Ep. 53 – Using Continuous Glucose Monitoring (CGM) To Optimize Your Diet and Lifestyle – Dr. Casey Means from Levels Health

Our health isn’t defined by our DNA. But historically, our power to understand and control it has been limited. We visit doctors who don’t ask about our lifestyle, choosing instead to treat symptoms over causes. We are bombarded by unhealthy processed foods, and pressured into sedentary lifestyles. All of these factors work together to create our overall picture of health. Dr. Casey Means hopes to change that by empowering individuals with daily lifestyle feedback using Levels, a continuous glucose monitoring software. Dr. Means joined Dave Korsunsky of Heads Up Health on their Data-Driven Health Radio to discuss the root of disease, why glucose is key to determining future health, and how to reverse damage through lifestyle choices.

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2:35 – DNA doesn’t define health outcomes

Dr. Means has concluded that inherited genes play a role in health, but ultimately lifestyle choices control how these genes are expressed.

“As I thought about biomedical sciences and healthcare, I was thinking about the body as this unique biochemical genetic blueprint. And that really the difference between health or disease was how this genetic blueprint was expressed. And the main drivers in how that genetic blueprint is expressed are dietary and lifestyle factors. How you live, what you expose yourself to, what goes in your mouth. This is the molecular information that goes into the body and literally physically binds with the genome and tells it what to do so well…Epigenetics is so fascinating. Because we’re learning that even things like our thoughts can translate into biochemical reality through our hormones and through our nervous system. And that this actually changes the three-dimensional structure of our genes. And that is heritable. You can pass along the folding structure of the genes, not only what’s in your genetic blueprint. So the fact that changing our thoughts, changing the way we perceive stress, the food and the molecular information we put in our mouth, the composition of our microbiome, how much sleep we get, exposure to different traumas, low grade or high grade. All of these things actually change the expression of our genome. So it’s exciting. We’re learning a lot. And what I think is great about it is that it’s actually radically empowering because when you know this information, you realize that there are actually levers to change the outcome.”

5:41 – Moving from conventional medicine to a coaching model could save lives

Medical training is currently about recognizing patterns of symptoms and matching these to known conditions and treatments. Dr. Means believes that the focus needs to turn to a personalized approach that considers lifestyle factors.

“Conventional medicine and the way medicine is practiced today is actually much more about pattern recognition. And it’s much more about labeling and reacting. And so you see a patient in the clinic and you’re sitting there with them and you ask them all the questions and then you do an exam and you do tests. And all of that comes together to become this collection of signs and symptoms being objective, signs being objective. And when you can mix and match a bunch of symptoms and signs and they meet some sort of criteria, you label a diagnosis on it. And then you turn around into your toolbox and you say, okay, I’m going to prescribe this drug for this condition, this disease, or potentially going to do some sort of invasive intervention. And that’s really it. That biochemical individuality is much less a part of things and certainly the dietary and lifestyle factors are very minimally used as tools. Unfortunately in medical school, people are getting on average about 4-8 hours of nutrition education in their entire medical school training. Even though we know now that the vast majority of healthcare costs and the conditions that are bankrupting the human capital and the economic capital of our nation and increasingly our globe, our diseases rooted in dietary and lifestyle choices, chronic disease. So I think there’s a lot of catch-up to do in healthcare in terms of helping empower physicians with the knowledge base and the coaching abilities to be able to really use those levers to help people.”

07:10 – It all comes back to inflammation

Inflammation is at the root of many diseases. This is the body’s response to perceived threats from unnatural foods, stress, poor sleep, and the environment we live in.

“All of the conditions I was treating as an ear nose and throat doctor were inflammatory in nature…Inflammation is a complex physiologic process of the body responding to a perceived threat and surgery is essentially plumbing. You’re busting a hole in something allowing drainage. But that’s actually doing nothing to fundamentally change the underlying physiology that’s leading to disease. So what I was seeing was a lot of patients coming back for visiting surgeries. A lot of people coming back with recurrent symptoms. And that really made me step back about four years into my career and say, why are all these patients inflamed? Why is everyone’s poor body saying white flag, inflammation? What is the threat? And what that really led me on was a journey towards trying to understand what are the big triggers of inflammation in our population. And it really, again, comes down to these unnatural dietarian lifestyle exposures that our bodies are experiencing that we haven’t really had to deal with throughout human evolution. So things like ultra processed foods, genetically modified foods, ultra processed sugar in quantities that our bodies never were meant to witness. We’re eating 150 pounds on average of refined sugar per year per person, when 100 years ago that was probably around two pounds. And environmental toxins, sedentary behavior, chronic low-grade stress from all our digital tools, all the beeping and the honking and the emails. This is all registering in our body as chronic stress.”

16:07 – Diet could be the answer to the US health epidemic

Millions of Americans are showing signs of metabolic dysfunction. Studies have shown that even short periods of dietary change can lead to disease reversal.

“The most imperative thing that needs to be appreciated in medicine right now is that blood sugar dysregulation, which we see overtly manifesting in our obesity epidemic and our diabetes epidemic. 74% of Americans overweight or obese, 128 million Americans pre-diabetic or diabetic. These are not small numbers and a recent study out of UNC showing that 88% of Americans are metabolically unhealthy. 88 and moving up, but not if we can help it… In April, I published a paper in the Journal of Metabolism talking about how it was abysmal, the fact that we weren’t having a massive public health campaign against metabolic dysfunction. Because it was already emerging in April in over a hundred papers published that obesity and diabetes and blood sugar were the key drivers of COVID mortality. And yet there was no concerted, centralized effort to reverse metabolic dysfunction at scale. Which I think would have been one of the highest value interventions we could have done early on. And if you look at the work coming out of Virta Health and Sarah Hallberg’s work. And this is a program, Virta, which is for diabetes reversal. And they’ve published peer-reviewed studies showing that in 10 weeks of just coaching and ketogenic diet, people can get from a diabetic hemoglobin A1C to a non-diabetic hemoglobin A1C. So 10 weeks of a program that only involves diet and coaching, it doesn’t even involve exercise or anything like that, was able to get people down to a statistically significant reduction in A1C to non-diabetic levels in a really large population of that study.”

24:35 – Closing the loop between the kitchen and the scales

It’s currently difficult to understand the link between food and its impact on the body. Levels is bringing a wearable tool to the market to show this link, just like Oura for sleep or Fitbit for workouts.

“Nutrition is this notoriously open-loop system where you eat multiple meals a day. You eat tons of different ingredients a day and you don’t have any direct one-to-one relationship between what’s happening. You might the next day weigh a little bit more. You might later in the afternoon feel a little bit fatigued or have a post-meal slump. You might six months from then have a fasting glucose that was five points higher than the year before. But it is very difficult to really take ownership over: this food caused a problem for me. And so I became really focused on just changing this behavior at scale. We had to close the loop between what people are eating and doing, and what is the immediate reaction. And that is where continuous glucose monitoring technology became a really obvious choice as a wearable tool to do this exact thing for people. And we have it for almost every other lifestyle choice. For sleep, we’ve got amazing tools out there. We’ve got WHOOP, we’ve got Oura, we’ve got Fitbit, we’ve got Eight Sleep, the mattress that measures all your biometrics. It’s amazing. And with stress management you’ve got all these HRV trackers. You’ve got Leaf Therapeutics. You’ve got HeartMath. You’ve got WHOOP. You’ve got exercise trackers galore out there. We have nothing to close the loop in the kitchen.”

27:32 – Minimize spikes to stay out of the danger zone

Glucose increases tell the body to release insulin to soak up the glucose into the cells. The more this happens, the less the cells respond and the more insulin needed. This path leads to diabetes and other disorders, but glucose monitoring can improve the process.

“Every time you spike that glucose you’re spiking your insulin in your body. When your glucose spikes, your pancreas releases insulin to help you take up that glucose. And as you constantly spike, that insulin has to interact with your cells. And over time, the cells are like: ‘Oh my God, there’s so much insulin in the bloodstream, we are going to become numb to this.’ And that process is called insulin resistance. And you can imagine as the cells stop responding to insulin well, then they’re not able to take the sugar up from the blood as efficiently. And so now you start having blood sugar rise over time in the blood. And that’s when fasting glucose starts rising. And over time, fasting glucose rises enough that you end up in the pre-diabetic range or the diabetic range. And so as you minimize these spikes throughout the day, you minimize your exposure to insulin throughout the day, and you can move in a good direction on the spectrum of metabolic health.”

29:31 – A tank full of sugar

The more sugar in the body, the less it uses fat for energy. Insulin tells the body it has energy from sugar and so keep the fat stored in cells. This is why weight loss plans often fail, because they don’t look at keeping insulin low.

“Insulin has a second function, which is to block cells from burning fat. Because it’s essentially a signal to the body that we have tons of energy from glucose, from sugar essentially, so we don’t need to use this other source of energy, fat. So we’re just going to stop the burning of fat cause we’ve got to use all this glucose that’s in the bloodstream. And so you can imagine in our culture where we’ve been told you need to eat six times a day to rev up the metabolism and our food pyramid, which for years said we need to have 6-11 servings of carbohydrates per day. Carbohydrates convert into sugar, glucose in the blood. So all of a sudden we had this population who is essentially being told that we should be spiking your insulin all the time throughout the day. So you can really see how that would lead into an obesity epidemic, because we are not able to burn fat at scale. And that’s a hormonal issue. That’s not a calorie issue. The concept of calorie in calorie out is just a very flawed model that we’re learning now.”

30:47 – Have your cake and eat it… without a crash

There are ways to moderate the impact of sugar on the body: eating carbohydrates after protein or fat, pairing carbohydrates with fat or protein, and certain ingredients like cinnamon or apple cider vinegar.

“If you look at the research of the different ways that you can modulate a glucose spike. So one thing you can try is food sequencing. You can actually eat your carbs last during a meal. If you precede your carbs with protein, fat or fiber, you’re going to have less of a glucose spike….Apple cider vinegar, cinnamon, those are both insulin sensitizers. Berberine is an insulin sensitizer. MCT oil would fall into the category of preloading with fat. So pre-loading carbs with fat blunts spikes. But also things like deep yogic breathing after a meal may actually improve glucose function, because you’re toning down your sympathetic nervous system, your heart rate. You’re getting your body into that sort of more rest and digest. You’re telling your body by deep breathing that you’re not in threat. And so your liver, which stores your glucose says, okay, we’re not in threat. We don’t need to dump out glucose to help this person fight a threat. So it keeps the glucose in the liver. Intermittent fasting is a great lever you can pull. More muscle mass, building a better metabolic rate. And then also even just walking after meals. So there have been actual research studies showing that if you just walk for 20 minutes after each of your meals, 20 minutes before each of your meals, or if you walk for two minutes every half hour for the entire waking day, you can greatly decrease your 24 hour glucose compared to someone who doesn’t do any of those things. So it’s really about not restricting foods, but building this awesome metabolic context for foods to lower your exposure to glucose.”

36:00 – Close the loop to truly understand what’s going on inside the body

With wearable technology, it is now possible to match subjective feelings with objective data that shows exactly what is going on in the body .

“It just takes away a lot of that pain point mystery of life of not being able to close that loop. And actually there’s this really cool concept in behavioral psychology called interoception, which is essentially another term for somatic awareness. So in understanding a sense of what’s going on inside your body, what the internal view of your body is interoception. And there are different clinically utilized interoception techniques to help people essentially gain a better sense of somatic awareness. And the big one that you focus on is heart rate. So people who can sit quietly and actually feel their heart rate very accurately tend to do better on all sorts of scales of health: mental health, anxiety, and connection. Exactly like hearing what your body is trying to say…The nice thing about having a bit of a biofeedback tool is you can start linking your post-meal slump or your late afternoon anxiety with these spikes. And then you then are able to pair that as well with your subjective experience of how you’re feeling. And I think over time you develop what I would call metabolic intuition. And I think at this point for someone who’s used glucose monitors for months, I feel like I can predict my glucose in my body to probably within 5 to 10 points at all times, because I know now what it feels like. So I’m excited about the ability of these tech-enabled solutions to actually get people to listen more to the internal cues of their body. It’s like going deep into tech to actually get back to very simple roots.”

41:45 – Everyone is an individual. Diet should be too

Research has shown that people can have opposite reactions to the same foods. This shows that there is no universe diet that will suit everyone and understanding each individual’s response to foods is vital.

“I think the point about the biochemical individuality with response to carbs is such a huge one. And I think even to most clinicians it’s probably still a black box and unknown…This paper out of the Weizmann Institute and Eran Segal, Personalized Nutrition by Prediction of Glycaemic Responses, this paper was in Cell in 2015. It really is the foundation of why we’re doing what we’re doing at Levels. Because like you said, two people can respond equal and opposite to the exact same food. So you and I could eat a banana and I could go up five points and you could go up a hundred points and then we could eat the same cookie and I could go up a hundred points and you go up five points. Obviously what we’ve talked about. And there are so many factors involved: microbiome, and it’s body composition, genetics, everything that goes into it. So the only way for you to dial yourself in is really to have this personalized feedback.”

48:28 – It takes repetition to build fitness

Just like working out the body, it is possible to exercise metabolism to make it stronger and more flexible. Repeating good habits like sleeping well, eating well, reducing stress will all contribute.

“So my hope is that everyone would be able to, at some point in their life, use this technology and be able to essentially create their personalized diet and their personalized glycaemic index. Their personal metabolic toolbox that they can then work on, what we would call by this term I love, which is building metabolic fitness. So just like we work out every day, just like Eight Sleep coined the term sleep fitness. These are things that you have to work on, and these are biologic pathways that you have to get stronger. You have to do reps of keeping the glucose spikes down to actually get the payoff. It’s not a one-time thing. And so having a tool to help you build the fitness in regards to athletics, to food, to sleep is very important. But it’s achievable and that’s what’s really exciting is that it is modifiable and we all have the power to move in the right direction on that spectrum.”

49:42 – Learn to flip the switch from one fuel source to the other

By constantly relying on glucose for energy, the body doesn’t know how to use fat for fuel. It is possible to train the body to be more insulin sensitive. This is particularly useful for athletes to train the body for better performance and endurance.

“I think our bodies by and large only knew how to process glucose because we were giving it mostly glucose and the insulin was always high and we weren’t burning fat. And so then you get to a point where you don’t have glucose. Let’s say you haven’t eaten for a few hours. And that’s when people get panicky and super hungry and irritable. Because that’s the time when the body should be able to flip on the switch to burn fat and get energy and other way, but can’t because you haven’t worked those pathways of fat burning. So you start building up those pathways by reducing your spikes, by maybe doing a little bit more time restricted feeding, and all of a sudden you start working that fat pathway a little bit, and now you are all of a sudden flexible… When you have glucose on board, you can process it cause you’re more insulin sensitive. And when you don’t have the insulin or glucose on board, you can tap into your fat and burn it. And this is becoming really important for a lot of athletes. Athletes don’t want to be constricted by having to eat food all the time during endurance training. And so what if an athlete could train in a low carb, low insulin state, get really good at processing fat for an endurance workout. And then on a game day, maybe have a bunch of carbs and get that really quick energy. But when those run out, they’re able to just flip the switch right into fat burning and not be relying on pounding gels or protein shakes the whole time and not having to get these constant insulin rises throughout their workout that are going to have them on an energetic rollercoaster.”

Dave Korsunsky [00:04]                         Hey, everyone. Welcome back to another season of Data-Driven Health Radio. I’m your host Dave Korsunsky. On this show, we speak to the experts and break down the technology and the data that’s allowing us to measure, optimize and understand our health in ways that have never been possible before. This show is for the health hackers, the data nerds, the athletes, the execs, the high performers, and anyone looking to take their health and their game to the next level. Be sure to check out our website and our health analytics app, at headsuphealth.com and feel free to shoot us an email [email protected] with any comments, questions, or feedback on this show or our app. We’d love to hear from you. Thanks for listening and let’s get into our next episode. Hey everyone. Welcome back to data-driven health radio. And today my special guest is Dr. Casey Means. She is the co-founder and chief medical at Levels Health, which is an exciting up and coming company in the digital health space. Casey, welcome to the show.

Casey Means [01:14]     I’m so happy to be here, David. Thank you so much for having me on.

Dave Korsunsky [01:17]                         Yeah, we had just some banter before we got going here and we’re definitely kindred spirits in our passion for bringing technology to market that helps people better understand their health. And what we’d love to do is first of all, I’ll just get a little bit about your background. I know you just made a transition from working in a medical clinical setting, now to being a startup founder. So that’s got to be an interesting transition. So we’d love to learn a little bit about your background, and then we want to talk about continuous glucose monitoring technology and why I believe. Probably you do as well. It’s probably the most powerful thing that we can bring to market given the number of metabolic health disorders that are completely 100% preventable and treatable. So I think there’s incredible promise. So we’re going to talk about continuous glucose monitoring technology, and then we want to have you walk us through demystifying these numbers and how can this be used in an individual setting. And if I’m a practitioner on the other side, my clients are using CGM. So we got a lot to talk about here, but before we get into Levels and continuous glucose monitoring and all the nerdy details, tell us about the co-founder, Casey.

Casey Means [02:34]     Absolutely! We’ve got so much good stuff to talk about. So I’ll give a brief intro about myself and my history and kind of what led me to co-founding Levels and really shifting my career to be laser focused on reversing the epidemic trend of metabolic dysfunction. It actually started way back I would say in college. I was at Stanford as an undergrad, right after sort of the human genome project wrapped up and 23andMe was coming online direct to consumer genetics. And it was like a really big wave of personalized genomics and direct to consumer testing. And so I was able to be in that sort of ecosystem as I was coming to healthcare. And fundamentally, as I thought about biomedical sciences and healthcare, I was thinking about the body as this unique biochemical genetic blueprint. And that really the difference between health or disease was how this genetic blueprint was expressed. And the main drivers in how that genetic blueprint is expressed is dietary and lifestyle factors. How you live, what you expose yourself to, what goes in your mouth. This is the molecular information that goes into the body and literally physically binds with the genome and tells it what to do. So.

Dave Korsunsky [03:41]                         Well, that is probably one of the most succinct, elegant explanations of epigenetics I’ve ever heard. That was awesome.

Casey Means [03:47]     Thank you. Thank you. And epigenetics, it’s so fascinating because we’re learning that even things like our thoughts can translate into biochemical reality through our hormones and through our nervous system. And that this actually changes the three-dimensional structure of our genes. And that is heritable. You can pass along the folding structure of the genes, not only what’s in your genetic blueprint. So the fact that changing our thoughts, changing the way we perceive stress, the food and the molecular information we put in our mouth, the composition of our microbiome, how much sleep we get, exposure to different traumas, low grade or high grade. All of these things actually change the expression of our genome. So it’s exciting. We’re learning a lot. And what I think is great about it is that it’s actually like radically empowering because when you know this information, you realize that there are actually levers to change the outcome, right? And health is not deterministic. Certainly there can be predispositions for moving on the spectrum of health towards disease, but even with diseases that have a one-to-one relationship between a genetic mutation and a clinical outcome, for something like the Huntington’s disease gene, like there’s still this concept of penetrance, which is how much at a population people with that gene not a hundred percent will necessarily develop a disease. And so there’s always that room for differential expression. And that’s where I think it’s just so interesting to think about how our exposures, particularly diet and lifestyle, are the key knobs we can turn there. So that was- Came to medicine with that very empowering perspective. The biggest tools in our toolbox being diet and lifestyle and using those in a really evidence-based way to change the expression of health or disease. So then flash forward, I go to medical school and I was also at Stanford medical school. And it’s actually a very different ethos, very different vibe because conventional medicine and the way medicine is practiced today is actually much more about pattern recognition. And it’s much more about labeling and reacting. And so you see a patient in the clinic and you’re sitting there with them and you ask them all the questions and then you do an exam and you do tests. And all of that comes together to become this collection of signs and symptoms being objective, signs being objective. And when you can mix and match a bunch of symptoms and signs and they meet some sort of criteria, you label a diagnosis on it, and then you turn around into your toolbox and you say, okay, I’m going to prescribe this drug for this condition, this disease, or potentially going to do some sort of invasive intervention. And that’s really it, that biochemical individuality is much less a part of things. And certainly the dietary and lifestyle factors are very minimally used as tools. And unfortunately in medical school, people are getting on average about four to eight hours of nutrition education in their entire medical school training, even though, we know now, that the vast majority of healthcare costs and the conditions that are bankrupting the human capital and the economic capital of our nation and increasingly our globe, are diseases rooted in dietary and lifestyle choices, chronic disease.

Dave Korsunsky [06:46]                         Hundred percent agree.

Casey Means [06:46]     Yeah. So I think there’s a lot of catch-up to do in healthcare in terms of helping empower physicians with the knowledge base and the sort of the coaching abilities to be able to really use those levers to help people, but went on to become a head and neck surgeon and your nose and throat surgery. And in my practice, I practiced for about five years. And during that time it was, it floored me after a while, as I realized that most, all of the conditions I was treating as an ear nose and throat doctor were inflammatory in nature. So sinusitis for instance, is inflammation of the sinuses. When that tissue in the nose gets inflamed, it blocks the whole of the sinuses and you get pus build-up and you get sinusitis. The same thing happens to the ear, if the drainage tube between the ear and the nose, the eustachian tube, when that’s inflamed, you get pus build-up in the middle of your ear and that’s an ear infection. And then you. If you use your vocal cords too much, you’re singing a bunch or whatever, you can get these inflammatory mass of the vocal cords called vocal cord granulomas. They’re inflammatory masses. And so I’m here and I’m treating all of these inflammatory conditions with surgery, which started to make not a lot of sense to me because inflammation is not a surgical disease. Inflammation is a complex physiologic process of the body responding to a perceived threat and surgery is essentially plumbing. You’re busting a hole in something allowing drainage, but that’s actually doing nothing to fundamentally change the underlying physiology that’s leading to disease. So what I was seeing was a lot of patients coming back for a, visiting surgeries, a lot of people coming back with recurrent symptoms and really made me step back about four years into my career and say, “Why are all these patients inflamed? Why is everyone’s body, poor body is saying, “White flag inflammation, what is the threat?” And what that really led me on was a journey towards trying to understand what are the big triggers of inflammation in our population. And it really, again, comes down to these unnatural dietarian lifestyle exposures that our bodies are experiencing that we haven’t really had to deal with throughout human evolution. So things like ultra processed foods, genetically modified foods, ultra processed sugar in quantities that our bodies never were meant to witness, we’re eating 150 pounds on average of refined sugar per year per person, when a hundred years ago that was probably around two pounds. And environmental toxins, sedentary behavior, chronic low-grade stress from all our digital tools, all the beeping and the honking and the emails, this is all registering as our body has chronic stress. And then of course, sort of sleep deprivation where we’re not getting as quality and-

Dave Korsunsky [09:17]                         That’s the cherry on top of it all, is we’ll just throw some sleep deprivation in there for good measure.

Casey Means [09:22]     Just throw some sleep in there. And then our microbiomes, which they’re trashed because we’re using tons of antibiotics. We’ve got pesticides in our foods and we’re eating very little fiber in our diet. So basically sleep, stress, diet, sedentary behavior, microbiome factors. These are all telling our body, “Threat mode.” Inflammation. And it became really imperative to me, I’m thinking, “If I’m going to really try and help people fundamentally reclaim their health, it’s not going to be by punching a hole in their sinus or their eardrum,” which can be a helpful adjunct. And it can be a temporizing measure, but it’s not fundamentally getting them healthy.

Dave Korsunsky [09:55]                         Absolutely.

Casey Means [09:55]     Yeah. So that really led me to shift gears. I transitioned my practice to functional medicine, to a really longevity and metabolic optimization practice and got really very much involved in the network and systems biology community, which is, traditionally, we think of diseases as isolated silos. So we think about, like depression, is this isolated silo and then prostatic hypertrophy and hypertension and obesity and cancer, like there are all these separate things and we’re going to turn around and treat them all separately. But with network and system biology, by using big data and proteomics and looking at the underlying molecular mechanisms that actually linked disease. So thinking of diseases as a web, what are the connections molecularly between diseases? Now you stop thinking about things as silos and you think about what’s the connection? And I think the future of medicine is treating the connections between the diseases, because it’s so much more efficient. That is going to be a path that it’s going to have pleiotropic multifarious effects, as opposed to just giving a Flomax for someone with prostate issues, which is going to help no other system in the body. So what if you can really get at that root? And the thing that connects most of the chronic diseases we’re seeing these days is metabolic dysfunction, is metabolic issues. And so that to me seems like the lowest hanging actionable condition that we should be really thinking about changing, to have the highest impact on our population as a whole and feeling better and be able to live their best lives. So that’s my journey.

Dave Korsunsky [11:27]                         That’s incredible. For those who have been listening to this show for a while, they’ve probably heard me say that, on more than one occasion, I believe that if you could start giving people real time feedback on their blood sugar, you would rapidly eradicate these metabolic disorders, because most people are not receiving the education in school, or anywhere for that matter, in terms of the connection between the food that they put into their mouth and how that affects their blood sugar. You don’t necessarily feel it until you go to the doctor and you have a diagnosis. So if you could just simply look at your phone or look at your watch and be getting this real-time feedback, everyone is now comfortable with the notion of sensor feedback on their body. Anybody who’s worn a Fitbit or done any type of health tracking knows you can get this feedback from your body. But for lots of different reasons, the access to continuous glucose monitoring has been prescription only in this country. And it’s relatively easy for someone to check their blood sugar with a glucometer in the morning, but that’s not going to give you the real-time feedback that you need. And if people could see, “Wow, I just went for lunch and had this particular thing, and my blood sugar is 240,” or whatever. It’s not that hard to then start making those course corrections, but that has not been accessible technology to everybody. And I think, and I said it before, that is the one thing that could come to market that could have the largest lever on the health of the population is course correcting the blood sugar disorders to start with. We’ve done a lot of work with people on ketogenic diets, and those are just everyday people who are starting to learn how to control their own blood sugar. And they’re learning how to control it to the point where the body shifts fuel sources. And so there’s all these people figuring it out for themselves, but we’ve still never really had a direct to consumer technology for real-time blood sugar monitoring. So that’s why I was so excited about what you guys are bringing to market. So maybe you could tell us how you got connected to Levels. Was it an idea you hatch, did you link up with a co-founder who already had this idea? What was that transition point from the medical functional backgrounds to the startup, and then maybe we can segue into the technology itself.

Casey Means [13:55]     Definitely, man, you brought up so many great points there in what you just said, and yeah, can’t wait to dig into more of that. And so in terms of my journey to Levels, so I was practicing functional medicine and I really just created the ideal practice that I wanted to start, I just, I throw away the entire rule book and said, I’m just going to start the practice that gets people healthy. And it’s going to look like whatever I want it to look like. So what that looked like for me was spending two hours with every patient for the first visit, having a giant whiteboard in my office, where we mapped out the links between all the different symptoms and the different diagnoses that has been given and really talked about root cause physiology that may be underlying a lot of their different sort of seemingly disparate symptoms. So it was a lot of fun. It was a lot of education. I spent a lot of time writing up really detailed sort of educational reports for people to explain the true physiology and not dumb it down. Like we were talking about mitochondrial dysfunction and oxidative stress and chronic inflammation and, nutrigenomics and how foods are going to change the expression of their inflammatory genes. And people really, when they understand it and they can wrap, really wrap their heads around that, I think it makes it a lot easier to change behavior.

Dave Korsunsky [15:09]                         If you know why, if you know the underlying goal of what you’re trying to do, and you can explain it to someone, they just internalize it so much better.

Casey Means [15:18]     Yeah. Exactly. There’s that great like Nietzsche quote that I think ultimately was then repurposed by Victor Frankl who wrote Man’s Search for Meaning-

Dave Korsunsky [15:27]                         I read it.

Casey Means [15:27]     Who wrote something like, “For a man who knows his WHY, he can bear almost any HOW.” And I really love that same because I think sometimes we’re just so busy in life doing, like going through the motions of the HOW of life, it’s hard to sometimes step back from all of the noise and really think about the WHY. And I think we have to do that in health. We really do. And someone who wrote a lot about this in his recent book, Dean Ornish, he wrote, “Undo It,” about reversing heart disease through the Ornish program, which is stress management, diet, exercise, and human connection is a four pillar process. And you need all four to reverse cardiovascular disease, but the human connection-

Dave Korsunsky [16:04]                         That last one there is probably the one a lot of people want to appreciate.

Casey Means [16:09]     Absolutely. And it was key. It was absolutely key. People connecting with others, tapping into love in their lives. Not just with other humans, but love in terms of things that they cared about and really tapping into their WHY. And so I found in my practice that that upfront investment of a lot of time with the patient, a lot of education led to radically quicker outcomes. And in two to three months, people, their symptoms, they came in 45 symptoms and have two after a few months because of that upfront investment. So that was really wonderful. But what I started to realize that I was seeing a lot of the same things over and over again, a lot of the conditions that we’re seeing these days, as we’ve talked about, are linked by common, underlying pathways, metabolic dysfunction, being one of them. And what I don’t think is widely appreciated now, but I think is the most imperative thing that needs to be appreciated in medicine right now is that blood sugar dysregulation, which we see overtly manifesting in our obesity epidemic and our diabetes epidemic, 74% of Americans overweight or obese, 128 million Americans pre-diabetic or diabetic. These are not small numbers. And a recent study out of UNC showing that 88% of Americans are metabolically unhealthy. So this.

Dave Korsunsky [17:22]                         That’s it? 88?

Casey Means [17:23]     88. I know. 88. And moving up, but not if we can help it.

Dave Korsunsky [17:27]                         That also speaks to why we’re suffering, potentially suffering so bad from coronavirus because there’s so much metabolic dysfunction. That’s a whole separate topic, but anyhow, 88% is a staggering number.

Casey Means [17:38]     It’s huge. And the COVID thing is such an important thing. I actually, in April, I published a paper in the Journal Metabolism talking about how it was abysmal, the fact that we weren’t having a massive public health campaign against metabolic dysfunction, because it was already emerging in April in over a hundred papers published that obesity and diabetes and blood sugar were the key drivers of COVID mortality. And yet there was no concerted centralized effort to reverse metabolic dysfunction at scale, which I think would have been one of the highest value interventions we could have done early on. And if you look at the work coming out of Virta Health and Sarah Hallberg’s work, and this is a program Virta, which is for diabetes reversal. And they’ve published peer reviewed studies, showing that in 10 weeks of just a coaching and ketogenic diet, people can get from a diabetic hemoglobin A1C to a non-diabetic hemoglobin A1C. So 10 weeks of a program that only involves diet and coaching, it doesn’t even involve exercise or anything like that was able to get people down to a statistically significant reduction in A1C to non-diabetic levels in a really large population of that study. And I was just trying to make the point in this paper that people are at home with their devices. If we could just roll out something really big to help people reverse metabolic dysfunction during this time, when they’re already locked in their homes and have extra time to cook, this would be so high ROI for COVID, but we’re starting to see a little bit more of that coming out now a few months later. Bill Frist, former Senate majority leader, just put out an awesome article last week in CNN that was, I think the title was like, “The US Food System is Killing Americans,” which was basically about how until our policy changes around food and healthcare, the way we’re funding, a lot of the more high level policy things, until those change, we’re not going to see the type of reversal of these metabolic diseases that we need to be able to be resilient in the face of this pandemic, but any future pandemic. COVID’s not the first virus that has discriminated against people with metabolic dysfunction. Even the common flu has a much higher mortality rate in people with underlying diabetes and obesity. So this is something we have to solve, but I also don’t think people realize that aside from impairing immunity through a lot of well understood molecular mechanisms, high blood sugar is a direct driver of obviously diabetes and obesity, but also Alzheimer’s dementia, which is now being called type three diabetes.

Dave Korsunsky [20:00]                         I’ve heard that before. Yep. And presumably why that responds well to a ketogenic diet because the brain now can start to use an alternate fuel source. But yeah, these neurodegenerative disorders as well.

Casey Means [20:12]     And the brain is such a glucose user that when insulin resistance starts emerging, the brain is just more cells. So all those cells can become insulin resistant too. So as the brain becomes insulin resistant, it really has a huge impact on the brain’s ability to use energy effectively. So you can imagine how that would feed into neurogeneration and high blood sugar. There’s at least six proposed mechanisms why hyperglycemia affects neurogeneration. One of which is insulin resistance in the brain, but it also seems to have a direct impact on neuroplasticity. And it’s a driver of inflammation in the brain that can cause problems. Cardiovascular disease and heart attack, significantly higher rates with underlying metabolic disease. Non-alcoholic fatty liver disease, which we’re seeing now in children. We’re seeing chronic kidney disease, preventable blindness, infertility. The leading cause of infertility in the US is polycystic ovarian syndrome. Peripheral vascular disease, which leads to amputations. That’s also a result of chronic end-stage diabetes. There’s just, even things like gout and acne and like even lower level things. And then the mental health stuff is huge. Depression and anxiety are twice as high in people with metabolic dysfunction.

Dave Korsunsky [21:21]                         Absolutely. Yep, even circadian disruption, sleep cycle disruption. There’s. It’s driven by the food system, it’s driven by companies that unfortunately, they are for-profit corporations and they are not incentivized financially on rates of metabolic disease. That’s a whole separate policy level thing. So you’re seeing this in your practice day to day. So then what was the switching point? Where you’re like, “We’re going to do this. We’re going to bring a medical device to market to tackle this.” When did that moment happen?

Casey Means [21:57]     It happened when I realized I was spending the majority of my week talking to people about this and I also-

Dave Korsunsky [22:01]                         About blood sugar disorders?

Casey Means [22:03]     About blood sugar and about diet and lifestyle. And then I realized that ultimately what I wanted as a doctor to do was, because, so blood sugar is a result, as we’ve talked about of not only food, but also sleep stress and movement. Those are the four key things, sleep, stress, movement, and food. And really for me to be effective in getting them to move the needle in their behavior, it wasn’t just about me telling them what to do and educating them. But I actually wanted to be on their shoulder 24 hours a day. Every time they decided what to eat for breakfast, how to respond to a stressful email, when to decide to get ready for bed, whether to jump on the Peloton or not. Like I wanted to be there for those thousands of micro decisions to help move in the right direction, but you can’t. Like a physician, I mean a human is fundamentally unscalable. And so when I realized that for this to be effective for more people, it had to be scalable, I really started shifting my focus to, these concepts are understood, I get them. And when people do them, they get way better. So then how do we actually scale metabolic improvements? And that’s what really led me to think about more complex behavior change models. And it came down to, “How do you get people to change their behavior?” People have to close the loop between their actions and then what’s actually happening. And nutrition is this notoriously open loop system where you eat multiple meals a day, you eat tons of different ingredients a day, and you don’t have any really, like direct one to one relationship between what’s happening. You might the next day weigh a little bit more. You might later in the afternoon, feel a little bit fatigued or have a post-meal slump. You might six months from then have a fasting glucose that was five points higher than the year before, but it is very difficult to really take ownership over, “This food caused a problem for me.” And so became really focused on, to change this behavior at scale, we had to close the loop between what people are eating and doing, and what is the immediate reaction. And that is where continuous glucose monitoring technology just became a really obvious choice as a wearable tool to do this exact thing for people. And we have it for almost every other lifestyle choice. For sleep, we’ve got amazing tools out there. We’ve got Whoop, we’ve got Oura, we’ve got Fitbit. We’ve got Eight Sleep, the mattress that measures all your biometrics. It’s amazing. And with stress management, you’ve got all these HRV trackers. You’ve got Lief Therapeutics. You’ve got Heartmath, you’ve got Whoop, you’ve got exercise trackers galore out there. We have nothing to close the loop-

Dave Korsunsky [24:36]                         Go figure. The largest driver of these health conditions, the closest we’ve been able to get, is for the average Joe is to go buy a glucometer. And I’ve tested my blood sugar in the morning for years. And I’ve gotten to the point where I can test my fasting blood sugar in the morning, and it gives me a pretty good report card of the day before. And that was moderately helpful, but I’ve always wanted the ability to see 24 /7 feedback. And I’ve long surmised this will be incredibly powerful for behavior change. So there’s probably people listening who don’t know what continuous glucose monitoring is. They may have heard the acronym CGM before, but why don’t we start there? And then we can go into more information on the technology and how to use it?

Casey Means [25:24]     Absolutely. Yeah. So a continuous glucose monitor is just this tiny wearable sensor that you essentially stick on the back of your arm and it measures your glucose 24 hours a day and sends that information to your smartphone. So diving a little bit more into that, you can imagine like a quarter sized device on the back of your arm that has this tiny little hair-like four millimeter filament that goes under the skin, just straight in. And that has an enzyme glucose oxidase on it that basically measures the glucose in between cells called your interstitial fluid. And it’s taking an automatic reading every 15 minutes, no matter what you don’t have to trigger that. It’s just doing it. And then it transmits all that data to your phone. This is it right now is an FDA approved device for type one and type two diabetes management, and has been a total game changer for these populations who formerly were having to prick their finger with a needle multiple times a day, to get four data points, maybe. So you can graph those, but it’s not giving you full granularity into the up and down swings throughout the day. And what’s critical that we know now is that those up and down swings throughout the day, which we call glycemic variability, those, aside from your morning glucose or your average glucose, those swings are actually independent predictors of problems related to metabolic dysfunction. So people with higher glycemic variability are more likely to have anxiety or fatigue during the day. They’re more likely to generate insulin resistance down the road and develop worse metabolic disease because every time you spike that glucose, you’re spiking your insulin in your body. When your glucose spikes, your pancreas release insulin to help you take up that glucose. And as you constantly spike that insulin, that has to interact with your cells, and over time, the cells are like, “Oh my God, there’s so much insulin in the bloodstream. Like we are going become numb to this.” And that process is called insulin resistance. And you can imagine as the cells stop responding to insulin well, then they’re not able to take the sugar up from the blood as efficiently. And so now you start having blood sugar rise over time in the blood, and that’s when fasting glucose starts rising. And over time, fasting glucose rises enough that you end up in the pre-diabetic range or the diabetic range. And so as you minimize these spikes throughout the day, you minimize your exposure to insulin throughout the day, and you can move in the good direction on the spectrum of metabolic health. And so with finger pricks, you are losing a lot of that granularity –

Dave Korsunsky [27:55]                         Well, it’s almost impossible to see the spikes. You might get a one and a two hour postprandial, if you’re lucky, out of a client or a patient on a given day, but seeing it right from morning til night as different lifestyle choices. Now you, as the clinician can see those spikes and you can look at someone’s glucose variability, and you can start to help them bring that down under control on a 24 hour basis. And that’s, I think where this can have incredible impact is. Possibly for the first time ever, a clinician has full insight into those spikes. Or an individual themselves has insights into those and they can start to make these corrective actions and keep the variability down. And then it leads to all types of improvements, whether it’s just disease reversal, weight loss, health optimization. So providing that continuous feed is incredible. And I think that’s the promise here.

Casey Means [28:54]     Absolutely. Like I think you just touched on the weight loss thing and I think that’s huge because the insulin piece really plays into that. Essentially insulin, is hormone that causes glucose to be taken up into the cells, has a second function, which is to block cells from burning fat, because it’s essentially a signal to the body that we have tons of energy from glucose, from sugar, essentially. So we don’t need to use this other source of energy, fat. So we’re just going to stop the burning of that because we’ve got to use all this glucose that’s in the bloodstream. And so you can imagine in our culture where we’ve been told, “You need to eat six times a day to rev up the metabolism and our food pyramid,” which for years said, we need to have six to 11 servings of carbohydrates per day, carbohydrates will convert into sugar glucose in the blood. So all of a sudden we had this population who is essentially being told that we should be spiking your insulin all the time throughout the day. So you can really see how that would lead into an obesity epidemic, because we are not able to burn fat at scale. And that’s a hormonal issue. That’s not a calorie issue. The concept of calorie in calorie out is just a very flawed model that we’re learning now. And most weight loss studies that are published, even if they do have some beneficial outcome in the short term study, almost all weight loss studies at two years end up being failures if you like go back and look at those populations, because we’re not approaching this with sort of a rational physiologic approach of looking at insulin and that the fact that you cannot burn fat without having a low insulin state. So there’s this really cool opportunity for weight loss, with continuous glucose monitors to essentially teach people very rapidly what foods are causing glucose spikes. And either they can eliminate those that they want to, but they don’t even necessarily have to eliminate the food. They can modulate the way they’re eating this food.

Dave Korsunsky [30:39]                         Yeah, just change the portion size. You can still enjoy it, perhaps. Maybe try cutting the portion size in half and notice the change and modify from there.

Casey Means [30:48]     Portion size for sure. But then there’s so many other factors as well that we talked about in the metabolic toolbox. If you look at the research of the different ways that you can modulate a glucose spike. So one thing you can try as food sequencing, you can actually eat your carbs last during a meal. If you precede your carbs with protein, fat or fiber, you’re going to have less of a glucose spike.

Dave Korsunsky [31:08]                         That’s a clinical pearl right there that Casey just dropped, for those who are listening. That’s an awesome one.

Casey Means [31:13]     Apple cider vinegar, cinnamon. Those are both insulin sensitizers. Berberine as an insulin sensitizers.

Dave Korsunsky [31:18]                         MCT oil?

Casey Means [31:19]     Well, MCT oil would fall into the category of preloading with fat. So pre-loading carbs with fat blunts spikes. But also things like deep yogic breathing after a meal may actually improve glucose function because you’re toning down your-

Dave Korsunsky [31:35]                         Heart rate.

Casey Means [31:37]     Sympathetic nervous system, your heart rate. You’re getting your body into that sort of more rest and you’re telling your body by deep breathing that you’re not in threat. And so your liver, which stores your glucose says, “Okay, we’re not in threat. We don’t need to dump out glucose to help this person fight a threat.” So it keeps the glucose in the liver. And so that, intermittent fasting is a great lever you can pull. There’s just so-

Dave Korsunsky [31:58]                         More muscle mass on your body.

Casey Means [31:59]     More muscle mass, higher metabolic, building a sort of better metabolic. And then also, even just walking after meals. So there have been actual research studies showing that if you just walk for 20 minutes after each of your meals, 20 minutes before each of your meals, or if you walk for two minutes every half hour for the entire waking day, you can greatly decrease your 24 hour glucose, compared to someone who doesn’t do any of those things. So it’s really about not restricting foods, but building this awesome metabolic context of the foods to lower your exposure.

Dave Korsunsky [32:34]                         And now people can see it. People can see the numbers, the glucose numbers themselves, and work on a protocol for their own day that works and say, “Okay, I just ate a meal that’s higher in carbohydrate. I’ve seen my glucose go up. I’m going for a 20 minute walk.” Or they’re doing these other interventions. So what the Levels device i s doing is giving you the individual, this real-time feedback and helping you basically learn how to self-regulate your own blood sugar. So you get the device. Now I ordered one from you guys and the process was very smooth. I’ll try to articulate it here, but maybe you can correct me if I make any mistakes, but the problem with these incredible devices, CGMs, they’ve historically been reserved for diabetics. Type one and type two diabetics. And you can’t get one necessarily without a prescription, at least not here in the United States. And so for the people that are wanting to work on health, longevity, weight loss, all of these other use cases you have now had access to this amazing thing. So if I’m a customer, I can go to Levels Health, and you can facilitate the process of getting a continuous glucose monitor. For me, my understanding is there’s a consult with the doctor in your state, the telemedicine consult, and then you can get access to one of these devices and install it and start using it and start doing that. The real-time monitoring. So that’s my rudimentary understanding of the process, but if I’m listening to this and I want to go for it, what do I do?

Casey Means [34:05]     You got it exactly. So it’s a three-part process when you work with Levels. And so you come to our company and you join-

Dave Korsunsky [34:13]                         levelshealth.com.

Casey Means [34:14] levelshealth.com And right now we’re in a beta phase. So we’re very early and we have a waitlist that you can join and we’re slowly getting people in and planning for a full launch later this year. But what you’re going to get when you join is essentially access to this 28 day metabolic awareness program. And what that involves is first a physician consultation through telemedicine to be evaluated for whether it’s safe for you to have a continuous glucose monitor. So you’ll essentially fill out a form online and a physician in your state, who’s in our partner, physician network, will review that, look at all your information. And if it’s safe for you to have one, then that will then be fulfilled by our partner pharmacy and shipped directly to your house. And what you’ll get in the mail is a various snazzy Levels box with two prescription only Abbott Freestyle Libre 14 day sensors. So those two sensors add up to a 28 day program. You wear each sensor continuously for 14 days, stuck to your arm.

Dave Korsunsky [35:13]                         It’s on the back of the arm, on the tricep, for those who are not familiar with it. Yes, Casey’s showing when you don’t even really notice it. It’s the size of a, I don’t know, like a quarter or something like that. And it sticks on the back of your arm. Non-invasive, super easy to install. It’s very non-disruptive to put it on.

Casey Means [35:31]     Non-disruptive and in fact it becomes, for us, I’ve been wearing one for about a year now and totally feel empty without it. I love having it there. It feels like a superpower to me at this point, because there’s no mystery, right? Like if I am feeling anxious or I’m feeling particularly tired, it’s no longer, “Huh, I wonder what’s up?”

Dave Korsunsky [35:50]                         That’s so cool. Yeah. You just check. You’re like, Oh, I’m a little low. I’m a little hypoglycemic right now. Or I’m too high. You have that feedback loop.

Casey Means [35:58]     Exactly. And so it just takes away a lot of that pain point mystery of life of not being able to like to close that loop and actually, so not to get too off track, but there’s this really cool concept in behavioral psychology called interoception, which is essentially kind of another term for somatic awareness. So in understanding a sense of what’s going on inside your body-

Dave Korsunsky [36:23]                         Interoception?

Casey Means [36:23]     What the internal view of your body is. Interoception. And there are different clinically utilized interoception techniques to help people essentially gain a better sense of somatic awareness. And the big one that you focus on is like heart rate. So people who can sit quietly and actually feel their heart rate very accurately tend to do better on all sorts of scales of health, mental health, anxiety, and-

Dave Korsunsky [36:47]                         Just that connection, that physiological mind-body connection.

Casey Means [36:51]     Exactly. Like hearing what your body is trying to say.

Dave Korsunsky [36:54]                         Cool.

Casey Means [36:55]     And they’ve actually done really interesting study in asthmatic patients as well, and also patients with GI disorders, because those are also things you can sense and people who have a really good sense of what’s happening in their GI tract, or even as Maddox who can accurately predict that the true airway resistance in their airways, they can measure this in studies and then ask people like, “How tight do you think your airways are right now?” And people who can predict that well, actually do better with their asthma outcomes. So it makes a lot of sense. Functional medicine doctors like to say that symptoms are a signal from the body of what’s going on inside and you have to listen to them. They are telling you the answers. And with our busy lives and our busy digital world, and we’re moving all the time, it’s hard sometimes to hear, and also with our processed foods, which don’t give us really good signals of whether to be full or hungry. It’s kinda

Dave Korsunsky [37:40]                         They’re also engineered to be as hyper palatable as possible. So you have food companies who are designing foods that are as compelling for us to eat as humanly possible. Food companies have quarter million dollar FMRI machines in their labs to design foods that trigger the reward behaviors in the brain to the greatest extent possible. They don’t even realize how our brain is basically pre-programmed for foods that are hyper palatable for us. Rob Wolf wrote about this in his book, Wired to Eat, and that’s what the average Joe is up against. They’re up against companies, for profit company that understands your brain sensors and how they respond to different things, and stuff is engineered for us to be as hyper palatable as possible. So what you’re saying with interoception now, if I’m trying to see where you’re going, is now your body has a way to give you the feedback.

Casey Means [38:36]     Yes.

Dave Korsunsky [38:37]                         So your body will tell you what it needs in terms of how to manage, or at least give you the numbers that you can use now to make the decisions.

Casey Means [38:46]     Definitely. And I think with the sugar or the food hijacking hyper palo example, like two fun things, one in some studies, if you give mice the option of having intravenous cocaine versus oral sucrose, they will choose the sucrose almost invariably over the cocaine.

Dave Korsunsky [39:03]                         Hmm, that’s terrifying.

Casey Means [399:03]  That’s my one fun thing to know.

Dave Korsunsky [39:04]                         Little fun fact for you there, friends.

Casey Means [39:06]     Fun fact, so in terms of rewards circuitry, it’s absolutely. And this even happens in mice who are already addicted to cocaine.

Dave Korsunsky [39:14]                         Oh my gosh. They’ll take the donut over the-

Casey Means [39:17]     They’ll take the donut. Yeah. So our cards are stacked against us. And then of course, the digital world, it’s a very similar culture of trying to make experience-

Dave Korsunsky [39:25]                         Hyper stimulus.

Casey Means [39:26]     Hyper stimulus. And the nice thing about having a bit of a biofeedback tool is to be able to say, you can start linking your post-meal slump or your late afternoon anxiety with these spikes, and then you then are able to pair that as well with your subjective experience of how you’re feeling. I think over time you develop what I would call metabolic intuition. And I think at this point for someone who’s used continuous glucose monitors for months, I feel like I can predict my glucose in my body to probably within five to 10 points at all times because-

Dave Korsunsky [39:58]                         You changed your cells.

Casey Means [40:00]     I know now what it feels like. Yeah. So I’m excited about the ability of these tech-enabled solutions to actually get people to listen more to the internal cues of their body. It’s like going deep into tech to actually get back to very simple roots.

Dave Korsunsky [40:14]. Well, I’ll bring up one more point on that Casey, which was the study out of Israel, where they rigged up 800 people with CGMs and delivered every single meal to them throughout the course of this study. And they actually found that even two people who were on the exact same meal plan had very opposite glycemic responses to the exact same foods. So even if people are saying I just count my carbs, and so I know pretty much how my blood sugar should be, that doesn’t bear out to be true either. And actually they found the number one influencer of your glycemic response was your microbiome.

Casey Means [40:50]     Yes.

Dave Korsunsky [40:51]                         And they analyzed everything- steps, sleep, quality, physical activity, genetics, and they’re like, “It’s the composition of the microbiome.” So even if you think you know how your body’s responding, you probably don’t.

Casey Means [41:04]     I know.

Dave Korsunsky [41:05]                         It’s just another reason why this is so incredibly empowering for everybody. If everyone can figure this out and just get the feedback to make the course corrections, whether you’re trying to get rid of the love handles or you’re working on some other metabolic disorder. I think, for me personally, Casey, my, just genetically speaking, I have to keep a really tight control on my blood sugar just to keep my weight off, no matter how much I exercise. And so it’s something for me, that’s a lifelong weight management tool. That’s what the CGM is for me personally, or before that, just taking blood sugar measurements. For me, it was just a 24 /7 tool to help me with weight loss. So there’s so many reasons why this is empowering.

Casey Means [41:47]     Yeah, I think the point about the biochemical individuality with response to carbs is such a huge one. And I think even to most clinicians, probably still a black box and unknown, and I, the paper that you’re talking about, out of the Weizmann Institute, Eran Segal, for anyone listening, Personalized Nutrition by Prediction of Glycemic Responses, this paper was in cell in 2015, it really is the foundation of why we’re doing what we’re doing at Levels.

Dave Korsunsky [42:13]                         Awesome.

Casey Means [42:13]     Because like you said, two people can respond equal and opposite to the exact same food. So you and I could eat a banana and I could go up five points and you could go up a hundred points. And then we could eat the same cookie and I could go up a hundred points and you go at five points.

Dave Korsunsky [42:26]                         Or down. Sometimes.

Casey Means [42:27]     Obviously what we’ve talked. Right. Yeah. And there are so many factors involved. Microbiome and late night snacks activity-

Dave Korsunsky [42:32]                         Age, body composition, genetics. Everything goes into it. it’s body composition, genetics, everything that goes into it. So the only way for you to dial yourself in is really to have this personalized feedback.

Casey Means [42:41]Yes. And I think, the keto movement right now and the low card movement, like I think, you’re seeing great results in terms of people getting lower flatter glucose curves. And I think there’s certainly something to that. Obviously if you only take five to 10% of your calories per day from carbohydrates, you don’t even have the substrate in your body. So you’re going to be starting to build those other pathways for using energy. And so you start tapping into your fat, which is more your long-term storage and start making ketones for energy, which the body can also use for cellular energy. And so that makes sense. If you’re not putting the substrate in the body, you’re going to use a different one. You have to, and the body luckily has these like very interesting redundant pathways, producing ketones versus processing glucose to create cellular energy. So the thing though is that not everyone wants to do a ketogenic diet might not be good for everybody. And the reality is that with some close, nuanced understanding of how specific carbohydrates affect you, I feel that you actually can have quite a high carbohydrate diet. And not necessarily have high glucose exposure in your blood.

Dave Korsunsky [43:50]                         That’s the next level I think. And that’s what this can help facilitate. I think low-carb keto for many of us, just a godsend because we finally had the information and knowledge to do something. But like you said, it’s also possible to have an extremely healthy diet with the strategic use of carbohydrates. And for a lot of people that may be even healthier, especially from a hormonal level and especially for people doing heavy training. So this can help you, even if you can get to a more balanced way of eating.

Casey Means [44:21]     Definitely. Yeah. And I think I’m the perfect example of this because I’m vegan and I’m very high carb, but because of using CGM, my fasting glucose is in the low seventies. My average 24 hour glucose is like 75.

Dave Korsunsky [44:36]                         Damn, that’s impressive.

Casey Means [44:39]     And my triglycerides are 47. And, but I eat probably a hundred to a hundred grams of carbohydrates a day. But over the past year, I’ve essentially eliminated anything that’s going to be a massive spiker for me. And then. Now the idea of, for example, the idea of eating fruit now without being covered in fat and fiber. So it’s usually nut butter plus chia seeds all over it. I just don’t even ever think about eating fruit without that combo.

Dave Korsunsky [45:07]                         That’s a really important example. Can we pause on that one for a second?

Casey Means [45:10]     Sure.

Dave Korsunsky [45:11]                         So like a piece of fruit that would normally be a very high glycemic piece of fruit, banana for example. So through your own self experimentation with the CGM and I’m paraphrasing here, but you found that if you are able to modify it slightly with some high quality fat and some of the seeds, for example, you can turn that into a meta- What was once a metabolically-

Casey Means [45:39]     Unfriendly.

Dave Korsunsky [45:41]                         Unfriendly. I guess just use that, unfriendly food, you’ve taken something that you enjoy and made it metabolically friendly and have gotten the biofeedback to cheat you that works. Is that correct?

Casey Means [45:52]     That’s exactly right.

Dave Korsunsky [45:53]                         It’s totally awesome. I love that.

Casey Means [45:55]     Yeah. And I post about this pretty much constantly on social media, like showing examples of just gigantic salads and brown rice sushi, and exactly how for my body, I have to modulate it to essentially get a flat glucose line. So.

Dave Korsunsky [46:10]                         That’s incredible.

Casey Means [46:11]     Yeah, but it takes time. But this is the whole journey of metabolic awareness. And I actually think, and this is just, again, my personal, totally anecdotal story is that as I, over time, started eliminating those spikes, I think I became a lot more insulin sensitive and-

Dave Korsunsky [46:27]                         And I think it takes a couple of years. That’s kind of like what the Virta data is showing out. It’s like for full reversal of metabolic insulin resistance, full restoration of insulin sensitivity, it doesn’t happen overnight.

Casey Means [46:39]     It doesn’t happen overnight, but I think you can make huge gains in months.

Dave Korsunsky [46:43:]                       I see. Okay.

Casey Means [46:44]     I think that you can, and that’s where like really our software where, what we’re trying to do and what we’re, what we’ve built is to help people take this raw data stream that comes from this device and turn it into actionable insights. So telling people like, “This is not a good option for you. This is a good option. This is a good pairing for you so that it can become a quicker process.” But-

Dave Korsunsky [47:04]                         Some intelligence built in to the system?

Casey Means [47:06]     Mhm.

Dave Korsunsky [47:06]                         Cool.

Casey Means [47:07]     So my hope is that yeah, is that everyone would be able to, at some point in their life, use this technology and be able to essentially create their personalized diet and their personalized glycemic index, their personal metabolic toolbox that they can then work on what we would call. And I, this term I love, which is building metabolic fitness. So just like we work out every day, just like we eat, sleep, coined the term sleep fitness, these are things that you have to work on, and these are biologic pathways that you have to get stronger. You have to do reps of keeping the glucose spikes down to actually get the pay off. It’s not a one-time thing. And so having a tool to help you build the fitness in regards to athletics, to food, to sleep is very important. But it’s achievable and that’s what’s really exciting, is that it is. modifiable and we all have the power to move in the right direction on that spectrum and build on-

Dave Korsunsky [48:00]                         Yeah, my story’s exactly the same, Dr. Casey, when I came off the standard American diet. And this is over the last few years, I noticed that the first six, 12 months I could get the refined carbohydrates and sugars out of my diet. But as soon as I introduced them, even just a little bit, it would set me back and it was like going to the gym. I just didn’t have the muscle memory and it would take me like another two weeks just to okay, really get back on track, get them back out and get back onto a really clean eating template. And I was on this, like a rollercoaster up, down, up, down and it took time, like you just said it, it took time and practice. But now, I’m at the point where I have complete 100% ability to flex into eating something that is very high in carbohydrate and wake up the next morning without even skipping a beat and get back onto the really clean template that I like to stay on. But, it took a lot of work and it took reps and it took a lot of commitment and a lot of sticking my finger with test strips to get it. And even that, I was only really doing it once in the morning, before I went out the door to work and then I didn’t have that feedback until the next morning. So it does take time. It does take reps. Having this feedback is incredible. Presumably having a coach on the other end, who can help and provide information. So we’re not figuring out for ourselves. Can be super helpful. So yeah, I’m just agreeing with you basically that there’s a component of reps and exercise to this before it gets really natural and intuitive.

Casey Means [49:42]     Totally. Yeah. And I think you alluded to the word flexibility, which I think is also an important concept that I don’t think has really made the zeitgeist of healthcare yet, which is the concept of metabolic flexibility, which is this idea that. So traditionally standard American diet, we basically, I think our bodies by and large only knew how to process glucose because we were giving it mostly glucose and the insulin was always high and we weren’t burning fat. And so then you get to a point where you don’t have glucose. Let’s say you haven’t eaten for a few hours. And that’s when people get panicky and super hungry and irritable because that’s the time when the body should be able to flip on the switch to be able to burn fat and get energy and other way, but because you haven’t worked those pathways of fat burning ever.

Dave Korsunsky [50:25]                         They’re all rusty and dusty in those pathways, we’ve never used them.

Casey Means [50:28]     We’re literally dust-

Dave Korsunsky [50:28]                         We probably never used them since we were born for a long-

Casey Means [50:32]     We’re giving kids now, at six months like processed rice puffs and stuff, like we’re just, the insulin is just spiking all the time. And I love what you just said, like they’re rusty. And so you start building up those pathways by reducing your spikes by maybe doing a little bit more time restricted feeding, and all of a sudden you start working that fat pathway a little bit, and now you are all of a sudden flexible. When you have glucose on board, you can process it because you’re more insulin sensitive. And when you don’t have the insulin or glucose on board, you can tap into your fat and burn it. And this is becoming really important for a lot of athletes and athletes don’t want to be constricted by having to eat food all the time during endurance training. And so what if an athlete could train in a low carb, low insulin state, get really good at processing fat for an endurance workout? And then on a game day, maybe have a bunch of carbs and get that really quick energy. But when those run out, they’re able to just flip the switch right into fat burning and not be relying on pounding gels or protein shakes the whole time and not having to get these constant insulins there, just throughout their workout that are going to have them on an energetic rollercoaster. So there’s a lot of athletes going towards the low carb training or the concept of carb cycling, which is training in a low carb state. And then maybe using carbs really advantageously during performance events. And there’s a really awesome blog post on Geoff Woo, who runs HVMN Human blog. It’s a really great, really science-based article on carb cycling and I love it. It explains it really well, but- So the opportunities for performance here is awesome, but also just people who are “metabolically flexible” tend to just be healthier overall, when you look at long-term outcomes. So we want to be able to flip those switches and it makes sense from an evolutionary standpoint, because we didn’t always have access to carbs into food, and we needed to be able to rely on our fat stores. And so that’s advantageous.

Dave Korsunsky [52:21]                         Yeah, that awareness that is building that we have these two different ways of managing our metabolism and getting to the point where you can effortlessly switch between the two, it takes work. But like you said, it’s the key to longevity. It’s the key to sustainable health, sustainable wellness, prevention of a lot of the common elements that we’re all dealing with day to day. I want to just, in closing here, say thank you to you guys for bringing this technology to market and making it more accessible. We’re on episode 50 something here and we’ve been doing the show for years. And over the course of those years, I’ve been saying that we need continuous glucose monitoring available to the general public. And for a long time, I would say that even with all the work we do, I would say that’s the number one thing that we can do to have the biggest impact on health outcomes in this country. And here we are August 14th, 2020, and I’m talking to the founder of the company that has this mission. So it’s just incredible. We’re really excited and heads up to be partnering with you guys. This is really just the beginning. So congrats. And I hope you guys have a wonderfully successful journey at Levels Health.

Casey Means [53:37]     Thank you. We are so grateful to talk about this with you on the podcast, and also just be connected with you guys as a company. I think that the integration of different data streams on that higher level, which is something that I know that you guys are working on, that we didn’t even touch on that in this episode, but the power of how those can then start to talk to each other, to get it to the next level, I think is huge, how these data streams together, can even catalyze more insights. Yeah. Thank you so much for your kind words. And I feel exactly the same way about what you guys are doing in terms of building these higher level data integration platforms. So yeah, really wonderful to be connected and thanks so much for having me on.

Dave Korsunsky [54:1 8]                       Just in closing here, Dr. Casey. So we’ve mentioned the website here, of course, but for individuals who are listening, practitioners for listening, any other tidbits you want to pass on about the company and how they should get in touch with you guys. And just anything else for those who want to integrate continuous glucose monitoring into their functional medicine practice, we’re having tons of those conversations now. That seems to be coming very top of mind, very mainstream. So for the people who are out there listening, and I want to take the next step aside from just going to the website. Anything else that they should know about?

Casey Means [54:54]     Yes. Thank you. So come check out levelshealth.com and then I would highly recommend going to www.levels health.com/blog. We are writing voraciously about the future of healthcare, about what we think needs to happen for people to just feel well at scale. And I’m writing a lot of those articles along with just an amazing team of thought leaders who are contributing to the blog. So yeah, it’s definitely not fluff, a lot of really great research based articles there. So definitely encourage practitioners and anyone to go check it out. You can find us on Twitter and Instagram @unlocklevels. So just one word, unlocklevels. And then for me, if you’re interested in some of the plant-based metabolic friendly content, I post a lot about that on my Instagram and Twitter, which is drcaseyskitchen. D-R Casey’s kitchen.

Dave Korsunsky [55:44:6]                      Yeah. We’ll link everything. But that’s incredible, like being on a vegan diet and being plant-based and being carbohydrate-based and still maintaining those absolutely phenomenal glucose levels. So we’ll definitely- Say that one more time.

Casey Means [56:01]     Dr. Casey’s kitchen.

Dave Korsunsky [56:04]                         Dr. Casey’s kitchen.

Casey Means [56:07]     So we’ll look forward to connecting. And like I mentioned, we’re in our closed beta program. So sign up for the wait list and we will be in touch with you. And when you sign up for the wait list, we’ll also start sending you our newsletter, which has really great information. Our mission is to empower and educate people to take control of their own health and live their best lives. And so all of our content and stuff we’re putting out is trying to just support that effort. So yeah, we’re here to learn with everyone and share good information.

Dave Korsunsky [56:35]                         We are mission aligned on that. Dr. Casey.

Casey Means [56:36]     Yes.

Dave Korsunsky [56:38]                         Thank you for your time. And I think this is the beginning of a great partnership between our companies. You’ve shared some absolutely awesome information. A lot of really technical stuff presented in some really accessible ways. And then you came along and provided the technology solution that compliments it all. And really just man, it’s been such a black box for people to know what the heck is happening with their blood sugar. And there’s so many people suffering, so you guys are going to crush it and look forward to connecting with you guys again soon. Thank you.

Casey Means [57:07]     Thanks David.

Dave Korsunsky [57:11]                    Thank you for listening to Data-Driven Health Radio.

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