, paired with refined products in them like refined sugars and just paired with other unhealthy, you can still label something whole grade, even if it’s got a lot of other stuff in it that we don’t want to be eating. So there’s some confounders there. I think also there, within food groups like fruit or like whole grains, there can be a lot of variability between how you respond to different foods. So I know for myself personally, I actually respond pretty high to most fruits. And so I actually have had to learn how to pair fruits properly so that I actually can blunt my glucose spike a little bit when I eat them. And I think that’s something that you can really develop some skill and some intuition about as you use biofeedback regularly. So here’s an example. I had a pint, a small pint of blueberries, and my glucose went to 150. I never want to go to 150. I like to stay between 70 and 90 almost all the time. And at most go up to 110. So 150 is really, for me, like not where I want to be. But if I take that same kind of blueberries and I dump it in a cashew unsweetened yogurt that has 15 grams of fat. Maybe add a little bit of almond butter, a bunch of chia seeds, which have protein and fat and fiber. All of those things actually will completely change the glucose response to those berries. Many research studies have shown that fat, fiber, and protein in conjunction with a high carbohydrate food can minimize the glucose response. And it has, there’s a number of different mechanisms involved there. Gastric motility, insulin sensitivity, a number of things. And so, pairing foods properly is I think a big key piece to this. I don’t necessarily know if we’re meant to eat a huge Apple or a pint of blueberries completely by itself late in the evening. You know, that’s another piece, is food timing. We become more insulin resistant as the day goes on. Melatonin, which is released in anticipation of bedtime, has an impact on our beta cells and on our insulin, both secretion and insulin sensitivity. And so we generally are going to have a higher glucose response to the same food eaten later in the evening than if we ate it first thing in the morning. So all of a sudden I take that kind of blueberries and I pair it. I eat it at a different time. I maybe tackle a little bit of exercise on it before or after. Make sure I’m eating a big carbo load like that after a good night of sleep. All of these factors, food timing, food combining, exercise, sleep, even how stressed we are that day have an impact on how we process carbs into glucose. So it’s really about thinking bigger picture about the context that those carbs are going into. And that’s where nutrition research. We don’t have that, like that type of granularity in these population studies, and where I really want to see the research go. And ultimately the goal being that people build these metabolic toolboxes that they can grab from to make sure that they’re eating healthy and nutrient rich foods without the collateral damage. That’s really my goal.

Dr. Brett Scher:  [32:25]                      Yeah. That’s a great point about how there are so many variables to factor in and the food pairing is certainly one of them. And sleep and stress and exercise are absolutely also very important variables because what your response after eight hours of sleep to the same meal, after four hours of sleep, it can be completely different, which kind of, at first doesn’t make sense. “Like it’s the same food, it’s the same food. You should have the exact same response,” but no, it’s almost like two different people are eating it based on your sleep, based on your stress. So I think that’s such a powerful motivator, but also something that can be confusing, even with a CGM. You could take a look at a food and say, “Oh, I can tolerate that just fine.” But then if you eat it without the same amount of exercise you had that day, or with less sleep, all of a sudden is not going to be so fine. So you can’t be so confident about that. So that seems like a very important behavioral learning tool as well from CGM. So do you see that a lot in your patients?

Casey Means:  [33:22]   Seeing the confusion about some of these modifiers?

Dr. Brett Scher:  [32:27]                      Yeah.

Casey Means:  [33:28]   Yeah, I do. And I think, and this is where I think digital health really has an amazing opportunity because the hardware and the glucose sensors are available and they’re generating a raw data stream that, like you just mentioned, can be a little confusing because there are so many mitigating factors of that glucose, like we talked about. The really big ones that have been studied in detail is food timing, food combinations, stress, sleep, exercise, but there’s also other things. There’s our micronutrient status, our zinc, magnesium, carnitine levels. There’s our microbiome. We know that a bacteroides is a Firmicutes ratio, and how much of those particular bugs we have in our microbiome have an impact. We’ve of course got genetics and epigenetics. There’s many, many factors that feed into this. So of course it could feel very, very confusing, but my feeling is that the lowest hanging fruit is these four main pillars of, the food, sleep, exercise, and stress. And that’s where I think software that is overlaid on top of that raw glucose stream and really integrating data sources. So the glucose, the raw glucose data stream with other data streams, like objective measures of exercise, sleep and stress. So we think about heart rate, heart rate variability, other noninvasive biomarkers we can track at home. When we start merging some of those data streams, you can actually really start to pick up really interesting trends and help people parse out and weight how these different lifestyle and dietary factors are affecting that glucose readout essentially. So it’s really a multivariate thing, but that’s where I think machine learning AI software is going to revolutionize this and sort of hand it to a person on a silver platter. Like, “Hey, when you, every time you eat those apples with peanut butter, you have a 15 point lower glucose response.” And you know, “Every time that you don’t eat these foods, X, Y, and Z, after 6:00 PM, your sleep, your deep sleep is 20% better.” That’s where I think we’re going to see people being able to have those actionable insights, but certainly parsing on your own is a challenge. And I help my patients that, in my practice. But I think that that’s where software machine learning and integrated data streams is just really the future of metabolic health.

Dr. Brett Scher:  [36:55]                      So for the data junkies, it seems like there’s a limitless amount of data that you can get, and people are, some people are going to love that. And some people it’s going to make them want to crawl under a rock and never come out because it gets so overwhelmed with the data, which is why I like you can also sort of boil it down to the four major pillars with the food pairing, sleep, stress, and exercise. I think those are so important. And I want to get back to another thing that you said though about you, you mentioned some specific numbers of where you want to stay under. Now, traditionally, our diagnosis, our use of blood sugar numbers are so poor, like, you know, 126 for a fasting blood sugar, or 140 after a two hour glucose tolerance test. Like these are the magic goals. And as long as you’re under that, you’re fine. But it’s really not. I mean, it’s just the unfortunate way that our medical society has diagnosed things. But when it comes to this term of optimal and I’m using air quotes for the people who aren’t, or who watch it on YouTube here, the optimal blood sugar, the optimal blood sugar response, do we really know what that is at this point? Or are we sort of making it up and defining it as we go?

Casey Means:  [37:00]   We 100% do not know, and this is where we need to make progress in the next five years. And I know that there are many people thinking about this deeply. People like Dom D’Agostino, people like Ben Bikman, people like Peter Attia, people like Sarah Gottfried, Mark Hyman. All of those individuals I just mentioned are thinking deeply about the question of, “What is the optimal glucose level?” We know we want to stay below a fasting glucose of a hundred to not be labeled pre-diabetic, but that doesn’t actually tell us what to shoot for. What’s going to keep us thriving in our current day-to-day lives and also out of trouble down the road. So this is where we really need to do some research. And I think part of the reason we haven’t done that research is because our medical system is very much a reactive system. We wait until diseases and symptoms have manifested before we intervene. And we are certainly moving, I think, more towards prevention. There’s efforts with value-based care to really focus on the front end of health. And I think that’s great. But we need to be thinking about glucose when people are not pre-diabetic or diabetic, because that’s where we can really move the needle on keeping people out of trouble down the road. And so I think the more CGMs and data we can produce in a non-diabetic population, the more we’re going to start to understand some of these trends. There’s a lot of people doing great, like hardcore research on this. There’s Michael Schneider out of Stanford who wrote a paper last year, the year before, about gluco types, which was putting CGMs on a bunch of non-diabetic individuals and seeing all these different patterns and sort of subtypes of normal within the normal population and being able to start to predict what of those, which of those patterns, responses to food, responses to different lifestyle variables, which of those were most predictive of problems down the road? How can we look at this glucose curve on a CGM data and actually take, make inferences about the future? Eran Segal, his lab at the Weizmann Instituteis doing similar stuff like that as well, looking at these patterns of glucose. So we’re not just focusing on these single time point measurements like once a year fasting glucose, maybe once a year hemoglobin A1C, if your doctor orders that. And rarely would a non-diabetic individual get an oral glucose tolerance test. So we maybe have an A1C and a fasting glucose, and that’s just not enough to know the full picture of metabolic health. So, some of these labs are trying to figure out, how can this continuous glucose data stream may be predictive about future outcomes? So there’s super exciting stuff there, but optimal, bottom line, optimal glucose levels is likely much, much lower than what we are seeing in terms of standard diagnostic criteria for non-diabetic.

Dr. Brett Scher:  [40:00]                      So I think it’s pretty clear that lower is better, obviously, as long as you’re not symptomatically hypoglycemic, but lower is better. But then the question becomes how hard do you fight to get it lower. So is a postprandial response to 110 versus 99 a big deal? Is that a big deal? Like, I guess we don’t really know. So what kind of criteria do you give to your patients to say, “This is what you should shoot for.”? Do you give them hard numbers or do you tell them to focus more on just trends and patterns? Like how do you kind of help your patient practically process this and define a goal?

Casey Means:  [40:37]   Yeah. Well, I think your first point about, “How do we determine the difference between 110 and 99?” That’s a question that I would love for us to understand the answer to. And I think that some of the research we need to do to figure that out is to pair those glucose readings with other readings, like insulin levels after meals, inflammatory markers after meals. What are the other actually downstream physiologic effects of those numbers? Because it’s going to be hard to just take those numbers and say, “One’s good, one bad.” But if we understand what they’re generating in terms of maybe a stress response and inflammatory response, an oxidative stress response, this can actually, and an insulin response, this can get us farther down the road. So I know people are thinking about doing this research and I really fully support that because if you go to 110 and your insulin’s shooting up to thirties, forties, you know, high, versus a lower number, it’s totally different physiologic landscape. So that’s one.

Dr. Brett Scher:  [41:37]                      That’s a great point. So, sorry, just to follow up on that point then, I guess the next question is then, is glucose enough? Like, is this even good enough for us if we don’t have the insulin response? Because that’s such an important part, but we don’t have on demand insulin testing. So is it even good enough as is, or is it kind of, is it not quite there yet?

Casey Means:  [41:56]   I think it’s, I think it’s an excellent start because it is so much more than we’ve ever had. The average person, you walk down the street, ask them to predict what their metabolic health is or their glucose is. No one’s going to have any idea. And you can go from that to essentially being an absolute expert in your glucose very quickly by using CGM. And I think you actually can make some inferences about sort of the underlying downstream stuff by tracking your glucose long-term. So for instance, you might go to a post-meal glucose level of 110, and go up and come immediately back down and then stabilize the rest of the day. Or you might go up to 110 and stay elevated for an hour and then come down. Or you might go up instantly after a meal, or you might actually not peak for an hour after your meal. All of those little, extra pieces of data actually tell us something about our insulin sensitivity, our insulin response. So this is where these labs are really starting to figure out how does a glucose curve and the patterns within that curve tell us about the bigger picture. So we. Actually translating that to simple, easy to understand information, we’re not there yet, but I think as we do research, pairing insulin levels to glucose curves, and we’re going to actually be able to use glucose as a much more viable, predictive marker. So that’s what I would say on that front is, we’re not there yet, but glucose is a really, really amazing, amazing start. And I would just hope for most people, what I’d like to see is that everyone’s getting a fasting insulin level at least a few times a year, and then pairing that with their glucose monitoring experience. Because if you start with a really low fasting insulin of like two, three, four or five versus a fasting insulin of 25, you know right off the bat, you’re probably on a very different part of the metabolic spectrum, just, and I think your listeners are all very familiar with insulin, but just the basic concept there being that as we spike our glucose over and over again throughout our lives, produce insulin spikes over and over and over again throughout our lives, our cells become numb to that insulin and our pancreas has to produce more insulin to get the same amount of glucose into the cell. So at baseline, that fasted insulin will look higher if you’re sort of farther down that spectrum. So we want to shoot for those lower levels. And so by pairing that one piece of data with CGM, I think you can actually open up even more insight, but. Yeah.

Dr. Brett Scher:  [44:26]                      Yeah. I agree that it’s so much better than anything we’ve had and I think it’s so useful. And I want to emphasize the point you made that it’s not just the absolute number, but it’s also the curve and the steepness of the curve and the sort of the tail, the length of the tail before coming to normal. And that’s what sort of highlights the importance of working with someone who knows how to interpret the data or working with a technology platform that can help you interpret the data because it’s not just all cut and dried. And, one concept is this degree of glucose variability versus sort of the area under the curve, meaning your average glucose. And just to find that a little bit, traditionally hemoglobin A1C has been used as a marker for danger of blood sugar and diagnosis of diabetes. And that’s an average of your glucose, but what it doesn’t tell you is how high are the spikes and how steep are the curves. So there’s some evidence now that regardless of your average glucose, the high spikes may be more dangerous than a chronically elevated, but not high spikes. So how strong would you say, is that evidence and is that something we absolutely need to pay more attention to rather than just our average glucose?

Casey Means:  [45:42]   Yeah, absolutely. I think glycaemic variability is going to be a term that’s going to make its way into the zeitgeists and we’re going to be talking about it on the tip of our tongues in five years. We haven’t been able to talk about glycemic variability in the past because we haven’t been checking our glucose levels 24 hours a day. We’ve just been pricking our fingers. You cannot assess glycemic variability by pricking your finger, unless you are doing it 50 to 60 times a day, which my co-founder, my business partner, has done in the past because he couldn’t get access to a CGM. And so you can basically graph your own continuous glucose curve if you’re pricking your finger 56 times a day, but no one wants to do that. So.

Dr. Brett Scher:  [46:22]                      Did he have to start using his toes if he ran out of fingers? Does he have to start breaking his toes? I can’t imagine.

Casey Means:  [46:28]   So many bruised fingers. Yeah. But, so glycemic variability refers to these up and down swings in the glucose throughout the day. And they can be from food. They can be from having a high spike and then crashing down and then having sort of like a bunch of bumps after that, as the body kind of plays tennis with insulin and glucose and insulin and glucose. It can be from stress, you know, having a stressful conversation can give you a glucose spike. There’s a lot of things that can do it, but primarily refined carbohydrates and refined sugars are going to be the big culprits there. So glycemic variability is an independent predictor of increased cardiovascular mortality and an independent predictor of developing diabetes down the road. So in itself, just having those swings is problematic and there’s a number of physiologic mechanisms for this. Having a giant spike and drop of glucose is going to cause a lot of downstream issues. It’s going to potentially cause inflammation. It’s going to generate oxidative stress and free radical burden in the body. It’s going to potentially lead to glycation. So sugar in the bloodstream, sticking to other proteins and fats and structures in the body and actually sticking to those molecules and causing dysfunction in that activity. So glycation, oxidative stress, inflammation. And then of course, that high glucose spike is likely going to generate a much higher insulin spike as well, and be just putting more gas on that pedal of pushing you towards insulin resistance if this is repeated over and over. And it also has pretty massive implications, I think, for the weight loss community and in ways that we don’t recognize yet. Of course, people who listen to your podcasts probably do. And anyone who’s read Jason Fung’s books, but you can imagine if your glucose curve throughout the day kind of looks like a radio static wave where it’s just up and down, up and down, up and down, up and down all day, because let’s say you got up and you had coffee with some milk that had, you know, some sugar, you know, skin milk, bunch of sugar, or you added sugar to your coffee, then you had oatmeal, then you had an Apple later in the morning, then you had a white bread sandwich for lunch. Then you had let’s say we’re trying to be healthy in the afternoon and had a bean salad, but beans really affect you. And then for dinner, you have a white potato with a small piece of chicken and then some ice cream.

Dr. Brett Scher:  [49:52]                      Our blood sugar is going up just listening to this.

Casey Means:  [48:53]   Wait, that is a totally normal borderline, someone might say a “healthy day of food.” You know, coffee, salad, fruit, potatoes, oatmeal. People might think they’re really winning there, but what you might see on your glucose is just this up, down, up, down, up, down, up, down, up, down. And from the weight loss perspective, this is really interesting because you’re almost invariably spiking your insulin with each of those spikes. And so when that insulin, so you can imagine your average insulin throughout the day is probably much higher than someone’s, who’s eating a low-glycemic impact diet, a personalized, you know, diet. And when that’s insulin’s on, it’s blocking fat oxidation. It’s essentially saying, “You can’t burn fat,” because the body registers that as, “Oh, insulin’s around, which means we’ve got tons of glucose for energy. So why would we ever burn fat for energy?” And so that is just thwarting weight loss efforts. So glycemic variability, for all those reasons, you know inflammation, oxidative, stress, glycation, insulin resistance, and just blocking fat oxidation. It’s just not what you want. You don’t want the ups and downs.

Dr. Brett Scher:  [50:03]                      Right. And you won’t learn that unless you have a tool like a CGM. So I agree. That’s so powerful. Yeah.

Casey Means:  [50:08]   I think yeah, and one other just interesting factoid, you know, they’ve done some studies basically giving two different populations the exact same set of calories throughout the day, the same standardized meals and had some people eat it in a short window, like 8:00 AM to 2:00 PM. And then some people eat the exact same meals between 8:00 AM and 8:00 PM. And the people who ate it in the shorter window had better overall metabolic parameters. And you can kind of imagine thinking about glycemic variability, if you’re compressing it, you’re keeping that variability into a much shorter window versus spreading it throughout the day. Every time you spike your glucose and insulin, it has to go up and down. So if you’re just spreading out those calories, you’re just exposing the body to more time with that. So that’s kind of, you know, another one that- There’s many, many studies that really highlight this, but that’s one that I always kind of come back to, really trying to just tighten up the window that you’re exposing your body to all these molecules.

Dr. Brett Scher:  [51:05]                      Yeah. And along those lines, one study that I thought was really interesting was when they looked at either having dinner at like 6:00 PM or having dinner at 10:00 PM and with the same dinner. And then when they woke up the next morning, their blood sugars were the same when they woke up. But their response to the same breakfast was totally different, which just shows there’s like this carry over insulin resistance even for the group that had dinner at 10:00 PM that they had a much higher blood sugar spike to the same breakfast the next day, which I just think is so interesting how that is not just affecting you in the moment, but it’s affecting you over time, which is so interesting. And I really like about what you said, how you sort of brought it back to the inflammation. Because we sort of started this whole conversation with you noticing these chronic inflammatory conditions. And then we kind of started talking about metabolic health and glucose. But what you just talked about there with the glycemic variability brought it right back to the closed circle of how that leads to the chronic inflammation. And I think that’s such an important point to make, that it is, it may seem disconnected. We were talking about glucose, we’re talking about inflammation, but they are not always, but many times, especially when it’s in a dysregulated system, they are absolutely related. So that was a great, great summary there.

Dr. Brett Scher:  [52:18]                      Yeah, absolutely.

Dr. Brett Scher:  [52:20]                      So now moving on though, I want to make sure we get into some really practical advice and some specific questions. So are you ready for a little rapid fire questions here?

Casey Means:  [52:29]   Let’s do it.

Dr. Brett Scher:  [52:30]                      All right. So what are your, what do you tell patients are your goal blood sugars, and what’s the number one advice that they need to pay attention to when they’re checking their blood sugars?

Casey Means:  [52:40]   Yeah. So my goal ranges. So these are really based on my review of the literature. I will caveat this by saying these are not standardized. This is what I shoot for. And my interpretation of the research out there. And most of this is coming from reviewing the six or seven main papers where they put continuous glucose monitors on healthy individuals, tracked their glucose over time and saw what the glucose does. And when you look at the, and no intervention, just observational studies. And when you look at these studies, what you find is that for healthy populations who do not have pre-diabetes or diabetes, people tend to spend about 90 to 95% of their day between a glucose of 70 and 120. In some studies, that’s a little bit more liberal and you’ll see 70 to 140, but people are spending less than one to 2% of the day above 140, or below about 60 or 70. So really just to start, we’re tightening up that range of just stick below 140 after meals. We’re tightening it now to 70 to 120. So that’s sort of one thing I’ll start with. The second thing is there’s been some interesting research showing that as fasting glucose increases, even in the normal nondiabetic range, which is a fasting glucose less than 100, you actually see that as your glucose goes up from 70 to a hundred in the normal fasting glucose range, you actually increase your risk for multiple diseases. So as you get closer to that hundred threshold, you increase your risk for diabetes. You increase your risk for ischemic or hemorrhagic stroke and a number of other conditions. So there’s evidence that being in a much lower, tighter fasting glucose range, probably in the seventies to eighties, is going to be where you want to be for reducing your risk for chronic conditions down the road. And then knowing what we know about glycemic variability, we also want to keep those post-meal spikes pretty tight. So I tend to recommend to people that they want to have a fasting glucose between 72 and 85 milligrams per deciliter, want to keep their glucose between 70 and 120, ideally 70 and 110 because when you sub stratify somebody studies and look at the healthiest people in those studies, it’s really more between 70 and 110. So sticking between 70 and 110 pretty much for the whole day. And I don’t really like to see excursions. So post-meal glucose spikes more than about 15 to 20. So really solidly under 110 for the day, ideally in the 80s at baseline, and getting your morning, waking fasting glucose when you haven’t eaten any calories for about eight hours between 72 and 85. For me personally, I like to be at fasting glucose low, seventies. I keep my average glucose height. So 24 hour glucose in the high seventies to low eighties, and rarely try and go above a hundred. And that’s just from years of experimenting with this.

Dr. Brett Scher:  [55:45]                      Yeah. So that was a terrible answer for a rapid fire, but it was a great answer, but it was a fantastic answer. So it was my fault for even trying to do a rapid fire because you just have too much knowledge. And that was a wonderful answer. And I want that detail. So forget the rapid fire.

Casey Means:  [56:02]   No, no. We’ll go back to rapid fire. Sorry.

Dr. Brett Scher:  [56:06]                      No, because that was a great answer. And my next question might be even harder for rapid fire. So, the next question is, people, especially if they’re following a low carb diet, will find that they wake up with blood sugars of a hundred, 105, 110. And it’s like, “Oh my goodness. Based on these definitions, I am pre-diabetic based on my waking blood sugar,” but then they may find that that’s their highest blood sugar of the day. So, and then you look at the literature though, and the literature says, if you wake up with elevated blood sugar and have a Dawn phenomenon, you are more likely to go on to develop type two diabetes. But those studies weren’t done in anybody following a low carb diet. So what is your take on this specific situation that has some people very worried?

Casey Means:  [56:50]   This is such an interesting question. And I wish I had Ben Bikman here to back me up because he thinks about this really, really deeply. And he has a term that he talks about which is called reverse metabolic inflexibility, where you see sort of a paradoxical glucose rise and people who are on a low carb diet. And we really don’t know if that’s, you know what the clinical implications of that are. But I suspect that it may have something to do with glucagon and sort of changing other hormone- The glucagon has an impact on our glucose levels, in a sort of antagonistic way to what insulin does. And so, low carb diets may affect some of our other hormones to keep that morning insulin, that baseline insulin a little bit higher, but you know, it’s hard to know, these people are likely keeping their insulin levels very, very low. And we know that insulin is really the devil in the details here. You know, glucose certainly has its own problematic effects, but insulin, the downstream effect of high glucose is what I think is causing your majority of the damage that we’re seeing in chronic disease. So the bottom line is really hard to know. I suspect that there is some different physiology going on with our hormones that makes it probably not something to be a huge cause for alarm, but we have to do more research in that population, this paradoxical sort of glucose elevation that, in the context of low carb diet. Study the hormones, study the inflammatory cytokines, study the oxidative stress and see whether it’s a problem or not. But we just don’t know.

Dr. Brett Scher:  [58:27]                      Yeah. And I think it’s, I think that’s a great point you brought up about the difference between, say a fasting blood sugar of 108 with an insulin of 35. And a fasting blood sugar of 108 and an insulin of two.

Casey Means:  [58:39]   Yeah.

Dr. Brett Scher:  [58:39]                      Those are completely different physiologic circumstances that we don’t, like you said, we don’t have perfect evidence to say that they have different implications, but gosh, it sure makes sense that they would have absolutely different implications. And that also goes back to the glucose variability, because if that’s one of your highest blood sugars of the day and you’re not having postprandial glucose spikes, hard to imagine that that signifies anything concerning from a glucose standpoint, at least from my standpoint. So even in the absence of literature, would you disagree with that or agree with that?

Casey Means:  [58:09]   I agree completely. And I would, in that type of patient, in my own practice, what I would be doing is I’d be ordering some of these other tests. I’d be definitely ordering a fasting and a postprandial insulin levels. I’d be ordering potentially glucagon levels if I can, I’d be ordering oxidized LDL. I’d want to see what is, is there any downstream oxidative stress we need to be worried about? I’d be ordering some inflammatory markers, CRP, maybe an inflammatory cytokine marker, but that would be a little extreme, but just seeing like what’s the other context of these numbers? It’s very hard to interpret them in the context of a unique diet in their own right. And so it’s, there’s just a lot of physiology there. And the nice thing is that we can probe a lot of it. You know, there’s other things, you know, uric acid there, there’s a lot you can look at.

Dr. Brett Scher:  [59:58]                      So someone’s listening to this podcast and writing these labs down. Then they bring them to their doctor and say, “Doctor, I want these labs.” They’re going to just look at them like they have two heads and they’re not going to know what to do with it. So what kind of advice can you give to patients if they’re in that type of situation?

Casey Means:  [01:00:11]Totally. Yeah. I think if someone’s at home checking their glucose levels on a low carb diet with just a finger prick, which I know a lot of people are starting to do now, just check even a fasting glucose or a post-meal glucose. And let’s say you’re seeing some concerning numbers. The things I’d probably recommend for like low hanging fruit would be to potentially check ketone levels. See what’s going on with the ketones. See if, and things that I think that a doctor would potentially order is a fasting insulin level and a CRP, which is C-reactive protein, which is an inflammatory marker. And maybe a cholesterol panel, take a look at triglycerides, LDL. And if you’re lucky, maybe an advanced lipid panel, which is going to look at some more complex markers, but CRP, fasting insulin, maybe check some ketones and kind of get a picture of where you’re at in the fat oxidation, insulin inflammatory realm. And I think most doctors would order an insulin and a CRP. And that would give you a lot of information, because I do think if your insulin is quite, quite low in the context of those slightly elevated glucose as you, you have a lot more information there that certain pathways are. I’d be curious from your perspective if you had, have any, others that you might probe.

Dr. Brett Scher:  [01:01:29]              Yeah. I mean, I think for the person going to their general doctor, it’s so easy to get them confused and sort of frustrated with asking for too many things that they feel like they can’t order. So I think the ones you mentioned are perfect to get started. Definitely the fasting insulin, and a CRP I think would be helpful in correlating that with your blood sugar check, if you can, like at the same time, it would be so helpful. Yeah. So, next rapid question. Are these devices good enough to really give us the level of detail and granularity that we’re looking to get? Because like you said, they were started for patients with type one diabetes and basically to make sure you’re not 60 and going to have hypoglycemic coma, which can happen at a level of 60 for people with type one diabetes or 300 and going to get DKA. They weren’t really meant from the beginning to tell the difference between 90 and 85. So is the technology good enough to really inform us to this level?

Casey Means:  [01:02:30]Yeah, it’s a great question. I mean this technology is FDA approved for treatment of diabetes. And so it is deemed by the FDA to be precise enough for management of these conditions and in times when this can be a life or death situation. And so, I certainly have faith in the hardware. There are interesting intricacies about the hardware that is important to know about, and you can look up some of the validation data for the hardware itself, actually online, it’s all published. And you can go to the FDA, there’s these SSED documents, which are the summaries of safety and efficacy documents. And they’re fascinating reads. I’ve of course, because I’m passionate about this, dug deep into that, but on page 16 of the one for the freestyle Libre, which is one of the three hardware manufacturers, it’s a continuous glucose monitor. It’ll show you the exact accuracy of these sensors at different ranges. And what you’ll find is that these devices are optimized for more of a diabetic glucose profile. So for between about 120 and 200, you’re going to have the most accurate readings. And as you get below 120, you’re actually going to see more variance between the interstitial CGM monitor glucose and the blood glucose. And there’s going to be the lowest overlap at very low numbers, like fifties and sixties of glucose. That’s where you can sometimes see a 20 point Delta between actual glucose and interstitial glucose. So at lower levels, they tend to be slightly more inaccurate. But what you’ll find is that the Delta, so a pre-meal and a post-meal, that difference between the two will generally be quite accurate. And that Delta I think is very important to know. So the key points are, they are increasingly inaccurate at lower values. They’re really primed for that, like 120 to 200 range. That’s where they’re going to be most accurate. And there are sensors, there’s the Dexcom, which is another piece of hardware that allows you to calibrate with the finger sticks. You can get them most accurate. So the Abbott does not calibrate, it auto calibrates. The Dexcom, which is another brand, allows you to finger stick and calibrate. So there’s a lot of ways to get it as close as possible. And I think the future generations of hardware are just going to get more and more accurate. From what I’ve heard, the new Libre, which is the Libre 2, which was FDA approved in June, they’re SSED, I don’t think is out yet, with all this data, but from what I’ve heard in the pipeline, it’s going to be more accurate at lower values. So a lot of progress on the hardware front, but those are some of the key things to be aware of.

Dr. Brett Scher:  [01:05:23]              And I think just as simple advice can be when you’re first starting out, maybe it is worth checking your finger sticks with the more accurate monitor, just to see kind of what the variance is and see if there’s a consistent variance, so you can know to make adjustments in your brain based on the findings. I think that could be good advice sometimes.

Casey Means:  [01:05:39]Definitely.

Dr. Brett Scher:  [01:05:40]              Alright, we’re sort of nearing the end of our time, but I have another question here, and then we can wrap it up. So post exercise or during exercise, rather, a number of people can see their blood sugar go to 120, 130 during a hard interval training session. And you know, they’re concerned about that as well, is that high blood sugar something you want to avoid? “And here it is during something that’s supposed to be good for me. Is this something I need to worry about?” So what’s your advice there?

Casey Means:  [01:06:05]Yeah. So it’s a really interesting mechanism that’s going on, which is that high intensity exercises. So heart rate or V̇O2 max above the sort of 70 and 80% range, people will see this odd paradoxical rise in their glucose levels that can sometimes be big, like 40 points, 50 points. And this can even be in the fasted state. So no PowerBar or protein drink before the workout. The mechanism of this is that when you start doing that high intensity workout, your body senses physical stress. And so your body’s going to release catecholamines and cortisol. And those hormones, those stress hormones are telling your body, “There is some stressor. We probably need energy for our muscles. Let’s dump it out of our stored bank of glucose,” which is the liver, “Get into the bloodstream so that we can feed those muscles.” And so this is actually a physiologic adaptation to what our body perceives as a physical stress that we need energy for. So it is not likely that those exercise induced spikes are going to be detrimental for metabolic health in the way that food related spikes are. They are going to have a different impact on insulin and the muscles are primed and ready to be a sync for that glucose. And so there’s just this sort of temporary mismatch in the bloodstream where you’re producing a lot of liver glucose, and then there’s some time before your muscles use it, but the muscles are able to take up that glucose rapidly and even in an insulin independent way. So just the contraction of the muscles can allow you to actually take up that glucose without the insulin binding to bring it in. So it’s a very different physiologic process. And the research on high intensity interval training, powerlifting, these activities actually can rapidly improve our insulin sensitivity and people who even do a single HIIT workout can see improved insulin sensitivity over the next 24 hours. And so. And those effects, you know, are only compounding over time. So it appears that these activities are net net positive for metabolic health and sort of hormetic sort of type stressors that are putting our body under this acute stressor, but ultimately with advantageous, adaptive, downstream effects.

Dr. Brett Scher:  [01:08:22]              Yeah. Great answer. And again, sort of goes back to the elevated blood sugar with elevated insulin or elevated blood sugar with lower insulin and how completely different physiologic response. So such an important caveat to understand that there are different circumstances where you need to pay more attention or less attention to it. But this has been sort of a whirlwind tour of metabolic health CGMs, how people can use it and what the literature is behind it. You clearly are passionate about this and have so much knowledge about it. So how would you summarize any last advice to people and then of course, where can they find you if they want to read more about you?

Casey Means:  [01:08:59]Yeah, absolutely. So I would just summarize it by saying, all metabolic health is a spectrum, we can all move in the right direction on that spectrum. Research shows that most of us are probably not in the best place on that spectrum. And we may not be seeing the overt signs of that, but it still can be brewing under the surface. And I guess one last thing I would kind of leave people with is that, that glucose variability and that moving along the spectrum can be related to a lot of the pain points in our lives that we don’t typically associate with blood sugar. So things like mood lability, brain fog, low energy, poor exercise, fatigue, even things like acne, and things like infertility. You know, these are conditions that we know are related to glucose even when we’re not diabetic. And so there is just a whole host of things that we can improve in our lives by tightening up glucose. And of course the downstream effects of chronic disease, the heart disease, stroke, diabetes, obesity, non-alcoholic fatty liver disease, et cetera, et cetera, et cetera, cancer, dementia. So really, it’s worth thinking about and learning more about, and in that vein, I write a lot about this on a website, www.levelshealth.com/blog. I write all about metabolic health for the non-diabetic students. The person who wants to learn about this, kind of from the perspective of why we should think about it now. And I also write a lot about this on Instagram and Twitter 2drcaseyskitchen. And there I talk about metabolic health, and using glucose biofeedback to personalize our diet and lifestyle. And so, yeah, we’d love to connect with anyone on those platforms.

Dr. Brett Scher:  [01:10:43]              Great. Well, I’m very excited to see what the future is going to bring for CGMs and how much people are going to learn from it and how it’s going to change the whole concept of how we view nutrition and metabolic health. So thank you for all you’re doing to sort of help further the information behind this and really push this cause. And I really appreciate your passion, and thanks so much for joining me today.

Casey Means:  [01:11:03]Thank you so much for having me.

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