Dr. Casey Means – Unlocking Your Optimal Metabolic Health

Dr. Casey Means is a former Stanford-trained surgeon who pivoted to functional medicine when she started to see a pattern emerging of chronic inflammation and diseases that could be prevented through better lifestyle choices. She’s now the co-founder and Chief Medical Officer of Levels Health, a health tech startup that uses continuous glucose monitoring to give users actionable data to improve their day-to-day behaviors and health. On this episode of PAVELCAST, Dr. Means talks to Pavel Tseytlovskiy about chronic inflammation and how it hurts the body, the effect of high glucose on our long-term health, and how wearable tech is the future of preventative medicine.

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06:55 – Challenging the normal course of medicine

Dr. Means has been pushing back against the medical status quo since medical school.

“Something that really bothered me in medical school was during our cardiovascular block, we were talking all the time about how important, Oh, you should tell your patients to exercise, and here we are medical students sitting in this dark room for eight to 10 hours a day, sitting in these chairs with virtually zero time in between classes to even go to the bathroom. And so I’m like, we’re actually engaging in the behaviors that are risk factors for the diseases that we’re studying. Not to mention, we only have access to our cafeteria food here, which is terrible and full of all the things that we’re saying we shouldn’t be telling patients to eat. So it was, it was funny. And I actually initiated this big launch where I tried to get Stanford to put standing desks in all the classrooms and so doing a big pilot study on that.”

15:16 – The role of inflammation

Acute inflammation is a normal immune system response and helps us to heal, but chronic inflammation is often the underlying cause of many chronic diseases.

“Acute inflammation is like you cut your finger. A little bit of bacteria enters. Your immune system, it releases signals for a bunch of immune cells to come that causes your finger to come red and swollen. And then in a few days, it all resolves and you’ve healed. So that’s great. Now, chronic inflammation is more something like you have gut dysfunction, your microbiome is screwed up. And so now your gut lining is constantly, your gut barrier has become a little bit tattered and, and all of a sudden, every day, every time you eat little teeny bits of bacteria are kind of constantly getting into your bloodstream. And now your immune system is like, Hmm, I always have to be on alert. I am always sending signals that there is a threat and that can be extremely sort of damaging to the body. Another thing that can do this is chronic stress. So, you know, we live in a, even though we don’t have a lot of really massive corporeal threats. Very unlikely we’re going to get shot. Very unlikely we’re going to get chased by a lion. And yet our bodies still think we’re under constant stress because honking, the cell phone going off, the emails, the constant meetings, you know, all these things are interpreted by our body in the exact same way as a real physical threat. So that chronic stress is telling our immune systems, get ready. A problem could be happening. And so when that’s happening all the time, it can be very destructive to the body.”

18:31 – Working on a solution

Dr. Means decided to leave surgery to focus on metabolic and preventative health to reduce these chronic diseases caused by our lifestyles.

“I kind of got pretty obsessed with this concept of metabolic health. And why are we so metabolically unhealthy right now? Why this is a key root cause of our inflammation, our metabolic dysfunction, and what are we doing to ameliorate this? I mean, the USDA puts out a food pyramid that doesn’t help really at all with metabolic disease. Doctors don’t have any idea how to recommend the right diets or exercise regimens or anything. So who is fixing this because it’s driving the majority of our healthcare costs, it’s driving the majority of suffering and it’s driving the majority of what’s going to the operating room. So, I spent some time, couple of years thinking, how can I merge the surgical world with this and kind of have this hybrid practice. And then ultimately I realized that I’ve been fortunate to have over a decade of medical training and that we don’t need a few more head and neck surgeons in the world. Like we need people to be working on solving this massive metabolic health crisis full-time and that I just felt I needed to focus on that issue with my career.”

22:10 – Glucose control is the low hanging fruit of metabolic health

Dr. Means compares the body’s metabolic process to a beautiful symphony when everything is working, but high loads of carbohydrates can throw it off.

“I would say foundationally, the number one thing that is easy and actionable is basically to not overload the body with energetic substrates. So that, if you put, for instance, tons and tons of carbohydrates and glucose into the body in a quantity that we were never, ever meant to process, there’s almost nothing you can do with that symphony to make it work. And that’s sort of the state that we’re in right now is we have what I would consider like glucose and carbohydrate toxicity. We ate like two pounds of sugar a hundred years ago per year. And now we’re eating on average 150 pounds of sugar per year. So when you think about it is complex, but in terms of lowest hanging fruit, there are things that are just no amount of nuanced finesse is going to fix it. And so I think the biggest one for that is our glucose intake. Because it’s just astronomically increased over the past a hundred years.”

27:52 – Everyone’s blood glucose responses are different

There’s no one-size-fits-all solution to the glucose crisis because each person needs their own personalized diet to keep those levels stable.

“Every single person responds to glucose differently. So you and I could both eat an apple and my glucose could rise 50 points, which is a lot, and your glucose might rise two points. And that has to do with a lot of different factors, which we over the past years have learned what those are. A huge one is the microbiome, a big one is body type, insulin sensitivity. And then other lifestyle factors, like just how much sleep you got, how much exercise you’ve done. All those things will basically translate that food into what actually happens in your bloodstream. And what matters is what’s actually happening in your bloodstream. So to say such a blanket statement about carb quantity, we’re learning that doesn’t really make sense because there’s such an amazing amount of biochemical individuality.”

33:32 – CGMs create a closed loop of nutrition information

CGMs give you feedback almost immediately on whether a food is metabolically healthy for you.

“If you look at big studies of non-diabetic individuals who are wearing the newest glucose monitors, people peak their glucose at about between 45 minutes and 60 minutes after eating. So it’s very fast. You can start to see a rise within five, 10 minutes. If you eat a big load of glucose, you’ll start to see the rise immediately. So this is hitting your GI system, dumping into your bloodstream and then you’re getting a reading super duper quickly, which makes it a really cool dietary biofeedback tool because there’s no delay. You know exactly a one-to-one relationship between what you’re eating or what you’re doing and what’s happening to your glucose. So you can now say, I know that this is the problem for me, or I know that this is good for me. I know this food combination is good for me metabolically. Whereas before there was no closed loop system with nutrition. You might eat four meals in a day and then the next day you weigh yourself and you’re like, well, wow. Who knows?”

36:33 – Smart software gives you clear guidance

The Levels software not only graphs your blood glucose levels throughout the day, but gives you scores for each meal so you know which foods to keep and which to ditch.

“People love seeing their glucose line, but a lot of people wanted even simpler metrics of like, tell me good or bad. Like, I love the curve of the 24 hours glucose. But I want to know yes or no. Like how bad is this food for me? How bad is this activity for me? And so we came up with a proprietary score, it’s called Tilt Zone Scores, which essentially take a number of different aspects of a glucose curve. Like how high your spike goes, what level you started at like what the delta is and a number of other things, merges it into a composite metric. That’s just a one through 10 score. This is good. This is bad. So for me, the 10 is really good. Perfect score. Basically like a flat line after a meal. And so for me now, I’ve been doing this for months. So I’ve got like dozens of foods that are eight nines and tens for me. And basically now that’s all I eat. I never will eat things now that were a one, two or three, because I know it’s not good for me. And now I know and I feel great.”

41:20 – Every kind of exercise is beneficial

Different intensities of exercise create different glucose and insulin responses, but they’re all good for you and your metabolic health.

“There’s actually interesting things that happen with glucose and insulin with exercise. So right after exercise, your muscles actually can take up glucose, independent of insulin. So there’s a lot of complexity of what’s happening with exercise, but from everything we can tell from the literature, high-intensity training, even though it does sometimes have a little bit of a glucose elevation is actually very advantageous to overall glycaemic control and people can actually see a decrease in glycemic variability the day after a HIIT workout. We also know that things as simple as walking are extremely helpful and so lower intensity workouts like between 50 and 70% of your max heart rate, those are usually going to be associated with a decline in your glucose…studies have shown that even two minutes of walking every 30 minutes can have a profound impact on 24-hour glucose levels. So the real take home point is: do something, do it regularly, do it consistently.”

47:31 – Eat earlier in the day

Intermittent fasting and longer fasting periods can have big benefits, but if you can’t do that, just cutting off late-night eating can help.

“I know fasting is very hard for a lot of people. So the most important thing I would say is if you can’t do a full fast, at least stop eating earlier in the night because we get much more insulin resistant as the evening goes on. And so the same food eaten first thing in the morning when the sun is up and eating late at night, the exact same food, you will have a much bigger glucose and insulin response generally at night. And part of that is because of melatonin, which is the hormone that’s released as we start to go to bed. It’s released from the pineal gland when things get dark, it’s part of our circadian rhythms and melatonin actually acts on the pancreas, which releases insulin and kind of changes things up a little bit. So you don’t want to eat late at night. So if you’re going to choose when to have your meals, or even when to put your feeding window, I would say shift it earlier in the day, as much as you can.”

52:40 – Wearable tech is the future of health

Tech can influence our daily decisions and help reduce metabolic diseases where doctors can’t.

“I think that a tech-enabled solution is the right approach. It’s not a different approach or another tangential approach. I think it is fundamentally the right approach. And the reason I say that is because this is a set of processes and diseases and symptoms that are coming on because of the hundreds of daily choices that we make every single day of when to move, what to eat, how to pair foods, how we manage stress, whether we choose to meditate, whether we choose to put our phone away before bed, all these things, every choice has some impact on metabolic health, how we choose to react to a difficult conversation. And so those are these choices that lead to these bigger picture things. So then to say like, Oh, one lab test a year and a 15-minute visit with a doctor a year is going to somehow impact those thousands and thousands of choices. So I started imagining, how can I be on my patient’s shoulder every second of every day, basically whispering in their ear what the right decision is. And I realized two things. One that’s not possible. Even if we had an army of coaches in the country it’s not possible. And two, I don’t know what is right for a patient because despite the research literature that we have that suggests that certain foods have a low-glycemic index and certain exercises are good for metabolic health. What we’ve learned over the past three or four years is that the biochemical individuality means that everyone responds differently. So not only can I not be there, I also don’t know. And so you need the technology and you need the real-time feedback.”

1:01:47 – Bringing together ancient and modern wisdom

In the future, Dr. Means would like to see wearable technologies that measure more biomarkers and help us understand how they all work together, but also a return to some health approaches we’ve left behind.

“Figuring out biomarkers that help us attack the underlying links of disease is where I want to see medicine go. Because ultimately that’s a really efficient way to approach health. If you can have a lever that affects multiple pathways, it’s more efficient. So that’s what I’d like to see happen in healthcare. And I think the second thing is that I am kind of like a holistic hippie at heart too and I think there’s a lot of really amazing ancient wisdom that we’re seeing now gets studied and we understand it more, things like mindfulness and meditation and really powerful medicinal herbs like turmeric and curcumin and ginger and these things that are traditional, but now we understand the molecular biology of it. And so what I’m excited about is to see this really merger of ancient wisdom and advanced molecular biology and Nutrigenomics and how those things are now kind of coming together.”

1:15:28 – Building a modular diet

Dr. Means uses nutritional building blocks to create each of her meals based on her Levels data and her years of nutritional research.

“Almost everything I make has the same set of components. Every single meal I make, I try to have a boatload of fiber, like some amount of protein, omega-3 fats, some sort of really healthy whole food fat and then like a ton of phytonutrients. So that’s going to be like cups of vegetables or whatever. So most of my meals require, basically the principles of whole food plant-based diet is you’re eating fruits, vegetables, nuts, seeds, legumes, and grains. Although I don’t really eat much grains because of the glucose stuff. So now you’re modularizing your diet. You have all of these different things and you’re just kind of pairing them together in different ways. So essentially I’m just kind of choosing what vegetables, fruits, nuts, seeds and legumes do I want to mix together for a meal and then the options for that are just like infinite so I can take nuts and I can blend nuts in the Vitamix with some lemon juice and tamari and garlic and make like a super thick, creamy, almost like sour cream sauce, like in two seconds. And put that on a little veggie scramble. I can take the same seeds and make a nut milk in two minutes. It’s really all about changing the forms and that way it’s kind of like a science experiment every day.”

Pavel Tseytlovskiy [00:00]   Ooh, another episode of the Pavelcast coming at you hot. Great show. We have Dr. Casey Means on the show. She’s a co-founder of Levels Health. She’s a Stanford trained physician, a former surgeon. She’s now really passionate about metabolic health and digital health. We talk all about nutritional health, our microbiome, how, you know, what is metabolism? Like our chronic inflammation in today’s society, like how that’s causing a ton of chronic diseases, really digging into the latest research on metabolic variability between people, you know, some of the new studies coming out using the continuous glucose monitoring. Well let’s talk about the start-up Levels Health, which is, you know, in kind of in a beta mode right now, launching later this year, very fascinating. They’re helping folks really track their metabolic health track, their glycemic response via this patch. I urge you to check it out. I want to sign up. I think it’s really interesting. I really want to know how my own glycemic response is affecting everything I do. We learned a ton. We have a few laughs, it’s a great show. Enjoy! And also find Dr. Casey Means at drcaseyskitchen on Instagram. caseymeansmd.com, levelshealth.com. And if you want to see me roll my eyes, move my, wave my hands around, we’re now on YouTube, youtube.com/pavelcast. Please enjoy!

Casey Means [01:26]     Love it!

Pavel Tseytlovskiy [01:28]                         Everybody, welcome to another beautiful episode of the Pavelcast. And we have a real get for a guest here today, Dr. Casey Means. What should I call you? Casey?

Casey Means [01:37]     Casey!

Pavel Tseytlovskiy [01:38]                         Of course. Okay. That’s what I thought. Thank you for coming on the show. How are you?

Casey Means [01:43]     Thanks for asking me. I’m doing great. It’s great to see you.

Pavel Tseytlovskiy [01:46]                   Yeah. Happy Friday, Shabbat Shalom. So let’s tell people a little bit about your story because I think it’s pretty fascinating and interesting. So you are a doctor you’re still practicing and you went from actually, what I found fascinating as I was reading about it, you went from being a surgeon first to becoming like really into functional medicine. And now you’re helping the startup Levels, which is doing like a really interesting thing with data and metabolism. And we could, and I really want to talk about that, but first of all, I want to talk about you. Like, yeah. Tell me your story. How did you end up, like surgeons, they’re like, they’re highly paid. Everybody wants to be a surgeon, super competitive, and you just decided to let that go?

Casey Means [02:29]     I did. Confusing a lot of people along the way, but the best decision of my life to move from surgery to digital health. But it kind of starts a little farther back. So I’ll still start with-

Pavel Tseytlovskiy [02:45]                         Please. Yeah, of course.

Casey Means [02:47]     The origins. I was born on, you know, but, so I was super fortunate to be at Stanford as an undergrad during like the height of the human genome project. The human genome project had like just kind of been wrapping up when I started college there, 23andMe was starting, direct consumer genetic stuff. So like personalized medicine was super hot right when I got there. And so that was really my big focus. I majored in you know personalized health, personalized genomics. I worked at 23andMe in college. And my whole framework for seeing the human body was just that we are these, you know, unique biochemically, individual blueprints, and basically health is basically differential expression of these blueprints. And environmental inputs is what is the lever that you can kind of pull to change the expression. So that mindset was very empowered in the sense that like, you know, we have this template and that template is uniquely ours, but we have a lot of agency and control over how it’s expressed. So flash forward, you know, I go to medical school and what’s interesting is that like our common medical paradigm is actually very different than this. The way that we practice medicine is a little bit, a lot bit more cookie cutter. You know, a lot of medicine now is pattern recognition. So, you know, you have a patient. A patient has a set of symptoms and signs, signs being more objective data, symptoms being subjective data. And if all those things match up, you label a diagnosis. And then based on that diagnosis, you turn around and you have, you know, some set of interventions, whether it be surgery or a medication. And that’s basically the way that medicine is practiced. It’s really you know, kind of textbook. And so medical school is really about learning all those patterns. You know, you learn like 15,000 new words in medical school. It’s crazy, but really it’s about labeling and reflexive action. So that was, coming from my perspective, is a little bit disheartening. But, you know, so I’m in medical school, that’s kind of what I’m learning. Not a lot of-

Pavel Tseytlovskiy [04:52]                         Oh, so you’re feeling already in medical school like, “This is not my jam,” a little bit? Like the way it’s, the way medicine is practiced basically, in the world?

Casey Means [04:59]     Yeah, it was-

Pavel Tseytlovskiy [05:00]                         But at least in the US system, I guess.

Casey Means [05:01]     And I think it is uniquely prominent in the US system. I talked to some of my colleagues from South America or especially, you know, Asia and Japan and China, and it’s a completely different approach. Obviously everything’s moving in that sort of like westernized direction. But in South America, in, you know, Japan, China, there’s still very much this focus, India as well, of nutrition, herbs, micronutrients as a huge part of health. And that’s still even a part of mainstream medicine. So-

Pavel Tseytlovskiy [06:36]                         So a doctor in that country is actually going to help you with your diet, prescribe you- I mean, obviously Chinese herbs right, that comes to mind, like Chinese herbal medicine, but like, you’re not thinking of that. You’re saying like a more holistic approach to it even like? Yeah.

Casey Means [05:49]     Absolutely. Yeah.

Pavel Tseytlovskiy [05:51]                         Interesting.

Casey Means [05:51]     So, you know, and that’s something that, you know, it is, we’ve sort of lost. We really don’t talk a lot about nutrition in medicine in the United States and the average medical student actually gets around like four hours of nutrition training in their entire medical school training, which is kind of incredible because the majority of the healthcare costs we’re spending today is about $3.4 trillion a year in healthcare costs, about 80% of those are from chronic diseases that are based in diet and lifestyle. So you would think that the biggest lever we could possibly turn in terms of, you know, increasing productivity, decreasing suffering, and mortality and morbidity, and also lowering our healthcare costs is to train doctors exquisitely on nutrition and lifestyle interventions, of which there’s hundreds of thousands of papers on PubMed showing that these interventions are extremely effective for chronic diseases. So, you know, long story short, that became a big, you know, a kind of a sticking point for me in medical school and actually something, you know, just like a funny little anecdotal aside, I, something that really bothered me in medical school was during our cardiovascular block, we were talking all the time about how important, you know, like, “Oh, you should tell your patients to exercise.” And here we are medical students sitting in this dark room for eight to ten hours a day, sitting in these chairs with virtually zero time in between classes to even go to the bathroom. And so I’m like, “We’re actually engaging in the behaviors that are risk factors for the diseases that we’re studying.” Not to mention, we only have access to our cafeteria food here, which is terrible and full of all the things that we’re saying we shouldn’t be telling patients to eat. So it was funny. And I actually initiated this big launch where I tried to get Stanford to put standing desks in all the classrooms and so-

Pavel Tseytlovskiy [07:38]                         I love it.

Casey Means [07:39]     Doing a big pilot study on that. And, you know, the students really liked it, but you know. So that was kind of a lot of-

Pavel Tseytlovskiy [07:47]                         It’s interesting. What do you think it is? Like, is it, I mean, obviously our society is like this, right? So we have, even though we understand that diet and exercise is so important and the stats are there, the data is there. It’s like, this is like almost cognitive dissonance that we just don’t do anything about it as a overall, I think society, let’s call it. I don’t know. Culture. Something. I mean, just even the medical school, they’re saying one thing, but you’re doing something completely different. Why?

Casey Means [08:17]     Well, I think that, you know, behavior really follows the money and we are, because of the way that our healthcare economics have been set up over the past 50 or 60 years, you know, we really haven’t incentivized techniques very, like [inaudible 00:08:30 – 00:08:36]      middle of the 20th century, this [inaudible 00:08:39]   service model with healthcare, which is basically that you pay for, you get paid as a clinician or as a hospital for doing things. So there is a bias towards action. There’s a bias towards doing. You can only really do things to people who are sick, or who have a problem. And so that subtly feeds into systems that sort of, you know, basically incentivize people to, you know, if you get a patient totally healthy, you lose a customer, essentially. And I don’t think that plays out on the individual doctor’s mind at all. But I do think that on a systems level, when we’re driving research, we’re driving medical education initiatives, there’s no question that that subtly plays in. And there’s other models of healthcare economics, which do tend to promote prevention more. So that’s more of like a capitated or HMO model where basically you’re paid some lump sum of money for a single patient. And then the system has to figure out how to use that most effectively and kind of what’s left over is their bottom line. So then you’re looking for the highest value interventions, value being cost over outcome. So you want lowest cost, best outcome is highest value. And so that is, so what we know about high-value intervention is nutrition and exercise, counseling and coaching are some of the highest value interventions in ROI you could possibly have. So in those systems, places like Kaiser and large sort of HMO type hospital systems, you start to see more investment in systems for keeping people healthy. So, you know, there’s a lot, I think that’s rooted in healthcare economics and we definitely, you know, there’s some inkling that we’re moving in the right direction with the initiatives towards value based care. I think there’s a lot of problematic stuff with that as well, but it’s a whole different story, but-

Pavel Tseytlovskiy [10:26]                         Yeah, we could probably go on hours for that. Yeah. Inkling would be, I love that term because  that’s the best way to put it, inkling.

Casey Means [10:32]     Yeah.

Pavel Tseytlovskiy [10:34]                         Yeah, it’s interesting. My favorites, one of my favorite stories about pop health, I think it was colon health, was it in Georgia or something? Basically they have this population. People are getting, I think a lot of (? chismatics 00:10:45). They just kind of dump it on a dashboard. They see a concentration, they go in, they figure out in this neighborhoods, like the ducts are like full of mold. So they, the hospital system pays to like fix all this housing, which you would think is like, what does that have to do with health care? But because they’re in this value based care system, it was like tremendously huge ROI on the investment, which has nothing to do with healthcare.

Casey Means [11:09]     That is absolutely fascinating. Yeah. There have been actually models done, financial models that have been published that say basically, if you give sick patients, you literally pay for their food and give them food for free, it would be, it would save our, it would save us hundreds of millions of dollars of healthcare costs. So.

Pavel Tseytlovskiy [11:29]                         That’s interesting. Okay. So you are okay, you’re like, “Oh, I’m seeing this stuff happening in this healthcare system, what I’m learning and I’m not, this is weird. I want something different.” What happens next?

Casey Means [11:40]     So, yeah. So in medical school, so then I got totally bit by the surgery bug. Surgery is very exciting. As a medical student, it’s very sexy, you know, you’re like, “I’m in the operating room, I’m a beast.” And so, you know, it was, that is, that was really compelling to me, both for just like, yeah, that sort of ethos. But also I was like, “Okay, here’s a field where I can go in and I can go into the operating room and I can fix something.” Someone has a lump in their neck, I’ll take it out. Someone has a clogged sinus, I’ll bust a hole in it. I’ll get the pus out. Like, it’s very, you just feel like it’s like, you know, you kind of have these tangible results at the end of the day, as opposed to a primary care doctor where sometimes you’re not seeing the effects of your advice for months and months, if ever. So went into head and neck surgery and became a head and neck surgeon and you know, the same little lingering stuff came creeping up. So I’ve sort of like that, you know, wanting to see more of a personalized approach. So I’m in the operating room and I’m doing a lot of vocal cord surgery, sinus surgery, ear surgery, and thyroid surgery, because it’s all head and neck stuff.

Pavel Tseytlovskiy [12:48]                         Okay.

Casey Means [12:48]     And what I’m realizing is that every condition I’m treating is a chronic inflammatory condition. So chronic ear disease is the tube that connects your ear to your nose is inflamed and you get pus built up in the ear. So you put a little ear tube in, the puss drains. Sinusitis, inflammation of the nasal tissue. It gets inflamed, it gets swollen, pus builds up in the sinuses. You punch a hole in it. You let the puss drain. You know, thyroiditis is inflammation of the thyroid, vocal cord granular.

Pavel Tseytlovskiy [13:13]                         Is there a bus there too?

Casey Means [13:15]     There. Not usually.

Pavel Tseytlovskiy [13:17]                         Not there?

Casey Means [13:17]     When there’s pus in the thyroid, you’ve got a big problem.

Pavel Tseytlovskiy [13:19]                         Big problem. Alright.

Casey Means [13:21]     But, and that’s not generally actually a surgically treated disease, but thyroid inflammation, which is called Hashimoto’s thyroiditis, is becoming pretty rampant. And then vocal cord diseases like vocal cord polyps and granulomas. I mean, these are inflammatory masses. So I’m sitting there like, “Okay, I’m treating inflammatory conditions with surgery. That doesn’t make a lot of sense.” Why is everyone’s so damn inflamed? And why are we giving people these packs of steroids?” Which are anti-inflammatories and not mentioning anything about the different things that can cause inflammation, which I think it’s becoming more and more understood widely that, you know, chronic inflammation underlies a lot of disease. And the stuff that we’re putting in our bodies and exposing ourselves to in the environment are huge inflammatory triggers.

Pavel Tseytlovskiy [14:07]                         What’s inflammation? I mean like what’s the biological, what’s happening underneath?

Casey Means [14:14]     Yeah. So our immune system is this beautiful part of the body that’s meant to essentially surveil our bloodstream and our tissues at all times for any potential threat and then go and attack it and fight it. And then the cells, the little immune cells that find the threat, they then release signals that tell all the other cells in the body like, “Get activated. We’re going to war. We have seen a fight.” So for, you know, a bacteria or virus, obviously this is extremely helpful, but those are not the only threats that our bodies sense. Our bodies can sense threat in a variety of different ways. So if you’re being chased by a lion and you are, you know, this is ancient times, you’re being chased by a lion, your body has a huge stress response. And that alone, that stress response will activate your immune system because your body is preparing for a potential injury. So stress is a huge trigger of inflammation. And a really, I think a good framework for thinking about inflammation is acute and chronic inflammation. Acute inflammation is like you cut your finger, a little bit of bacteria enters, your immune system goes, it releases signals for a bunch of immune cells to come that causes your finger to become red and swollen. And then in a few days, it all resolves and you’ve healed. So that’s great. Now, chronic inflammation is more something like you have gut dysfunction, your microbiome is screwed up. And so now your gut lining is like constantly, like your gut barrier has become a little bit like tattered and now all of a sudden, every day, every time you eat little teeny bits of bacteria are kind of constantly getting into your bloodstream. And now your immune system is like, “Hmm, I always have to be on alert. I am always sending signals that there is a threat.” And that can be extremely sort of damaging to the body. Another thing that can do this is chronic stress. So, you know, we live in a, even though we don’t have a lot of like really massive corporeal threats, like getting, you know, very unlikely we’re going to get shot, very unlikely we’re going to get chased by a lion and yet our bodies still think we’re under constant stress because, you know, honking, the cell phone going off, the emails, the constant meetings, you know, all these things are interpreted by our body in the exact same way as a real physical threat. So that chronic stress is telling our immune systems, “Get ready. Some, a problem could be happening.” And so when that’s happening all the time, it can be very destructive to the body. It takes a lot of resources to mount an immune response. So that’s kind of what inflammation, when we talk about inflammation as the root of disease, we’re talking about this maladaptive sort of unnecessary chronic inflammation that is kind of a function of our modern lifestyles.

Pavel Tseytlovskiy [17:00]                         Yeah. Modern life is going to kill us. It sounds like. Maybe you can help us. Okay, okay. So that’s interesting. So, okay. So we have the inflammation. You started noticing that as you practice surgery, that you’re treating all these things and it’s a classic, classic human, like, “We messed up, but now we’re going to fix it just by, you know, cutting it off and let’s pay a bunch of money on it.” Right? I’m sure there’s that piece of it. Like you said, that health economics keeps driving it more. What do you decide to do? You decide to just up and quit? Like, “I’m done this.”

Casey Means [17:23]     Yeah. So I started, it really was a journey, an intellectual journey of really trying to figure out what the root causes of inflammation were, and what that really led me to was metabolic health, which is what led to Levels. And so understanding sort of metabolic health and its relation to inflammation was like hugely eye-opening to me. And one of the parallels I was seeing was that a lot of the inflammatory chemicals that are released, these what are called cytokines and these like cellular mediators inflammation, are the same things that we’re seeing in a lot of these chronic lifestyle diseases that we’re seeing. So obesity, diabetes, heart disease, they all have a similar signature as the illnesses I was treating in EENT. And so there’s this really interesting relationship between metabolic health, which is just rampant in our country, obesity, diabetes, heart disease, Alzheimer’s, stroke, et cetera, all these things that are related to metabolic disease and what I was doing. And so I kind of got pretty obsessed with this concept of metabolic health, and why are we so metabolically unhealthy right now? This is a key root cause of our inflammation, our metabolic dysfunction, and what are we doing to ameliorate this? I mean, the USDA puts out a food pyramid that doesn’t help really at all with metabolic disease. Doctors don’t have any idea how to recommend, you know, the right diets or exercise regimens or anything. So who is fixing this? Because it’s driving the majority of our healthcare costs, it’s driving the majority of suffering and it’s driving the majority of what’s going on in the operating room. So I said, you know, at first I always thought, I spent some time, couple of years thinking, “How can I merge the surgical world with this and kind of have this like hybrid practice?” And then ultimately I realized that the, I’ve been fortunate to have over a decade of medical training and we don’t need a few more head and neck surgeons in the world. Like we need people to be working on solving this massive metabolic health crisis full-time, and that I needed, I just felt I needed to focus on that issue with my career. And so, yeah, in terms of.-

Pavel Tseytlovskiy [19:42]                         That’s awesome. Yeah. I mean the root cause, it’d be hard to fix though, as I’m sure you know, but it’s fun to try. Yeah.

Casey Means [19:50]     I think we’re making progress.

Pavel Tseytlovskiy [19:53]                         So metabolic health, it’s metabolism. Is that just like basically burning calories into energy to support your body? Is that what it is? I mean, how would you explain it to a lay person?

Casey Means [20:07]     Yeah, so I would, sort of stepping back just like, “What is metabolism?” I would define it as metabolism is the set of all sorts of cellular mechanisms that generate energy from our food and environment to basically power every single cell in our body. So every cell in the body, in order to function, you know, we’re made of trillions of cells, needs energy, cellular energy in the form of like what’s called ATP.

Pavel Tseytlovskiy [20:32]                         ATP baby. Yep.

Casey Means [20:33]     Yeah, ATP. And efficient metabolism is foundational for basically all health because that’s how cells run. So-

Pavel Tseytlovskiy [20:41]                         What is does efficient mean in that scenario?

Casey Means [20:44]     I would say efficient means that we are digesting, processing, transporting, utilizing, storing, and excreting all our energetic substrates in a way that does not cause an imbalance. So you  know, you take it in, you process it, you use it, you either store it properly or you excrete it. And when something is wrong there, it’s inefficient. So this comes down to, if you’re going from mouth to cell, basically we’re talking, efficient means a well-functioning microbiome, a well-functioning digestive tract, you know, a circulatory system that’s working, a hormonal system that is letting you actually, you know, take up energy into cells properly. Like you usually need a hormone to get energy moved in the right direction. Then you need intracellular processes like the mitochondria, which are the part inside the cell that process energy to be working properly. And then you need all your excretion. So your liver metabolism, you know, bowel movement.

Pavel Tseytlovskiy [21:43]                          Poop?

Casey Means [21:43]     All of, yeah, exactly. All of that, every step of that. And on top of that, the nervous system, because what causes the gut to move, what causes blood vessels to dilate nerves. So every aspect of that needs to be working in just like a beautiful symphony for it to work properly. So that’s kind of what I mean by-

Pavel Tseytlovskiy [22:04]                         That sounds very complex. Like there’s a lot of moving parts there.

Casey Means [22:09]     There are, but I would say like foundationally, the number one thing that is easy and actionable is basically to not overload the body with energetic substrates. So that like, if you put, you know, for instance, tons and tons of carbohydrates and glucose into the body in a quantity that we were never ever meant to process, there’s almost nothing you can do with that symphony to make it work right. And that’s sort of the state that we’re in right now, is we have what I would consider like glucose and carbohydrate toxicity. We’re eating, you know, we ate like two pounds of sugar a hundred years ago per year. And now we’re eating on average, like 150 pounds of sugar per year. So that-

Pavel Tseytlovskiy [22:51]                         Wow!

Casey Means [22:52]     When you think about, it is complex, but like in terms of lowest hanging fruit, like there are things that are just no amount of nuanced finesse is going to fix it. And so I think the biggest one for that is our, you know, glucose intake because it’s just astronomically increased over the past hundred years.

Pavel Tseytlovskiy [23:11]                         Yeah. And I mean, is sugar addictive? It feels addictive to me when I eat my cookies.

Casey Means [23:16]     Absolutely.

Pavel Tseytlovskiy [23:18]                         I want to have more cookies and then the box is gone.

Casey Means [23:21]     I mean mice will choose to eat sugar more than they’ll choose to eat cocaine. So it’s very-

Pavel Tseytlovskiy [23:29]                         Oh really? Wow.

Casey Means [23:29]     Yeah.

Pavel Tseytlovskiy [23:31]                         Ha! How come it’s? And so, you know, I’ve personally had a whole experience with sweets and having kind of a, addiction to sweets that can feel like binge-eating, which I’ve worked on, is better now.  And I’ve, for a while I was keto. So I’ve really low carb and felt great. Energy levels  were great. And then I got stuck back in because, you know, you just want to have a slice of pizza, then you’re going to have a cookie. And I find it really difficult to, I mean, to keep my carb intake under like 20 grams or whatever it was when, to get into ketosis. So, my first question is, so beforehand, like our hundred years ago, which is, I mean, I’m thinking about what about a thousand years ago? Because our bodies haven’t evolved that much. How much were we eating then? I mean.

Casey Means [24:24]     Yeah.

Pavel Tseytlovskiy [24:25]                         So, were we actually doing like 120 grams or is it, was it also like? It probably a thousand years ago was very different with hunter gatherers. Maybe it’s easier to compare it to a hundred years ago, but I’m trying to understand like, were we living in this kind of good, no problem metabolic health system for a long time? And most recently with the explosion of obesity, that it all correlates basically, because we have changed our society and culture. Was that too easy of a connection?

Host [24:56]                         No, I think that you’re right on the money. I mean, we’ve seen astronomical increases in diseases related to glucose management over the past hundred years, exponential rises. Even in the past 30 years, you know, these things have jumped three acts for many of these diseases. So, you know, and it’s not to say that that people were universally healthier throughout history. Our lifespan has increased over the past hundred years massively. And so, you know, there’s a lot of different things at play. And that increase in lifespan, you know, I would attribute life largely to reduction in infectious disease, you know, hygiene, antibiotics, reducing infant mortality, et cetera. But when we look at morbidity, so how long the process of decline at the end of the life is happening. You know, we start people start getting sick and trailing off towards essentially death starting in their like thirties, forties, fifties now. And so there’s these decades of sort of decay and, you know, increased suffering that we’re seeing that, you know, is virtually needless for most people. And so, yeah, but I think, you know.

Pavel Tseytlovskiy [26:15]                         Wait. What are you saying? You’re saying that people are now, because they’re sick with like, let’s say diabetes and they’re overweight for like 40 years of suffering. Is that what you’re saying? Are they just kind of-

Casey Means [26:26]     I, that sort of slow decline towards-

Pavel Tseytlovskiy [26:28]                         Slow decline?

Casey Means [26:29]     Towards death, like is-

Pavel Tseytlovskiy [26:31]                         Oh, used to be, boom, you’re gone. Now we’re just.

Casey Means [26:34]     Yeah.

Pavel Tseytlovskiy [26:35]                         I see what you’re saying. So, okay. I got you now.

Casey Means [26:36]     Yeah.

Pavel Tseytlovskiy [26:37]                         Hmm. So okay, this is interesting. So then that obviously goes to Levels with the continuous glucose patch. So I mean it’s, some sugar is okay?

Casey Means [26:49]     Well, sugar is a broad term.

Pavel Tseytlovskiy [26:53]                         Okay, that’s right.

Casey Means [26:54]     So a lot of different forms of sugar. I would say from my standpoint, the human body doesn’t really need any refined sugar. So sugar that’s been taken from a whole food, processed that it’s just sugar alone in a really easy, digestible, quickly absorbable form. That’s not something that the body needs to function. Sugar in whole food forms, in traditional quantities is, you know, can definitely be certainly part of a healthful diet. You know, the community, the keto community obviously keeps carbs extremely, extremely low, but I’m, you know, of the camp that for a well-functioning highly efficient body, we can certainly process a normal amount of sugar from whole foods. So, you know, small-

Pavel Tseytlovskiy [27:40]                         What’s the number to that? Do you have one?

Casey Means [27:42]     A number? You know, that’s the thing. I think it kind of differs for everyone, and this is exactly why, you know, I’m working on what we’re building at Levels, which is that every single person responds to glucose differently. So you and I could both eat an apple and my glucose could rise, you know, 50 points, which is a lot, and your glucose might rise two points. And that has to do with a lot of different factors, which we, over the past years, have learned what those are. A huge one is the microbiome, a big one is body type. Insulin sensitivity. And then other lifestyle factors, like just how much sleep you got, how much exercise you’ve done, all those things will basically translate that food into what actually happens in your bloodstream. And what matters is what’s actually happening in your bloodstream. So to say such a blanket statement about carb quantity doesn’t actually, we’re learning that that doesn’t really make sense because there’s such an amazing amount of biochemical individuality. And the research group out of the Weizmann Institute in Israel, they published a paper in this big journal cell in 2015 called Prediction of Personalized Glycemic Responses through Continuous Glucose Monitoring. It was basically, they put, they took a bunch of healthy people. They put continuous glucose monitors on their arms. They gave them a bunch of different tests meals, and they saw that there’s massive variability in how each food raises blood sugar. And so what that says to us is there’s probably not a universal diet for everyone. There’s probably a personalized diet for each person. And if we want to keep our glucose low and stable, that’s going to look different for every single person.

Pavel Tseytlovskiy [29:20]                         Fascinating.

Casey Means [29:20]     And this gets very interesting also with the keto community, because right now we just have these like strict blanket keto diets that basically say keep carbs super low, but we actually don’t really care about keeping carbs low. We care about keeping blood glucose low. And those two things are increasingly being understood to be very different things, carb quantity intake and glucose elevation. And so I personally think keto is going to move into a keto 2.0 sort of version, which is, you know, individually informed through data. And I think, especially when people and who are using Levels  and who are keto, we’ve actually found the overwhelming response to be that they have been able to liberalize their keto diets-

Pavel Tseytlovskiy [30:03]                         Right. I bet.

Casey Means [30:04]     Because they’ve learned things that don’t actually spike their glucose or kick them out of ketosis. So it’s pretty fascinating.

Pavel Tseytlovskiy [30:10]                         So yeah, so let’s talk some Levels, right? So how long has this continuous glucose monitor thing existed? Like the patch that you have on?

Casey Means [30:20]     Yeah.

Pavel Tseytlovskiy [30:21]                         Like the Abbott one or whatever.

Casey Means [30:23]     This technology has been around for over ten years, and this is a hardware that is, three companies have CGM hardware, Medtronic, Abbott, and Dexcom. And these are devices that have been traditionally used for an FDA approved for type one and two diabetes management. So it tells people basically how to dose their medications.

Pavel Tseytlovskiy [30:46]                         Yeah. How frequently does it sample?

Casey Means [30:48]     So it, so I’m using the freestyle Libre, which is by Abbott. And that is what Levels uses in our program. And that is going to automatically in the background sample glucose every 15 minutes, 24 hours a day. And then the sensor stays on your arm for 14 days. So you’re getting, you know, thousands and thousands and thousands of data points that are just automatically happening in the background. When you scan the sensor against your phone, it will transmit all that data from whenever the last time you scanned to your phone. And then anytime you take your phone and scan, you can like override that 15 minutes. So you could scan every 30 seconds if you want to. But the, if you just scan every few hours, you’ll just get chunks of data from every 15 minutes.

Pavel Tseytlovskiy [31:36]                         Okay. And why doesn’t everyone do that? So my grandma has diabetes and she like pricks her finger. This thing sounds nicer because then you don’t have to do anything. You just kind of put it on once and all the data’s being collected. You can always just check and figure out what you need to do.

Casey Means [31:53]     Yeah, it’s pretty wonderful. Some of the biggest issues with people using this for diabetic management is just the way that insurance reimburses it for them. So we’re a completely separate use case because we’re using this for, you know, health seeking individuals without diabetes. And so we’re not in the insurance sort of model at all. But for people who do have like diagnosed metabolic disease and need this for treatment, you know, often it just truly hasn’t caught on in all parts of the country. People who use it are obsessed with it. It makes life so much easier, no more finger pricks, way more data, much more granularity, but it’s just, you know, it hasn’t made it to, you know, all parts of the country. And also, insurance companies,  there’s sometimes difficulty with access. So, which is a real shame because it really should be available to every single person with.

Pavel Tseytlovskiy [32:48]                         Yeah. If you’re listening, Edna, fix it.

Casey Means [32:52]     Yeah. And I think-

Pavel Tseytlovskiy [32:54]                         No, I’m with you. I agree.

Casey Means [32:54]     It would actually cause savings for them because, you know, medication mismanagement, I mean, it would eliminate a lot of problems, and also the data for type of people with type one and type two diabetes shows that this somehow helps you manage your medication with more granularity. It actually lowers people’s hemoglobin A1C, and other markers of, that’s a three month average of blood glucose. So, you know, it would, I think we’ll get there, but yeah.

Pavel Tseytlovskiy [33:20]                         Not there yet. What’s a, from the time I eat to the time my blood glucose has to have a response, how, what’s the time there? Probably difference for people, but still, there’s a range?

Casey Means [33:30]     Yeah. It differs for people. But if you look at big studies of non-diabetic individuals who are wearing continuous glucose monitors, people peak their glucose at about between 45 minutes and 60 minutes after eating. So it’s very, very fast. You can start to see a rise within five, ten minutes. If you eat a big, a big load of glucose, you’ll start to see the rise immediately. So this is hitting your GI system, dumping into your bloodstream and then, you know, you’re getting reading super duper quickly, which makes it a really cool dietary biofeedback tool because there’s no delay. You know exactly a one-to-one relationship between what you’re eating or what you’re doing and what’s happening to your glucose. So you can now, you know, say, “I know that this is the problem for me,” or “I know that this is good for me. I know this food combination is good for me, metabolically.” Whereas before, you know, there was no closed loop system with nutrition. You sort of like, you might eat four meals in a day and then the next day you weigh yourself. And you’re like, “Well, I don’t know.” Who knows like which aspect of the day did like change the needle on the scale, but with this it’s like instant and you can start to say, “Well, okay, this food is not right for me, not helping with my health goals. It’s gone.” So that closed loop is really what people are finding, I think hugely valuable with the product.

Pavel Tseytlovskiy [34:57]                         So, and I saw, you know, in your ads or whatever, there’s like different zones. What does that mean?

Casey Means [35:04]     Yeah. So backing up like for optimal health and to move towards optimal metabolic health, which is just associated with a whole range of health benefits, you want to keep your glucose from spiking after a meal. You want it to be essentially instead of an up and down jagged line, little mountains and valleys, you want it to essentially be flat with like maybe some little gentle rolling hills. And that’s what you want to see on this graph of your glucose curve. So that’s just like backing up. You want less variability and over time as you have less variability, you’re, you know, and keep your glucose low during the day, you’re going to essentially make those processes we talked about more efficient, especially in regards to hormones. Insulin, which is the hormone that causes yourselves to take up glucose. When you constantly have high insulin, because you’re eating lots of carbs, your cells become a little bit numb to it. And so that makes your glucose start creeping up all the time. And so as you keep variability down, as you keep glucose low with better food choices, your insulin sensitivity starts to go up again. And so that line over time is better and your variability is going to get better. So we want low variability, we want low healthy values. And that’s kind of the goal. So getting into zone. So, you know, we’ve been, our company’s been around for about a year. We’ve been running a beta program for about six months and we’ve had about 600 customers come through and give us constant feedback. And people love seeing their glucose line, but a lot of people wanted even simpler metrics of like, “Tell me good or bad. Like, I love the curve of the 24 hour glucose, but like, I want to know yes or no. how bad is this food for me? How bad is this activity for me?” And so we came up with proprietary scores, called zone scores, which essentially take a number of different aspects of a glucose curve. how high your spike goes, what level you started at, what the Delta is, and a number of other things, merges it into a composite metric. That’s just a one through ten score. This is good. This is bad. So for me, the 10 is really good. Perfect score. Basically a flat line after a meal. And so for me now, I’ve got like, I’ve been doing this for months, so I’ve got dozens of foods that are eights, nines and tens for me. And basically now that’s all I eat. Like I never will eat things now that were a one, two or three, because I know it’s not good for me. And now I know and because-

Pavel Tseytlovskiy [37:32]                         How do you feel? Do you feel amazing?

Casey Means [37:34]     I feel great. Yeah. And the concept of zones, as opposed to a meal score, we call it a zone score because the cool thing about glucose is that it’s affected by more than just food. We talk about stress, but it’s also affected significantly by sleep and exercise. So the four biggest levers for what affects your glucose, which makes sense because they all have to do with energy, is sleep, food, exercise and stress. So, what we do, if you, let’s say you are on a stressful phone call and you eat a meal, both of those things could be impacting your response. So we have people basically log all these different things, or we have device integration with Apple Health Kit, so we know some of these things as well. And so we say, we can’t just say that meal did this to you. This combination of variables together had this outcome. And so that’s a zone. So if things are in close succession, you have to lump them together because biologically they’re all translating into the same thing. So then what our software can do is parse out the weight of these different variables and start telling people when you do X, Y, and Z, you have the best response. Like now you have these new tools in your toolkit to know how to basically manage your glucose going forward. So that’s the concept of zones.

Pavel Tseytlovskiy [39:02]                         Okay. That’s interesting. So what happens after I exercise? Does it always go up or go down? Or what happens during this? Is it, or is it? Yeah, tell me.

Casey Means [39:13]     It’s a great question. So, basically any exercise that you do over the long-term will make your glucose better. Exercise makes us more insulin sensitive. So our cells just respond to the insulin, take up the glucose process well. Exercise is one of the best things we could possibly do for longterm glycemic health. However, in your actual workout, you might see some really interesting things based on the intensity and type of the workout that you’re doing. So high intensity interval training, HIIT training, which is super popular now, people are actually going to see an increase in glucose when they’re doing HIIT training. So if you’re, you know, 80% of more of your heart rate or VO2 max, which we would kind of consider, you know, a HIIT workout, that actually is an acutely, very stressful moment for the body. And you’re going to dump out all these stress hormones, cortisol, catecholamines, and that’s going to tell your body, “There’s threat, you’re being chased by a lion.” And what’s going to actually happen is because your body thinks that you’re in threat and you need all this energy for your muscles, you dump out all this stored glucose from your liver to flood the bloodstream. You actually, you can. Yeah. And you can just get this big, big spike, and it actually overcompensates. So you get this big increase in dumping of glucose, but your muscles only need a little bit more. And so there’s a mismatch and you get this spike. That is actually, it’s not like a food-related spike. It’s actually HIIT training is associated with a really good glycemic control. And so that’s, we actually, in our app, we allow people to label if it’s a HIIT training workout and we have the heart rate data to kind of let us know. So that’s not going to be penalized in terms of your overall scores, but that’s something you might see. If you do a [crosstalk 00:40:54]      Oh, go ahead.

Pavel Tseytlovskiy [40:55]                         I was going to say like, so does that mean a high glucose response is not bad necessarily? It just depends on all these other factors, huh?

Casey Means [41:05]     Well, it’s sort of, it’s complex sort of what’s going on with the physiology. So eating glucose and having it released into your bloodstream is a whole different set of chemical processes than your body just releasing some glucose in the liver. And there’s actually interesting things that happen with glucose and insulin with exercise. So right after exercise, your muscles actually can take up glucose independent insulin. So there’s a lot of complexity of what’s happening with exercise, but from everything we can tell from the literature, high-intensity training, even though it does sometimes have a little bit of a glucose elevation is actually very advantageous to overall glycemic control and people can actually see a decrease in glycemic variability the day after a HIIT workout. We also know that things as simple as walking are extremely helpful and so lower intensity workouts between 50 and 70% of your max heart rate, those are usually going to be associated with a decline in your glucose or a stability of your glucose during the workout because you’re not going to be releasing those stress hormones and dumping out the glucose and dumping, from the liver. And also your body at those lower intensities are going to be able to actually burn more fat for the workout. It’s not going to necessarily be preferentially using glucose. So that lower intensities, our bodies use more fat than they use glucose for exercise. So in that case, you know, you’re either going to see a slight dip in glucose or pretty much stable. But even two, studies have shown that even two minutes of walking every 30 minutes can have a profound impact on 24 hour glucose levels. So the real take home point is like, do something, do it regularly, do it consistently. It does not matter what it is between low intensity, high intensity resistance or agility training.

Pavel Tseytlovskiy [42:56]                         What do you personally do?

Casey Means [42:59]     I kind of do all of it. My favorite thing to do is more of the high intensity stuff. So I’m a big runner and biker. I’ve joined the Peloton, you know, COVID I used to come to the Peloton, but. So I just, you know, I have an athletic history, basketball and volleyball, and so I just want to get in there and go crazy. You know, I love seeing what happens to my glucose and you know, but I do a lot of hiking as well. So that’s sort of a totally different response, you know, where it’s just hours of low intensity. And I see a major drop in my glucose the night. If I do an eight hour hike, I’ll see a measurable decrease in my glucose the next day. I think just as my body’s been so primed, you know, to be insulin sensitive. But yeah.

Pavel Tseytlovskiy [43:50]                         Cool. Go ahead.

Casey Means [43:53]     I was just going to say, it’s been, I would say the one thing that wearing a glucose monitor has done for me in terms of changing my behavior is I now do a lot more fasted workouts because now that I can see that, my glucose is fine and I like, I am not getting hypoglycemic during my workouts. Like, there’s this perception that like, you need to pound glucose before a workout. But the reality is we have hours of stored glucose in our livers and our muscle cells. So like, there’s not really a reason to do that. And actually it’s disadvantageous when you’re training for some sort of endurance event. And this is. There are people on different sides of the conversation here, but my perspective is if you eat a banana or a shake before a workout what’s going to happen is you’re going to raise your insulin level right before your workout. And unfortunately, insulin, one of the, it helps your cells take up glucose. But the other thing it does is it blocks any fat from being burned. It’s a fat blocker, basically. So all of a sudden you’ve basically stopped yourself from being able to burn fat in your workout. And you only have a limited amount of glucose. Let’s say, you know, I’m training for a half marathon and I want, I need to be running for two hours at a high intensity. I’m going to be burning through all my stored glucose. And then I’m either, I’m going to need to tap into my fat or I’m going to have to eat during the run. And if you’re constantly eating before your endurance training, you’re not training your body to ever use fat during the workout. So by running in or training in a fasted state, what happens is you burn through your glucose storage. You start with probably lower glucose storage, especially if you’ve slept and you’re fasted and then you work out, you have low glycogen storage in your body, and very quickly, you’re going to have to train your body to get those fat burning pathways active. And over the longterm, that’s what we call this term called metabolic flexibility, where your body basically learns how to use fat and glucose and switch back and forth whenever it needs to. And metabolic flexibility is something you have to train your body to do. And it requires not having insulin high all the time. And it’s associated with much better long-term health outcomes. So, and also it’s improved. It’s associated with improved exercise endurance, which is why a ton of athletes are just so excited to try CGM because it’s like a little bit of an extra edge of knowing how to fuel during your workout.

Pavel Tseytlovskiy [26:16]                         Uh, yes. So that’s what I do. I work out fast and most of the time, and then I love it. Yeah. What’s your opinion on intermittent fasting? Do you have an eating window that you do or no?

Casey Means [46:28]     Yeah. I mean, I’m very pro intermittent fasting generally. I think that the research evidence overwhelmingly suggest that almost any type of fasting is good for metabolic health. So intermittent fasting, but also prolonged fasting. So whether it be, you know, a 16/8 window that’s positive, but two, three, four, 20 day fast also have huge impacts on improved glycemic control. So yeah, I typically try to basically do a 16/8 type of thing, eight hour feeding window. But one thing I’ll say, I mean, it’s, and I use the Zero fasting app and I love that. And I love the biofeedback from the glucose data showing me that like, you know, if I fast, if I stop eating earlier in the night, my glucose overnight is flat. If I eat late at night, it’s like this, it’s like up and down all night, like a little jagged line. And to me, I’m just like, God, I can’t believe I did that to my body. Like it had to like, had to bounce back and forth like all night. And what I would say though, I know fasting is very hard for a lot of people. So the most important thing I would say is if you can’t do a full fast, at least stop eating earlier in the night because we get much more insulin resistant as the evening goes on. And so the same food eaten first thing in the morning when the sun is up and eating late at night, the exact same food, you will have a much bigger glucose and insulin response generally at night. And part of that is because of melatonin, which is the hormone that’s released as we start to go to bed, it’s released from the pineal gland when things get dark, it’s part of our circadian rhythms. And melatonin actually acts on the pancreas, which releases insulin and kind of changes things up a little bit. So you just don’t, you don’t want to eat late at night. So if you’re going to choose when to have your meals, or even when to put your feeding window shift it, I would say shift it earlier in the day, as much as you can.

Pavel Tseytlovskiy [48:29]                         How many hours before bedtime. Well it’s not even bedtime. It is actually the darkness. So. Yeah, it’s interesting. Like before six, before eight or 10, whatever you can do?

Casey Means [48:38]     Yeah. You know I think it’s not perfect. It’s whatever you can do, like any little bit matters. I mean, a lot of us like are snacking at midnight, you know, or like right before bed. That’s not abnormal. I certainly do that sometimes when I’m working late. So it’s really just about incremental gains. And I would say if I had to choose a number, I’d say like between 5 and 6:30 PM, maybe for the last meal, but that’s really challenging. So, but that would be like a goal to shoot for. One of the research studies that was like very powerful. It was very extreme. And they basically had people eating between the exact same number of calories between either 8 and 2:00 PM, 8:00 AM and 2:00 PM or 8:00 AM and 8:00 PM, same number of calories, same food content. And the people who ate in the 8:00 AM to 2:00 PM window had like significantly better metabolic health metrics. So that’s just, I mean, obviously it’s very difficult to stop eating at 2:00 PM, but that just goes to show like moving things, same amount of calories. Basically, you get more bang for your buck if you eat things earlier. So yeah.

Pavel Tseytlovskiy [49:42]                         I guess I’m going to have to move my treats over to the morning if I’m ever going to have treats. I mean, it makes sense.

Casey Means [49L48]    I would recommend that. Yeah.

Pavel Tseytlovskiy [49:49]                         And then you don’t have the psychological, like, I don’t know if you’ve ever had the psychological like, “Oh, I’m waiting for the treat.” And then you waited all this time and then you like kind of break versus “You have it in the morning. Okay. Live your life.”

Casey Means [50:01]     I like that. I think psychologically that’s a good strategy too. Less of like using food as a reward or tool and more of just like acceptance and you know, optimization. So.

Pavel Tseytlovskiy [50:16]                         Yeah. I mean, I love this Levels idea that you guys are doing because you getting oldest, I mean, you’re getting a lot of gorgeous data and I’m sure people probably logging some food and some logging, some exercise and kind of seeing it all. And I think the one thing I’ve found, you probably can relate. Like using data to improve something can be very powerful. So, you know, I know that I shouldn’t eat that whatever at 10:00 PM, but if I see that like you said, where I see that spike start to happen, like that reminder, I think that can have a really powerful thing. Like you’re saying, like doctors need to be taught nutritional intervention. Nutritional intervention is super hard for people to do, right? Like period. So I wonder if this, what you guys are doing here with Levels. I know you’re doing a lot of athletes too, but eventually you can just help regular people change their lives because they’ll be influenced by their own data. What do you think? It’s what I want to see happen.

Casey Means [51:13]     I think that’s exactly where we’re going. And, you know, my sort of like unpopular statement of the year, I would say is like, “I don’t think that doctors are going to solve the metabolic health crisis.” Like, I don’t think they’re the right people to do it because of the nature of the problem. So it’s, and that’s unpopular because like, this is a huge, huge industry, like metabolic health. But I think that a tech enabled solution is the right approach. It’s not a different approach or another tangential approach. I think it is fundamentally the right approach. And the reason I say that is because this is a set of processes and diseases and symptoms that are coming on because of the hundreds of daily choices that we make every single day of when to move, what to eat, how to pair foods, how we manage stress, whether we choose to meditate, you know, whether we choose to put our phone away before bed, all these things, every choice has some impact on metabolic health. Like how we choose to react to a difficult conversation. And so those are these choices that lead to these bigger picture things. So then to say like, “Oh, a 15, one lab test a year and a 15 minute visit with a doctor a year is going to somehow impact those thousands and thousands of choices.” So I started imagining like, how can I be on my patient’s shoulder every second of every day, basically whispering in their ear, like kind of what the right decision is? And I realized two things. One that’s not possible. Even if we had an army of coaches in the country, it’s not possible. And two, I don’t know what is right for a patient because despite the research literature that we have that suggests that some, you know, certain foods have a low-glycemic index and certain exercises are good for metabolic health, what we’ve learned over the past three or four years is that the biochemical individuality means that everyone responds differently. So not only can I not be there, I also don’t know. And so you need the technology and you need the real time feedback. And this has to be patient driven. It has to be user driven. On top of all of that, there is very little incentive for the food industry and the healthcare industry to take a huge role on this because it’s not actually aligned financially right now. It may move in that direction, but it’s not. So for all of those reasons, I think a patient driven, patient data-driven, you know, very much more of a behavioral focused intervention of closing the loop, letting them make the decisions, highlighting their biochemical individuality and their agency and empowering people to make the decisions, that is going to change it. It’s not going to be top down, it’s going to be bottom up. And so, you know, I’m basically saying that like, being a doctor is not that valuable in this regard, which is, you know,  and that’s, I’m being a little bit contrarian and like extreme there. But I do think there’s going to be a huge role for technology here to solve. And we have to be thinking creatively about these problems because they’re bigger problems than we’ve ever faced in health before. We’ve got, you know, well, over a hundred million Americans with diabetes, I’m sorry, pre-diabetes or diabetic. And we have 74% of Americans with overweight or obesity. Like this is not, these are, we’re talking in the millions, so we’ve got to solve it. So yeah.

Pavel Tseytlovskiy [54:28]                         I love it. You know, you keep saying there’s individual variability. And so does that mean like a hundred calories for me is different than a hundred calories for you? Like, and you, I think you even said it goes, you can have a blood glucose responsible from two when you eat something to 51, Joe eats it. That’s like a 25 X increase. Like how. It is like, this is, it’s, that sounds like, do you have any sense of, in terms of metabolism and I don’t know how they measure it, maybe it’s the glycemic response, but what percent? What is the variability there? Is it 10%? Is it like a 500% difference? Is it hard to measure? Because everything is so individualized. You could be stressed. I could be having a fun time. I had a lot of sleep. You didn’t. Like, I’m trying to get, like, what is that actual variability between people, if you control for everything you can control for?

Casey Means [58:28]     Yeah, it’s big. I don’t know the exact number, but I’ll describe a graph that you see in the four main papers that have looked into this. And it’s been repeated now multiple times in JAMA, CELL, the biggest journals. And if you do show notes, I’m happy to link the-

Pavel Tseytlovskiy [58:48]                         Yeah, I would love that.

Casey Means [55:49]     Because they’re graphs that will, they changed our lives, right? They like made us feel like this is, you know, we’ve got to get this information to people. So here’s a graph, you’ve got an X axis, which is,  time. And you’ve got a Y axis, which is glucose range. And you’ve got a bunch of curves like on that, which is people, different people’s glycemic responses. And let’s say that graph has 50 lines on it. Basically what you’re going to see is some that are flat and some that are huge peaks, and you’re going to see everything in between like a full-on spectrum. And so every one of those people have the exact same carb intake and you’re seeing just a full on spectrum from huge response to low response, to same amount of carbs. And that’s what pretty much all of the studies showed. So it’s not like it’s bi-modal where it’s like, there’s some non-responders and there’s some hyper responders. It’s very much a spectrum of response. And for people that are like high responders to that food, they probably should not be eating that food. I mean, and maybe down the road and sorry, I’ll back up. I shouldn’t say that. They probably shouldn’t be eating that food in isolation, the way that they were doing it in the study, you can certainly modulator that food. So let’s say it was a sweet potato, or actually let’s say it’s beans. This is something that we see a huge variability in our users. Like I am a hundred percent, whole foods plant-based vegan. So I eat, you know, 75 grams of fiber a day. I eat multiple cups of beans a day. And I think my hunch is that like my microbiome and everything has just like, sort of developed to a place where I just do not respond. I don’t have a glucose response to beans. And I usually cover the beans in some sort of, you know, fat source. So there’s fat, there’s protein from the beans, there’s fiber in the beans and all those things, lower glycemic response. But we have users who have like a 50 or 60 point jump in response to beans because they’re a very high carb food. So, you know, so what could one of those people do? Like if they still wanted to eat beans, which are a very healthy food. So they could eat their beans with extra fat and protein, both of which blunt glucose spikes, they slow gastric motility. They’ll make you absorb it slower. They could add vinegar to their beans with some sort of vinaigrette dressing. We know that vinegar actually makes us a little bit more insulin sensitivity and reduce glycemic response. They could make sure they do a high intensity interval training workout the morning before they have their huge bean dinner, they could make sure that they aren’t stressed or they’ve slept really well when they have their favorite bean dish. I mean, this is a funny example because no, one’s excited about beans. You know what I’m saying?

Pavel Tseytlovskiy [58:23]                         Yeah, i hear you. yeah. A hundred percent.

Casey Means [58:26]     You have to think about this as a multi-variant model that, you know, we have so many levers to pull. We just don’t know what they are and which ones work for us. And so nothing is like off limits, which is a part of why I love the technology and why I love glucose as a data stream. You can just create these, you know, contexts. And over time, what we’ve found, and because like our founding team we’ve been wearing CGMs now for, you know, almost a year. So at this point I am pretty darn dialed in. I know how to keep my glucose stable. I did not at first. And over time you really kind of build what I would call a metabolic intuition, which is just sort of this approach to all these different variables, exercise, sleep, stress, you know, food, you know, vinegar, food combinations, food timings, you just build a context where you just sort of understand what’s going to happen and what levers to pull. And it does get a lot easier. But I think the key to that is this constant feedback month after month, sort of saying, you build this awareness, this intuition, and that’s an exciting place to get. And I think what people are hungry for, because right now people are super confused about what to eat.

Pavel Tseytlovskiy [59:36]                         Yeah. I want it. I want, I mean, hopefully, you know, one of the co-founders will let me somehow get one of these things because I want one now like badly.

Casey Means [59:47]     Yeah.Let’s get you in!

Pavel Tseytlovskiy [59:48]                         Yes, totally!

Casey Means [59:49]     We have a 20,000 person wait list, but we-

Pavel Tseytlovskiy [59:54]                         Shh, don’t tell anybody if I skip the line.

Casey Means [59:57]     No, we’d love to get you involved.

Pavel Tseytlovskiy [01:00:00]                 That’s, so that’s really fascinating. Interesting. I think this can really going to, from personalized medicine. So obviously we’re looking at glucose, sounds like glucose, actually. I mean, it’s pretty well, it’s simple. It’s robust in its simplicity, so I love that about it. What else are you excited about? Like maybe 10 years, two years, three years down the line of what we can, how we can really personalize our life, our medicine, our health, you know, by looking at data that we can collect and analyze ourselves?

Casey Means [01:00:32]Yeah. So I’m very excited for more real time biomarkers. Right now, glucose is the only blood biomarker we can measure continuously at home. And good, luckily it’s super powerful and really wonderful, but I think there’s going to be other things that emerge as really useful, and many groups are kind of working on this, but so multi analyte sensors is something that, you know, measures ketones or inflammatory markers or along with glucose and other sort of internal markers. I think it could be really helpful to help people really shape the healthiest lifestyle possible. I do feel like glucose is the most important one, but something that measured inflammation in real time, I think would be really, really cool to see and help people really solidified behavior change. What my practice now clinically is focused on, I do functional medicine now, which is really focusing on like the root causes of diseases. So you don’t, not thinking about diseases as sort of these isolated silos and then playing like whack-a-mole with all of them, but actually thinking of how they’re interconnected. And this is really based on research and systems and network biology, where we’ve been able to really understand the underlying molecular links between disease and attack at that level. And one of those molecular links is glucose dysfunction. You know, inflammation is another one. But figuring out biomarkers that help us attack the underlying links of disease is where I want to see medicine go because ultimately that’s a really efficient way to approach health. If you can have a lever that affects multiple pathways, it’s more efficient. So that’s what I’d like to see happen in healthcare. And I think the second thing is that, you know, I am kind of like a holistic hippie at heart, too. You know, and I think there’s a lot of really amazing ancient wisdom that we’re seeing, you know, now gets studied and we understand it more. Things like mindfulness and meditation and, you know, really powerful medicinal herbs like turmeric and curcumin and ginger and these things that are traditional, but now we understand the molecular biology of it. And so, what I’m excited about is to see this really merger of ancient wisdom and advanced molecular biology and nutrigenomics, and how those things are now kind of coming together. And ultimately, I think it’s going to move people, hopefully through all this advanced tech and biofeedback, ultimately, I’m hoping it’s going to move people back to a really centered place of focusing on the fundamentals in a really nuanced way. Things like how we stress, how we connect to people, how we sleep, how we eat, get us back closer to the earth. You know, we know microbiomes has a huge impact on metabolic health and, you know, our microbiome is enriched by being close to the dirt, close to the earth. And so, you know, I’m seeing this sort of boomerang effect of really advanced tech and technology that hopefully brings us back to a really centered, you know, beautiful relationship with people in the earth. So.

Pavel Tseytlovskiy [01:03:28]                 I love that. Do you practice mindfulness yourself?

Casey Means [01:03:33]I try, you know?

Host [01:03:35]                 Yeah, sure. It’s hard.

Casey Means [01:03:36]It is hard. It is hard. And you know, I’m definitely not perfect at it, but I am a big believer in the power of breath. So breath work is my big-

Pavel Tseytlovskiy [01:03:48]                 So that just, that just felt good.

Casey Means [01:03:51]You feel good? I’m glad you did that. I’m pretty obsessed with the vagus nerve. Is that something you’re familiar with, the vagus?

Pavel Tseytlovskiy [01:04:01]                 Yeah.

Casey Means [01:04:01]Yeah. So the vagus nerve is, you know, from the brainstem down to the diaphragm and every time you breathe, you’re basically flattening your diaphragm, stretching the vagus nerve, and that’s the nerve that essentially releases neurotransmitters that make you feel relaxed. So, breathing and just stimulating that vagus nerve and doing different things that help stimulate that nerve are like what I focus on throughout the day. And there’s lots of different techniques for stimulating the vagus nerve breathing, I think being the most powerful one, but you know, there’s other things that you can do as well. You know, you can do alternate nasal breathing, which not only stimulates the diaphragm, but also is going to stimulate the vagus nerve,  invigorates basically your whole upper aerodigestive tract. So by having that like really slow, powerful breathing, you’re stimulating the nerves sort of all the way down. So, yeah, a lot of traditional breathing techniques.

Pavel Tseytlovskiy [01:04:54]                 I can’t believe all these stuff.

Casey Means [01:04:56]Exactly. Yeah.

Pavel Tseytlovskiy [01:04:58]                 I’ve been doing Waking Up by Sam Harris. That was my introduction to, love Sam Harris.

Casey Means [01:05:04]Love Sam Harris so much!

Pavel Tseytlovskiy [01:05:06]                 Sam Harris, baby! Yeah. And I mean that really, I did the 50 days and that was eye opening to me of how much do we have just this thing going on in our heads all the time that there’s a different thing that is actually conscious than us in life, which I found like real. And I wonder if there’s a study that shows you people that mindful, you know, they’re doing meditation, what happens to their blood glucose?

Casey Means [01:05:33]It goes down.

Pavel Tseytlovskiy [01:05:34]                 Something good, exactly. I had this figured.

Casey Means [01:05:39]But that’s wonderful that you, so you did 50 days straight?

Pavel Tseytlovskiy [01:05:41]                 I did 50 days and I’m still pressed.

Casey Means [01:05:43]That’s amazing. And you, have you noticed changes in your life?

Pavel Tseytlovskiy [01:05:47]                 A hundred percent! I mean, I noticed that sometimes I can just get myself into loop, into that stress loop and I can actually separate and say, “Hey, this is, wait a second. That’s just thoughts running through. That’s not necessarily me.” And, you know, for like a microsecond, you can glimpse kind of the ego death where you’re like, “Oh, wait a second. There’s nothing, I’m just, this is consciousness,” And whatever, this emotional pain, or even emotional happiness that you’re experiencing, well, that’s just like thoughts happening. It’s not, I mean, what is reality? But it’s not, you know, it’s different. So.

Casey Means [01:06:25]Definitely. Yeah. It’s exciting to see how much this is becoming part of the ethos of our culture right now. I think it’s powerful. And I think, I don’t know if we had a little bit of an era of disconnection and now people are really the pendulum swinging and people are really trying to, yeah, to get back to that sense of connectedness and centeredness, but it’s, I’m hearing, you know, you’re kind of hearing it everywhere and I think it’s very, very exciting, especially knowing what it can do for overall health as well. But yeah, I’m certainly very intrigued by that striving for that idea of ego death. Like you mentioned, you know, losing this sense of this artificial boundary of self and really feeling. You know, as a biologist and a scientist like I think of the body as this conglomeration of atoms that sort of this energetic hub existing in a larger energetic hub of the, you know, of matter. We’re kind of, you know, a clump of matter existing around all this other stuff. And you know, our perception of self is kind of artificial, right? It’s like we have these boundaries of what is self and what is other? And so like on a biologic level, you know, we know that we’re all just this big, it’s a big swarm of atoms right on our planet and our universe. But it’s interesting to think about meditation and kind of getting to that loss of, ego death and sense of oneness, Nirvana, whatever, you know, people would have so many different words for it. I’ve almost like getting to a place of feeling or embodying what we kind of know to be true on the material level, which is essentially unity. And so, yeah, I haven’t gotten as far as you have, I think to even maybe to have that sort of split-second feeling of it, but it’s certainly. It’s something I strive for as well. And it’s interesting to see so many people moving towards that. So.

Pavel Tseytlovskiy [01:08:17]                 That’s pretty awesome. I saw you made, like, it looks like delicious zoodles with like some cream sauce. That looks, I mean, it look tasty, I got to say.

Casey Means [01:08:26]Thank you.

Pavel Tseytlovskiy [01:08:28]                 So you.

Casey Means [01:08:30] [Inaudible] …. right there?

Pavel Tseytlovskiy [01:08:31]                 Dr. Casey’s Kitchen. Check it out on Instagram. So what are you doing with that? Is that just like your unique recipes or just sharing with people like how to? Yeah, tell me about it.

Casey Means [01:08:41]Yeah, it started, you know, like over a year ago where I basically was just, I’m, like I mentioned, I’m whole foods plant-based so I basically try to eat all unprocessed unrefined-

Pavel Tseytlovskiy [01:08:52]                 Have you been that way for a long time?

Casey Means [01:08:54]You know, I did this a little bit in medical school. Then I went to surgical residency and everything went out the window because it was just survival mode and I would just shove whatever I could in my face. When I had time to eat, I was working all the time and it was just like. Yeah, went totally off the wagon and concurrently my body kind of fell apart. So, when I was out of the surgical world, you know, it was very easy to recommit to really healthful eating. And my, I mentioned in college, I studied personalized genetics and my really big focus within that was nutrigenomics. So that’s how food compounds change gene expression. And that’s something I’m still really passionate about today and really is the foundation of why I’m a whole foods plant-based because essentially in my mind, like food is a molecular activator. And so I feel this sense of like every time I eat, I’m basically making a decision of how I want my genes to be expressed. And you know, what we know is that a lot of plant foods do kind of insane, magical things for gene expression. So, you know, for instance, like broccoli sprouts or any cruciferous vegetables, they contain a chemical compound called sulforaphane. And sulforaphane is an NRF2 activator, which basically reduces NRF2 as a gene that basically reduces our oxidative stress in the body, reactive molecules in the body. So like when I’m eating broccoli or broccoli sprouts, cabbage bok choy, like I’m like I’m activating NRF2. And when I eat, you know, turmeric, which I eat all the time, I’m like, “Okay, well, I’m getting curcumin, which is a NF kappa B inhibitor. NF kappa B is our master inflammatory gene and it’s activated by all of our bad dietary habits in our culture. And so like when I eat that turmeric in my smoothie, I’m like, “Yep. Down-regulating NF kappa B.” It’s like that for almost, you know, like everything I eat at this point. Garlic has allicin, which is, you know, got all this other properties. So my plant-baseness is very much rooted in molecular biology and nutrigenomics , and so it’s very easy for me to. People say like, “Oh, it seems restrictive. It seems hard.” And I’m like, “I don’t feel that way at all. I feel like it’s empowering. It’s makes my relationship with food exciting.” I think of the earth as this like incredible, I’m communicating with the earth through food in a way that helps me express my best self. Like it’s really the most beautiful relationship I’ve ever had with food. And ultimately like makes me, even though it’s very rooted in science, like makes me want to just like get closer to plants and get closer to the earth.

Pavel Tseytlovskiy [01:11:26]                 I love plants. Plants are cool.

Casey Means [01:11:27]I got my broccoli sprouts back here. So, but easily Dr. Casey’s Kitchen was like this is, I don’t see a lot of people talking about food that way. I also don’t see a lot of plant-based recipes that I think are actually that healthy. Like, and I’m like, I’m eating like Alfredo pasta made entirely of plants. I’m eating all this delicious stuff that’s like amazing and easy to make. I also cook like a surgeon. I have no time, you know, I don’t have a lot of time. So I am like rapid and efficient in the kitchen. I was like, “I don’t want to put this all together,” in a way that, you know, makes people think a little bit outside the box about plant foods.

Pavel Tseytlovskiy [01:12:02]                 Well, it looks, I mean, it’s interesting, like, yeah, I mean, I still eat meat and I love a nice steak, but vegetables are delicious and I’m sure a lot of people totally will tell you, “When I eat vegetables, I feel good. I feel light. When I eat a huge steak, I feel like meh.” And so it’s like, it makes sense, but I love how you’re bringing this like scientific approach. What I’m thinking about now is how long, I’m sure we’ll get there one day, like 50 years from now where, you know, we’ll be able to analyze our genetic variances and actually tell you exactly what you should and should not be eating and like, I mean, do you think that’s going to happen one day and is it going to happen in our lifetime?

Dr. Casey Means [01:12:46]There’s a company that’s already trying to do this actually called GenoPalate. And you can send in a little, I think, saliva sample and get some recommendations on like what foods are going to be most helpful for you. And then, you know, and then there’s other companies like Viome who are doing more like personalized diet based on microbiome. So I think things are moving in that direction.

Pavel Tseytlovskiy [01:13:13]                 Is it going to be exponential? You know, are we going to have Murphy’s law here?

Casey Means [01:13:17]You know, I honestly don’t think so with genetic testing for diet, because again, this is inherently, well, first of all, genetics is very dynamic. We have our genetic code, but like our current physiology and biology affects the genetic expression and kind of what we need very dynamically, but like a genetic test is a static one-time, one point in time thing. So it’s again, inherently an open loop form of feedback. It’s not like, I’m not confident that knowing your genetic results is going to have a huge impact on behavior change because behavior change is not rooted in knowledge. We know that people can know exactly what to do and still not do it. And so whether it’s going to actually be a huge motivator moving people in the right direction, I’m not sure. I think if we were able to measure genetic expression dynamically, I think that would actually, and I think we can definitely get there, that I think would be extremely powerful. And I actually believe there’s a company trying to do that with a few different genes.  And I’m totally spacing on the name, but basically like, what are your genetic readouts in- Oh, you know what it is? It’s a company that’s making a turmeric supplement that’s very high potency. And then I think you get a kit every three months to see how your NF kappa B expression has changed. So that’s, I think that’s getting in the right direction-

Pavel Tseytlovskiy [01:14:42]                 It’s cool.

Casey Means [01:14:42]Towards biofeedback, but again, it’s like very delayed reaction time. So whether it’s actually going to change people’s day-to-day behavior, not sure. Like I’m pretty biased towards, you know, closed loop feedback and hacking the reward circuitry of the brain because we’re dealing with addictive substances. So we have to combat that with like equally addictive feedback loops. And when you don’t, that will [crosstalk 01:15:08]

Pavel Tseytlovskiy [01:15:09]                 Oh, I love that equally addictive feedback loops. You should. That’s a good quote right there.

Casey Means [01:15:13]Haven’t said that one before.

Pavel Tseytlovskiy [01:15:16]                 And how do you come up with your delicious recipes? You just like, whatever, you’re just trying things out yourself, surgeon style?

Casey Means [01:15:22]Yeah, well, I cook based on principles. So like I basically, almost everything I make has the same set of components. Every single meal I make, I try to have boatload of fiber, like some amount of protein, omega-3 fats, some sort of really healthy whole food fat and then like a ton of phytonutrients. So that’s going to be like cups of vegetables or whatever. So most of my meals like require, basically the principles of whole food plant-based diet is you’re eating fruits, vegetables, nuts, seeds, legumes, and grains. Although I don’t really eat much grains because of, you know, the glucose stuff. But, so you’re basically just like, now you’re modularizing your diet. You have like all of these different things and you’re just kind of pairing them together in different ways. So, yeah. So essentially I’m just kind of like choosing like what vegetables, fruits, nuts, seeds and legumes do I want to mix together for a meal and then the options for that are just like infinite. So I can take nuts and I can make, I can blend nuts in the Vitamix with some lemon juice and tamari and garlic and make like a super thick, creamy, almost like sour cream sauce, like in two seconds. And like, put that on a little veggie scramble. I can take, you know, the same seeds and make a nut milk in two minutes. It’s just like, it’s really all about like changing the forms. In that way it’s kind of like a science experiment every day. So, yeah.

Pavel Tseytlovskiy [01:15:57]                 It’s pretty cool.

Casey Means [01:16:58]Infinite combinations. Yeah.

Pavel Tseytlovskiy [01:17:02]                 We have a segment on this show called Hot Tips. It’s basically, you can give any hot tip you want and you just gave a bunch of hot tips. Now you got to come up with another one. It can be about metabolic health. It could be about a book. It could be a song. It could be anything. It’s time for tips! Alright, it’s hot this time. Yeah, I know.

Casey Means [01:17:22]I love this. I love this. I feel like I’ve done a lot with food.

Pavel Tseytlovskiy [01:17:27]                 Yeah, you can do something completely different.

Casey Means [01:17:31]Yeah. Okay.

Pavel Tseytlovskiy [01:17:37]                 I know. It’s okay to take your time to think about it.

Casey Means [01:17:40]One thing I’ve been getting into, which I think has been really fun is reading the Stoics. You know, like Marcus Aurelius, Seneca, people like that. So I think the book, The Daily Stoic is a really fun book to get as a way to like, you know, I’ve been working like everyone on morning routines. And one of my favorite parts of my morning routine is reading the passage from The Daily Stoic. So yeah, I, that would be my like [crosstalk 01:18:08]

Pavel Tseytlovskiy [01:18:10]                 A collection of the Stoics.

Casey Means [01:18:11]It’s a collection of the Stoics and I forget the author altogether.

Pavel Tseytlovskiy [01:18:15]                 It’s okay.

Casey Means [01:18:16]But it’s a bunch of the different ones and it’s like a good sampler platter, but I’m just, it kind of makes me feel really connected to history because I’m like, the stuff they’re talking about is just so relevant to what we’re dealing with today.  And so it’s really good. And then I guess second hot tip, because we were just talking about this would be to listen to Sam Harris’s podcast.

Pavel Tseytlovskiy [01:18:38]                 Yes.

Casey Means [01:18:39]That gets me excited every time I listened to it.

Pavel Tseytlovskiy [01:18:42]                 He, you know, I applaud him for trying to tackle some of these really hard, challenging issues of our time in what I find to be a very like intellectual and emotionless almost, in a good way. That’s awesome.

Casey Means [01:19:00]Mhm. He’s rational. And we need that.

Pavel Tseytlovskiy [01:19:04]                 He’s rational. Yeah, yeah, yeah.

Casey Means [01:19:05]And we need more of that.

Pavel Tseytlovskiy [01:19:06]                 We need more of that. That’s for sure. Favorite waterfall in the Pacific Northwest?

Casey Means [01:19:13]Oh my gosh. Yes. Oh my gosh. Okay. So Falls Creek Falls, Panther Creek Falls, Tamanawas Falls. Those are the three I love, yeah.

Pavel Tseytlovskiy [01:19:27]                 And what do you do? You just go on a hike up, check it out. Do you go for a swim? Is it ever warm enough to swim?

Casey Means [01:19:34]Yeah, there’s a really great place to swim called Oneonta Falls. You actually wade, like it’s a very shallow river in the middle of a very narrow gorge, very narrow, like 30 feet wide. And you can wade a quarter mile in and then like sort of swim underneath the waterfall and it’s totally magical. So that’s Oneonta Falls.

Pavel Tseytlovskiy [01:19:53]                 That Portland? That sounds amazing.

Casey Means [01:19:55]It’s like 40 minutes from the city. It’s, yeah, Portland waterfalls game is very strong.

Pavel Tseytlovskiy [01:20:01]                 Alright. It sounds amazing.

Casey Means [01:20:02]Where are you located?

Pavel Tseytlovskiy [01:20:03]                 I’m in San Diego. So, I mean, it’s not so bad here either. And I, you know, I’ve been going to the ocean while the water’s gone just pristine right now. It’s been wonderful taking dips, but-

Casey Means [01:20:13]Have you noticed a change in the water?

Pavel Tseytlovskiy [01:20:16]                 Yeah.

Casey Means [01:20:16]Oh my gosh. Wow.

Pavel Tseytlovskiy [01:20:18]                 It’s much warmer now. Yeah.

Casey Means [01:20:19]Oh, I thought you meant, I was thinking you were talking more like pollution with COVID.

Pavel Tseytlovskiy [01:20:23]                 Oh, well, what I meant by clear is it wasn’t, it was just clear water. Like not, I mean, I don’t, I can’t say it’s because of COVID. I think it’s just, sometimes you have just more seaweeds, sometimes you have less seaweeds.

Casey Means [01:20:33]Yeah. Absolutely.

Pavel Tseytlovskiy [01:20:35]                 That’ll be interesting though, if there’s a correlation because I mean, I know that’s from the smart perspective, everything was like down. I wonder if we’re back to our crazy ways probably. Again, I know it’s sad.

Casey Means [01:20:47]That’s great for the ocean now. That’s wonderful.

Pavel Tseytlovskiy [01:20:51]                 Yeah, it’s, I’m very grateful. I love it here, but Portland is not bad either. Beautiful. Especially now, probably in July. Okay. Well, any questions for me? This was awesome. I think we learned a lot here.

Casey Means [01:21:04]Man, what a great convo! I feel like we could talk for so much longer-

Pavel Tseytlovskiy [01:21:08]                 We could.

Casey Means [01:21:08]And I’m so so happy to be connected now and-

Pavel Tseytlovskiy [01:21:11]                 Absolutely.

Casey Means [01:21:12]But this is just a really stimulating conversation. I really appreciate you having me.

Pavel Tseytlovskiy [01:21:16]                 I loved it. Thank you. Thank you for coming on.

Casey Means [01:21:18]Yeah.

Pavel Tseytlovskiy [01:21:19]                 I want to, listen, come on. You can get me on that list.

Casey Means [01:21:22]Yeah.

Pavel Tseytlovskiy [01:21:23]                 I want to try that patch.

Casey Means [01:21:22]Yeah, we will get you a sensor. And through those, if any, I bet there’s a lot of people who are like, “I want one, too.” So I’ll just plug. We are unlocklevels on Instagram and Twitter and www.levelshealth.com. And I have been writing voraciously on our blogs. So levelshealth.com/blog. It is not fluff. It is really like pretty intense research based articles. And so anybody who wants to learn more about like metabolic health stuff, that’s a great place to go.

Pavel Tseytlovskiy [01:21:52]                 That’s awesome.

Casey Means [01:21:53]So yeah.

Pavel Tseytlovskiy [01:21:53]                 How long until like, I can just, someone can just buy Levels and just get it going. What do you think? Or is that a secret?

Casey Means [01:22:00]Yeah, probably. We were planning for like a full launch later this year.

Pavel Tseytlovskiy [01:22:03]                 Awesome.

Casey Means [01:22:04] So, yeah. So it’s in the, but the best thing to do now is just to sign up for the wait list and you’ll start getting emails and education from us and, you know, start the process. And then when you get the sensor, you’ll be just ready to go. So, yeah.

Pavel Tseytlovskiy [01:22:17]                 I’m excited. Happy Friday, Shabbat Shalom.

Casey Means [01:22:20]Happy Friday!

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