Episode 86: Josh Clemente – Founder of Levels, Metabolic Fitness Company to Maximize Diet & Exercise

Josh Clemente was working as a lead Life Support Systems engineer for SpaceX when he became inspired by NASA’s use of blood biomarkers to monitor astronaut health and began to investigate his own health data. That research changed his life. Josh is now the co-founder and president of Levels Health, which pairs continuous glucose monitoring with an interpretive app that gives users actionable data on how to improve their health. On this episode of Habits and Hustle, host Jennifer Cohen talks to Josh about weight gain and glucose, what exercises are best for metabolic health, and what food hacks you can use to moderate your blood sugar levels.

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• Check out the Habits and Hustle Podcast
• Connect with Jennifer Cohen on LinkedIn or Twitter

07:46 – Physical fitness doesn’t always equal health

After initially getting denied a continuous blood glucose monitor (CGM) because he was in good physical shape, Josh eventually got one. The results changed both his life and his career path.

“Eventually I did get one and within about two weeks I had enough information that told me that I was either pre-diabetic or borderline, depending on who you ask. And so this is with 8% body fat and basically eating home-prepared meals — brown rice, sweet potatoes, you know, basically vegetables — what I thought were low-glycemic carbs and proteins. And so this was a total like sort of screeching tire moment for me, where I suddenly understood that what I was doing was not working for me. And I then used the CGM data to completely renovate my own lifestyle and take a more conscientious approach to sleep, stress management at work and out, diet, and exercise so that I could bring my blood sugar and my metabolic control into order. That experience and then an understanding of just how massive the epidemic of metabolic dysfunction is what caused me to start Levels.”

11:51 – Bad metabolic health is gradual and silent

Without hard data from a glucose monitor, the warning signs of metabolic dysfunction can be difficult or impossible to identify.

“When you’re looking at society today, we have 88% of American adults who are metabolically unhealthy. 71% of adults and 30% of children are overweight or obese. 90 million people are pre-diabetic in the United States alone, and 90% of them don’t know that they are pre-diabetic. So this dysfunction, it’s failing silently. And the reason that these numbers are so out of control is because there aren’t typically overt symptoms and they are a slow progression towards worse and worse outcomes. That is the real problem, and this is what we need to eliminate. It’s not the case that when you make poor lifestyle choices you immediately feel an acute pang of pain or discomfort. Like there’s no feedback loop. This stuff happens quietly behind the scenes. But when you have sort of the ability to bring real-time information to the front, you can start to see, oh, wow. That choice I’m making daily, like whether it’s sleeping five hours instead of the full eight hours, or let’s say skipping that salad before my meal and going straight to the heavy carb-rich meal without any sort of balanced macronutrients, like these small things, which I’ve kind of heard I should eat better and exercise more, but you know that feels very abstract. Once you can see the effect of the good choice versus the bad choice with objective data, it all becomes very clear and it stops being this like emotional experience and becomes an objective data-driven experience.”

16:25 – The glycemic index doesn’t give us enough information

Every person reacts to foods differently. Unfortunately, the current glycemic index doesn’t account for how individualized glucose sensitivity is.

“All of that nuance and individuality is completely blended out when you look at the glycemic index. And so recent studies like, the biggest one was out of Israel. The Weizmann Institute in 2015 showed that two people who are not, they don’t have diabetes, can eat the exact same two foods and they can have equal and opposite blood sugar responses. So the specific example was a banana and a wheat cookie. And so two people, well they had 800 people eat these while wearing continuous glucose monitors. They showed that one person can have a huge blood sugar spike on the banana and their blood sugar remains flat on the cookie, and the other person will have a huge blood sugar spike on the cookie or remain flat on the banana. So what this shows is not only is the glycemic index insufficient, it also is potentially just straight up not useful. Because this now undermines the fact that there’s so much variability, that there may not be any one-size-fits-all scale of glucose sensitivity. So it’s not useful for me to look at the glycemic index and say, oh, I should eat brown rice cause it’s lower than sugar. I need to know: am I sensitive to fruit sugars more than grain sugars? And the only way to do that is to have real-time blood sugar information available.”

18:36 – What is a continuous glucose monitor?

CGMs were developed to help people with diabetes better manage their glucose levels, and save them the trouble of having to prick their fingers over and over.

“The medical device industry developed this really impressive technology called continuous glucose monitoring. And so this is a little patch that you wear on the body full time and it has a little sensing filament that is measuring blood sugar levels in the skin full time. And so now you no longer have to prick your finger and you get a measurement every couple minutes continuously while you’re sleeping, while you’re exercising, in between meals, and you can just look at your phone and see the full history of your blood sugar. You now not only have just one data point, but it can also tell you, this is where you are right now. This is where you were 15 minutes ago, and this is the direction you’re heading. And so this completely changed the equation for people with diabetes. You can imagine how valuable that is when you’re trying to understand your condition. Now it’s super valuable and it was developed for that condition, but now we’ve gotten to the point where advances in the cost and accessibility and availability have made these devices more available for people without diabetes. We all have metabolisms, we’re all dealing with glucose levels day in and day out. They’re fluctuating. We all have hormones that drive those glucose levels. And so each of us, no matter where we are on the metabolic health spectrum, can learn from our blood sugar levels and improve.”

21:51 – Weight gain and glucose

Being healthy is not just about the amount of calories you consume. It’s about what makes up those calories and how your body processes it.

“It’s very contextual. It’s not just the calories that matter. It’s the hormonal effects that matter. And so this is all called the hormonal theory of weight balance, which basically says the context of our decisions will drive hormones, which will affect how our bodies manage the energy. And so if you have a very large blood sugar spike, your body will release a very large insulin release to correspond to it and that insulin tells your body, get this blood sugar out of the bloodstream and store it one way or another. So it will store it as glycogen first. Once your glycogen reserves are full, it will then store it as fat. And so this kind of implicates a bit of a difference between our old theory of just calories are calories. It makes us come to terms with the fact that it’s actually the calorie and the meal composition that in total will define the way we individually store our food as fat or use it directly as energy.”

23:54 – High intensity exercise and blood glucose

High intensity exercise like running releases cortisol, which triggers a rise in blood sugar for energy. But studies show the impact of exercise-related glucose spikes are different than those following a high sugar meal.

“The effects are physiologically very different from the response to a very sugary meal. So let’s say drinking a frappuccino that’s loaded up with syrups and sugar and sit on the bus or in the car commuting. Our blood sugar will spike. However, the effects of insulin are not inhibited, and so all of that is being stored directly as fat. Whereas when I’m doing an intense workout, I might have a blood sugar spike, but that spike is caused by my liver producing new glucose from the stores in my body, from my protein and fat and glycogen and releasing it for my muscles to power me through the workout. And the research that’s been done on high-intensity interval training has shown a very strong correlation between that intense exercise and actual insulin sensitivity, which means after the workouts, our bodies respond even more efficiently to the insulin levels in our bodies. So we need less insulin per unit of glucose to remove it from the bloodstream, if that makes sense. So that is the direction we want to improve. We want to minimize insulin levels and improve the effect of insulin on our blood sugar management and high-intensity interval training, in fact, all exercise has been shown to directly improve that.”

Moderate exercise is great for blood sugar management

Aerobic exercise, specifically Zone 2 training, can greatly improve your metabolic health. But even just walking regularly can lead to great results.

“I think the Zone 2’s threshold specifically is around 70-80% of your maximum heart rate. So it’s more intense than brisk walking, but specifically to managing blood sugar levels, I think any type of activity is really valuable. And so one of the things we’ve seen from our dataset is that the effect that a meal will have on our blood sugar, if we eat that meal and then sit on a couch versus eating that same meal and getting up and taking a brisk walk around the neighborhood is completely different. The reason for that is that no matter how sort of minimal the intensity level, if our muscles are working and contracting, they can pull sugar into the muscle and use it for energy immediately without insulin. Let’s say you have a personal pizza, you indulge a little bit at lunch. If you then go and get in your car and drive back to work or something like that, versus walking to that pizza place and then walking back, you’ll have a completely different blood sugar response because your body is using that glucose in real time, and it will modify the amount of insulin you need to maintain healthy blood sugar levels. So basically any type of movement distributed throughout the day, I think is a net benefit and everyone can start to implement this daily for better metabolic control.”

There are four main levers to control glucose

Sleep, food, exercise, and stress all play major roles in blood glucose management. If one is off, you have to compensate with the others.

“We’re starting to learn that when you’re compromised on one of those sort of vectors, so let’s say sleep-compromised, because maybe you had just had a baby and you’re not getting good sleep or maybe you switched jobs or something like that. All of these things now will cascade down. And so when you’re compromised on one of those four levers, it’s even more important to be mindful and make better choices on the other three. So when sleep is compromised, diet, exercise, and stress, you should do what you can to improve mindfulness and get some movement in day after day and choose meals that are better for you. We’re starting to see with better data in real time, we’re starting to close these feedback loops and understand how much context matters. This is not something that you just do the same thing day in and day out and here you get the same results. And this is I think why for so many the traditional diet concepts have just failed, because for someone who is living a very stressful life or has much worse sleep habits or hygiene, perhaps they have sleep apnea or something like that, they might try the exact same lifestyle choices as someone else who lost 25 pounds effortlessly and it doesn’t work for them. Well, that’s because they’re in a more compromised situation, and that we’re all individuals with different hormonal environments. And so there is no one-size-fits-all.”

37:30 – Balancing exercise and fuel

CGMs allow users to see exactly how much fuel is needed to power a workout, whether high intensity or lower intensity.

“So when I’m going more intense than 85% for at least 20 minutes, my blood sugar will skyrocket and that’s my body turning on cortisol, turning on adrenaline and basically unleashing a lot of blood sugar for me to fuel that workout. Whereas when I’m below that threshold, let’s say I do a two hour bike ride at only 65% of my heart rate, my blood sugar will just decrease slowly over time. I will use that glucose that’s available in my body, both stored and currently in my bloodstream, and it will just decrease monotonically and it’s a completely different effect from that high intensity interval training. And so the valuable thing there is to understand, depending on the type of training I’m doing, I should fuel completely differently. And so a lot of people, they just approach, if I’m going to work out, I need to have a bagel and a banana before I go and it doesn’t matter whether it’s jumping on the bike for two hours or going for an intense CrossFit workout. Well when I see the data, you realize for that CrossFit workout, my body’s producing all the energy I need from the stores available on my body, the body fat, I’m carrying the glycogen in my body. So my liver will produce that glucose. I don’t need to eat anything before the gym. Whereas if I’m jumping on the bike, that slow decrease in blood sugar, I will eventually run out and basically outpace my liver’s ability to produce it. And so if I want to avoid bonking, which is that  infamous term of running into the wall and losing energy, I can time additional fuel perfectly. Because I can see it happening in real time and I can get additional calories.”

39:52 – Turning lots of data into simple scores

Levels uses software to interpret a user’s data and give them back an easy to read score. Recommended lifestyle tweaks are also included with the feedback, so there’s no confusion or complex information to understand.

“For example, you eat a meal and you take a walk and then you eat that same meal the next day, and you don’t take a walk. You’re going to get two different meals scores for those events. And you’re going to see a report which compares them. And so you can see without doing any research without knowing anything about physiology, you can see the benefit of that walk on the meal that you chose to eat twice. And so you can now understand that my decisions stack together and very simply I get a report card that tells me, okay, I should optimize towards this type of pattern, not that one. And this happens for exercise. It happens for diet choices. It happens for sleep. In some cases we can track stress. That one’s a little bit trickier to really quantify still to this point. But we can start to do it in ways like we can detect when your blood sugar starts to rise, but you’re not working out and you didn’t log a meal. And so if your blood sugar starts to rise in the absence of those two things, we can basically surface that insight and say, ‘Hey, are you really stressed out right now? Because you’re not exercising and you’re not eating.’  And if he might say, ‘Oh yeah, I am actually, I’m preparing for this big meeting. I’ve been panicking all day. I’ve been rushing.’ And we can say, okay, well this is the effect of this stress. Maybe take a few minutes to practice some mindfulness, sit down, close your eyes, take some deep breaths and you can see your blood sugar recover from that stress-related increase. And so it’s all about just minimizing the cognitive overhead, we call it.”

45:51 – Fruit has a lot of sugar. Does that make it bad?

When considering health and fruit consumption, it’s all about how you eat it. Consuming whole fruit is much better than drinking juice.

“So for my personal data, one of the biggest blood sugar spikes I’ve ever seen was I was in New York. I had just gotten off a train and actually it was basically a red-eye train and I was going to a meeting and I wanted to, I was relatively new on this whole CGM thing, and didn’t really understand the effects of these different decisions. So I went to an organic juice cart and I got what was called Health Drink. And so this was a green Apple, carrot ,and celery, and it was a pressed juice. And that was it. There was no added sugar there. I watched the women press all of these fruits and vegetables into a cup and give it to me. And I drank this during the meeting thinking I was making a healthy choice. My blood sugar was in the diabetic blood sugar range for about an hour. After that, it was well over 200 and anything over 140 is considered abnormal. And so that specific example demonstrates. And you can then go and eat those whole fruits. So instead of drinking the pressed juice, eat the whole fruit, which has a lot of pulp and fiber in it, and see exactly how much worse that pressed juice example is for you. If you want the vitamins and minerals of fruit, eat a whole fruit, because the context matters. We have historically, throughout all of humankind’s development, we have been foraging for foods and eating them in their whole form. We haven’t been pressing them into these sort of refined, sort of essentially sugar bombs and stripping out all of the fiber that is necessary for us to digest them effectively.”

50:34 – High blood sugar can affect mood and cognitive health

Spikes and crashes in blood sugar levels can have both short term and long term consequences.

“When you have a very large blood sugar spike and then your blood sugar is coming crashing back down, that’s when people feel the lowest mood, feel shaky, fatigue, tired, hungry, all of those ‘hanger’ like effects. And that can often happen up to two hours after a meal. So this is a delayed onset. And so for many of us like myself, you don’t connect that directly to the meal, but that glucose variability is actually very inflammatory as well. So it introduces a lot of inflammatory cytokines, HS C-reactive protein, IL-6, TNF-alpha, all these things that you may be hearing about that are very closely connected to our immune system are also triggered by large blood sugar elevations and specifically variability. So this is happening over time. It can lead to very long-term effects, as well as that short term sort of qualitative experience of unhappiness, mood dysfunction, and fatigue. What we’re really trying to control when we’re saying blood sugar stability is not just that quality of life sort of in the moment of managing blood sugar levels so that you don’t have those ups and downs and feel the effects of them, but also insulin and insulin resistance. If you’re constantly spiking your blood sugar, you’re actually also constantly spiking your insulin. And if insulin is constantly spiked up and down, it can create over time this numbing effect called insulin resistance. And when tissues in the body become insulin resistant the consequences are pretty devastating.”

53:43 – Fasting and metabolic health

Studies have shown that intermittent fasting doesn’t really offer any additional benefits when it comes to weight loss, but there may be benefits in working out fasted or longer periods of fasting.

“Working out fasted, this doesn’t mean that you have to fast every day. But let’s say working out in the condition of not having eaten yet requires your body to derive energy from somewhere, and so that energy is going to come from what’s on our bodies. And so for the average human, we’ve got about 2,000 calories of stored sugar, which is called glycogen. We have about 80,000 calories of fat, and that’s a person with about 15% body fat at around 160 pounds body weight. So that’s a ton of fat energy and this person is not even overweight, right? So imagine all of that energy should be available. However, most of us don’t ever tap into it because we’re constantly eating and running our energy mechanisms off of the food we eat. So by doing exercise in the fasted state, you’re teaching your body to tap into the energy stores that are on us already and available. So I think there’s really something there in terms of metabolic flexibility and training ourselves to tap into those sources.”

1:00:49 – Blood sugar control hacks

Exercise after a meal is Josh’s number one hack to moderating blood sugar, but adding vinegar to meals and cutting back on alcohol also work.

“Vinegar does have a lot of benefit I’ve seen. So I like to put vinaigrettes on everything. I actually have kind of a strange, personal love of vinegar. I just really love it. And so it’s interesting to see that it also seems to have a positive effect on my post-meal blood sugar levels. So I tend to put it on a lot of things and that is also one that’s been studied quite a bit and it also shows a significant benefit in these research trials. Beyond that, you know, I think sleep is really powerful. And then because of that, alcohol control. So even if you don’t drink every day, it only takes one day of having alcohol late at night to completely obliterate your sleep and essentially introduce that vicious cycle that we talked about earlier, where that poor sleep introduces acute insulin resistance. And every decision you make, every meal you eat for the next day, two days, sometimes even up to a couple of days until you’ve restored that sleep, that can be much worse for you.”

Intro: [00:00:00] Welcome to the Habits and Hustle Podcast, a podcast that uncovers the rituals, unspoken habits and mindsets of extraordinary people, a podcast powered by Habit Nest. Now here’s your host, Jennifer Cohen.

Jennifer Cohen: [00:00:20] I wanted you to come on the podcast because your background was extremely interesting and unique. You came from SpaceX as a lead engineer and you were at Hyperloop.

Josh Clemente: [00:00:31] Yeah.

Jennifer Cohen: [00:00:32] And you were working right under, Elon Musk too. Right?

Josh Clemente: [00:00:35] So there were a few people in between us, but I was in a weekly meeting with Elon and definitely did a lot of – Got to see the way his mind works and generally, I think, developed an appreciation for tackling gigantic problems very quickly, despite the impossibility.

Jennifer Cohen: [00:00:50] You know what? I think it’d be interesting just to do a whole other podcast on just that experience working with someone like him. Right?

Josh Clemente: [00:00:56] Yeah.

Jennifer Cohen: [00:00:57] But I can only imagine to get inside that guy’s brain that close up in the meetings. It must be quite interesting and fascinating on its own right. Right?

Josh Clemente: [00:01:06] Yeah. It was – I consider myself one of the luckiest people in my generation for having the opportunity to – It was my first job out of school. I was able to land that and spend six years there. And I don’t think you could find a better incubator for learning how to think and how to tackle problems in a very principled way. You don’t have to get caught up in all the complexity and bureaucracy that a lot of other organizations do. You can just go right to the heart of the problem and just solve bite sized chunks of it and get a really good team to do it with you and you can do incredible stuff. And being able to get involved at that early age, I think was so helpful. It was just invaluable to me. I would love to figure out a way to replicate that environment somehow. I’m no Elon, but it’s definitely just powerful for young people trying to learn how to make a difference, to have that hands-on experience and see that it’s possible to pull off crazy stuff in short periods of time.

Jennifer Cohen: [00:01:58] What I think is so remarkable is that you come from a – Your background is all very much engineering and then you pivoted into, I think in a way, a very forward-thinking wellness company with Levels and what you’re doing there, and it was metabolic health.

How did you go from being an engineer with SpaceX and doing the Hyperloop stuff and with that background, why did you even decide to even start Levels? And explain what metabolic health is and what that path was for you?

Josh Clemente: [00:02:31] Yeah. So I originally had no idea what metabolism was. I’m not a medical professional. I don’t have really any history of working in the sciences of biology and physiology, but the path to discovering specifically the tremendous consequences of poor metabolic health was through my own experience, discovering that I had metabolic dysfunction by using this new technology called continuous glucose monitoring.

So while I was at SpaceX, I led a team working on life support systems. So these were the systems that have since kept astronauts alive while they’re on orbit. And so this was the breathing apparatus, the pressure controls that keep the atmosphere inside the spacecraft at a certain pressure and temperature and oxygen ratio and things like this.

And so I had an opportunity to read some of the research that NASA is producing with people like Dom D’Agostino from the University of South Florida. And when you’re thinking about keeping astronauts healthy longterm, imagine multiple years without access to doctors. You can either have doctors as astronauts, or you can ensure that they are truly healthy.

And so the way NASA is thinking about this, is very holistic, it’s not waiting for symptoms to arrive. They’re thinking about tracking data, biomarkers specifically and managing lifestyle choices, which are diet, exercise, sleep, and stress. And so seeing this research completely changed my perspective because I had always been just a workout fiend. I’m a CrossFit trainer, a Level 2. If you’re physically fit, if you can lift heavy weights and run fast, you’re healthy. That was how I thought. And so I assumed –

Jennifer Cohen: [00:04:14] I think a lot of people think that. Right? I think perception’s not always reality. And you’re a perfect example of that. Me too. ? People think just because you look the part, that that means in the inside that you’re on point.

Josh Clemente: [00:04:26] Right. For many reasons, it’s understandable because we don’t have any closed loop feedback right now. Traditionally we’ve had no way of actually knowing what is happening under the hood. And so we go off of these aesthetic markers like the weight on the scale, how you look, musculature and, okay, those are the visual indicators of health, or at least that’s what we use. And so that’s how I always was. And I have a crazy sweet tooth. Just because I never had a weight issue, I would eat whatever I wanted.

And so I got to this point where about five years into my time at SpaceX, I was physically and mentally burning out. My mood was really low. I was going through these crazy like roller coasters of fatigue and just trying to drink enough coffee to get me to the next meetings. And of course it’s a stressful environment, but I didn’t really step back and think, okay, what is this telling me, the fact that I feel so bad? Yet, I have this perception that I’m physically healthy. There’s some problem here. This is a juxtaposition that doesn’t make sense.

And so I started reading. Okay. Given this NASA research that diet and overall wellness matter, what am I doing to understand whether I’m actually healthy? Because it frankly feels like I’m very unhealthy today. And so I started digging into the research and realized that basically the metabolic system – So the endocrine system, and I’ll describe metabolism in just a second. It breaks down first. It is basically one of the leading indicators of eventual morbidity. So five out of the top 10 reasons that Americans die today and in most developing nations, is due to a condition associated with metabolic dysfunction. And these are things like stroke, cardiovascular disease, Alzheimer’s disease, cancer, all have metabolic underpinnings. And so realizing that, I decided, okay, I need to go and gather some quantitative data. I need to have objective information that’s telling me whether or not I’m making the right choices to set myself up for metabolic health.

And so one of the first things I did was start measuring blood sugar. You can prick your finger with these over the counter devices. And so I was measuring blood sugar. Couldn’t make much of it. And then I read about these devices called continuous glucose monitors which you wear and they continually monitor.

And so I asked my doctor for one of these. He had no idea why I would need this. He basically took my line of reasoning and said, “Look, you’re physically fit. You’re one of the fitness people that comes in here. So you don’t need this. This is for sick people.” And so –

Jennifer Cohen: [00:06:46] Diabetics typically, right,?  Usually the diabetics would be the people who would use those.

Josh Clemente: [00:06:50] That’s what it was traditionally – right – it was developed for. And eventually I did get one and within about two weeks I had enough information that told me that I was either pre-diabetic or borderline, depending on who you ask. And so this is with 8% body fat and basically eating home prepared meals, brown rice, sweet potatoes, basically vegetables – what I thought were low-glycemic carbs and proteins. And so this was a total  screeching tire moment for me, where I suddenly understood that what I was doing was not working for me. And I then used the CGM data to completely renovate my own lifestyle and take a more conscientious approach to sleep, stress, management at work and out, diet and exercise, so that I could bring my blood sugar and my metabolic control into order and that experience and then an understanding of just how massive the epidemic of metabolic dysfunction is, is what caused me to start Levels. And so to put a few points on that and just basically describe what metabolism is real quick. Basically metabolism is the set of processes in our bodies that takes food and environment and turns it into energy. So every cell in every tissue in our bodies requires energy to function and that’s our brains, our muscles, everything. And so these processes, they’re basically driven by hormones and they take our food and they take the environment like sunlight and they transform it into energy.

And so when those processes start to break down, we have severe consequences and those are those leading causes of death I touched on and they also extend it to more quality of life. So weight gain, PCOS or infertility, sexual dysfunction, everything all the way down to mood disorders and cognitive decline. And those are all a result of energy dysfunction. And that’s why this metabolism concept is what we call the underpinning, the foundation of physical health and mental health.

Jennifer Cohen: [00:08:37] I want to touch on a lot of things that you talked about, but one thing that I wanted to start with was someone like yourself, because you’re a great example, you looked physically, you were very physically fit. You were, like you said, a CrossFit Level 2 trainer. You were doing all the things. You were eating right. Before you went to the doctor and asked for the glucose monitoring system, what were some of the symptoms, because what you said to me, your lifestyle because of your work environment was so chaotic and so stressful. You would think that that in itself would be – You’re breaking down your body because you’re so stressed out. If you just eliminated that stress piece, because you’re not like the normal person working at an office from nine to five. You’re working at SpaceX with Elon and all these other people doing these crazy, extremely high profile projects. Were there any symptoms beyond just feeling stress and fatigue from your crazy schedule that made you want to take a deeper dive into your glucose levels?

Josh Clemente: [00:09:35] Unfortunately the answer to that is no. The primary issues where these nebulous things like fatigue and mood disorder. So just generally having low mood, not feeling happy or fulfilled and the things we all struggle with. And this is one of the complications with metabolism is that it is a very crappy –

Jennifer Cohen: [00:09:52] Could it be the job? I guess my point is couldn’t it just be that your job was just crazy stressful and you just need to get a new job.

Josh Clemente: [00:09:59] I think this is the way most people go about it. We feel our way through it. And so we feel emotional about it and we think, I’m stressed because of work and that’s why I feel so bad day in and day out and why I’m drinking so much coffee to try and keep my mood up because I’m not enjoying it.

And that could totally be true. Of course, there are qualitative things we can make choices about, but the numbers in terms of metabolic dysfunction are really telling. And when you’re looking at society today, we have 88% of American adults who are metabolically unhealthy, 71% of adults and 30% of children are overweight or obese, 90 million people are pre-diabetic in the United States alone and 90% of them don’t know that they are pre-diabetic. So this dysfunction is failing silently. And the reason that these numbers are so out of control is because there aren’t typically overt symptoms and they are a slow progression towards worse and worse outcomes.

That is the real problem and this is what we need to eliminate. It’s not the case that when you make poor lifestyle choices, you immediately feel an acute pang of pain or discomfort. There’s no feedback loop. This stuff happens quietly behind the scenes. But when you have the ability to bring real-time information to the front, you can start to see, oh, wow! That choice I’m making daily, like whether it’s sleeping five hours instead of the full eight hours or skipping, let’s say skipping that salad before my meal and going straight to the heavy carbohydrate meal without any sort of balanced macronutrients, these small things, which I’ve heard, I should eat better and exercise more, but that feels very abstract.

Once you can see the effect of the good choice versus the bad choice with objective data, it all becomes very clear and it stops being this emotional experience and becomes an objective data-driven experience.

Jennifer Cohen: [00:11:34] Yeah. And what I find so fascinating is – I heard you talk about this before – Let’s just talk about foods that they say are high on the Glycemic Index or low, because I find your research has proven that a lot of that is arbitrary, right? Everyone’s very individual. How I react to some food is very different than how you would react. So the idea of brown rice versus white rice, that brown rice is the superior type of carbohydrate, maybe to some people, but to me or to you, it really just increases your glucose level. So let’s talk about that. I think that’s really interesting because people are trying to biohack their way into all these ways to level up their life. And one thing that people haven’t really figured out until your company knew, is really about the tracking of that glucose to stabilize your blood sugar.

Yeah. Let’s talk about that a little bit.

Josh Clemente: [00:12:30] Yeah. Glycemic Index is really interesting. For people that aren’t super familiar, glucose is the primary energy molecule in the modern human. So we can basically produce energy from glucose, fat and protein. Those are the three major macronutrients and for all of us, we have blood sugar. That’s the glucose in our blood, and that’s the primary way that we produce energy, so it’s important that we have it in our bodies. But we need to maintain a tight range. Our bodies want us to stay in a very specific range and when glucose gets out of that range, bad things happen. So it’s a very reactive molecule. It can start to damage tissues. If it’s too high, we can have major consequences up to and including passing out, and/or morbidity if it goes too low. And so it’s very important that it stays in a tight range.

Traditionally there has been an effort for people to understand how their meals are affecting their glucose without being able to measure it. One of the metrics that was produced is this thing called Glycemic Index, and what it does is it tries to tell you how a specific food compares to pure sugar in the way it like affects your blood sugar control. So basically, you can imagine looking on the Glycemic Index, brown rice would have a lower glycemic index than white rice, which means that as compared to pure sugar, brown rice raises your blood sugar less than white rice. And so that makes sense, right? It’s a scale. The problem is that it’s normalized to a hundred. What that means is it’s basically averaging out all of the individuality. So it may be true that both you and I respond to brown rice with a lower blood sugar peak than pure sugar. The difference is I might go to 250 mg/dL blood sugar when I eat pure sugar and 180 when I eat brown rice and you might only go to 110 on pure sugar and 105 with brown rice. And so even though brown rice is less, it’s less effective for both of us, the fact is I should avoid both pure sugar and brown rice because I’m so much more sensitive to you. And all of that nuance and individuality is completely blended out when you look at the Glycemic Index.

And so recent studies, the biggest one was out of Israel. The Weitzman Institute in 2015 showed that two people who don’t have diabetes can eat the exact same two foods and they can have equal and opposite blood sugar responses. The specific example was a banana and a wheat cookie.  So two people – They had 800 people eat these while wearing continuous glucose monitors, and they showed that one person can have a huge blood sugar spike on the banana and their blood sugar remains flat on the cookie and the other person will have a huge blood sugar spike on the cookie, remain flat on the banana. And so what this shows is not only is the Glycemic Index insufficient, it also is potentially just straight up not useful because this now undermines the fact that there is so much variability that there may not be any one-size-fits-all scale of glucose sensitivity. So it’s not useful for me to look at the Glycemic Index and say, I should eat brown rice because it’s lower than sugar. I need to know, am I sensitive to fruit sugars more than grain sugars? And the only way to do that is to have real-time blood sugar information available.

Jennifer Cohen: [00:15:31] What is the CGM? Can you explain what that is actually? Can’t we just go – What is the difference between going to the drug store and doing what the diabetic people do, which is pricking your finger and getting a quick read on what your glucose levels are?

Josh Clemente: [00:15:48] Basically diabetes is a condition where, and there are two types Type 1 and Type 2, but basically the condition is that we’ve lost control of our blood sugar and insulin, which is a hormone that helps us manage glucose, starts to fail and we no longer can keep our glucose in that tight range. In order to help monitor and maintain healthy glucose levels, people with diabetes have to measure them and for the longest time they had to use these fingerprick devices where you actually prick your finger and you bleed onto a little strip and then measure it and you get one data point.

However, the medical device industry developed this really impressive technology called continuous glucose monitoring. So this is a little patch that you wear on the body full time. It has a little sensing filament that is measuring blood sugar levels in the skin full time and now you no longer have to prick your finger and you get a measurement every couple minutes continuously while you’re sleeping, while you’re exercising, in between meals and you can just look at your phone and see the full history of your blood sugar. You now not only have just one data point, but it can also tell you, this is where you are right now, this is where you were 15 minutes ago, and this is the direction you’re heading. And this completely changed the equation for people with diabetes. You can imagine how valuable that is when you’re trying to understand your condition.

Now it’s super valuable and it was developed for that intention, but now we’ve gotten to the point where advances in the cost and accessibility and availability have made these devices more available for people without diabetes.

We all have metabolisms. We’re all dealing with glucose levels, day in and day out. They’re fluctuating. We all have hormones that drive those glucose levels. And so each of us, no matter where we are on the metabolic health spectrum can learn from our blood sugar levels and improve. So we can always optimize no matter where we are, whether we’re an elite athlete or someone who wants to lose a lot of weight for health reasons. And this device, this little patch with the corresponding software is going to completely change the game in terms of understanding the reactions that we’re experiencing to the actions we’re taking every day.

Jennifer Cohen: [00:17:47] There’s a correlation between weight gain and your glucose and insulin levels. Right? So what is the impact? What is the impact? Why is it so – Explain a little bit about that.

Josh Clemente: [00:17:59] So we’ve historically thought about weight gain as calories in, calories out, and that’s a very simplified way of understanding the way that our bodies produce energy. We consume energy and then some of it turns into energy for ourselves. That is somewhat useful, but the problem is that our bodies are not like a clean stove where you put in wood and burn it, and you get a certain amount of heat. We’re basically a chemistry set where we have a bunch of hormones that are being released and those hormones are being released in response to the other molecules and chemicals that are in our bodies.

So you can imagine if you eat pure sugar, consume two tablespoons of pure sugar, our bodies have to release insulin to make sure that we take that pure sugar that’s getting into the bloodstream very quickly and get it out into the cells before damage starts to happen. That is a completely different process than, for example, eating a very fiber rich, we’ll just say eating some heavy bran. So it has a lot of carbohydrates in it, but it’s also packaged with fiber and maybe a little almond butter on top so you have a rich protein, fat and glucose meal. That might have the same number of carbohydrates, but the rate that that sugar gets into the bloodstream is much slower. And so now our bodies don’t have to release this massive spike of insulin in order to correspondingly control blood sugar levels for that different meal.

And so this is an example of how the hormonal response to the meals we eat. It’s very contextual. It’s not just the calories that matter, it’s the hormonal effects that matter. And so this is all called the hormonal theory of weight balance, which basically says the context of our decisions will drive hormones, which will affect how our bodies manage the energy.

And so if you have a very large blood sugar spike, your body will release a very large insulin release to correspond to it and that insulin tells your body, get this blood sugar out of the bloodstream and store it one way or another. And so it will store it as glycogen first, once your glycogen reserves are full, it will then store it as fat. This implicates a bit of a difference between our old theory of just calories are calories. It makes us come to terms with the fact that it’s actually the calorie and the meal composition that in total will define the way we individually store our food as fat or use it directly as energy.

Jennifer Cohen: [00:20:09] So you don’t want to spike your insulin. Right? So how about things like high-intensity exercise like running, things like that that really spike your cortisol levels. Is that counterintuitive then? Is it not a great idea to do high-intense exercise, according to what your resources show?

Josh Clemente: [00:20:28] It’s a really good question. So the effects of high-intensity interval training or any very strenuous exercise are that, like you said, it will release these hormones like cortisol and in some cases, adrenaline, depending on how intensive the workout is, and those hormones basically tell the body, all right, look, we’re in a very tough situation. We’ve got to make sure that there’s energy available. And it inhibits the effects of insulin. So it prevents insulin from getting the sugar in our blood out into the cells to be stored as fat. It basically says, keep this sugar available for our muscles to burn for energy and/or our brains. And although that is true, it will allow our blood sugar levels to rise and inhibit insulin.

The effects are physiologically very different from the response to a very sugary meal. So let’s say drinking a frappuccino that’s loaded up with syrups and sugar and sit on the bus or in the car commuting. Our blood sugar will spike. However, the effects of insulin are not inhibited and all of that is being stored directly as fat. Whereas when I’m doing an intense workout, I might have a blood sugar spike, but that spike is caused by my liver producing new glucose from the stores in my body, from my protein and fat and glycogen and releasing it for my muscles to power me through the workout.

And the research that’s been done on high-intensity interval training has shown a very strong correlation between that intense exercise and actual insulin sensitivity, which means after the workouts, our bodies respond even more efficiently to the insulin levels in our bodies so we need less insulin per unit of glucose to remove it from the bloodstream, if that makes sense.

And so that is the direction we want to improve. We want to minimize insulin levels and improve the effect of insulin on our blood sugar management and high-intensity interval training, in fact, all exercise has been shown to directly improve that.

Jennifer Cohen: [00:22:13] Is there a particular exercise that you think is a better exercise – What are the best exercises to do to manage the glucose-insulin impact levels that should get the best results for weight gain and weight loss?

Josh Clemente: [00:22:29] There’s two types of training I think that are really valuable. I think basically all types of exercise are going to be beneficial to the individual trying to maintain blood sugar control and improve metabolic fitness. The two key ones are Zone 2 training, which is basically training the threshold between fat oxidation and glucose oxidation. So when you’re pushing very intensely, your body basically has to switch over to burning pure sugar and this is called anaerobic exercise. When you’re going at a lower intensity, this is called aerobic exercise and this is where your body is getting most of its energy from fat stores. So when you train at the high end of your aerobic threshold, and especially in a condition where you are fasting or eating a higher fat diet, your body will be basically training its ability to increase fat oxidation using the stores of fat on your body, as opposed to using, let’s say, sugar gels or stored sugar or basically sugary drinks.

And so this Zone 2 threshold training for long periods can really improve our metabolic flexibility, which is the ability of our bodies to switch between food energy and stored energy on the body. So that’s one. I think training that Zone 2 region, it’ll improve mitochondrial efficiency and it will improve our ability to use the body fat stores, which is exactly what we want to generate energy daily.

The other one is high intensity interval training.

Jennifer Cohen: [00:23:45] Does that mean – I was going to say, okay, so did you say that brisk, would you say that brisk walking is more effective than running?

Josh Clemente: [00:23:52] So I think the Zone 2 threshold specifically is around 70% to 80% of your maximum heart rate. So it’s more intense than brisk walking. But specifically to managing blood sugar levels, I think any type of activity is really valuable. One of the things we’ve seen from our dataset is the effect that a meal will have on our blood sugar. If we eat that meal and then sit on a couch versus eating that same meal and getting up and taking a brisk walk around the neighborhood is completely different. And the reason for that is that no matter how minimal the intensity level, if our muscles are working and contracting, they can pull sugar into the muscle and use it for energy immediately without insulin. And so if you, let’s say, have a personal pizza, you indulge a little bit at lunch. If you then go and get in your car and drive back to work or something like that, versus walking to that pizza place and then walking back, you’ll have a completely different blood sugar response because your body is using that glucose in real time, and it will modify the amount of insulin you need to maintain healthy blood sugar levels. And yeah, basically any type of movement distributed throughout the day, I think, is a net benefit and everyone can start to implement this daily for better metabolic control.

When it comes to training, I think Zone 2 and high-intensity interval training are the two types that we should intersperse to really ramp up insulin sensitivity specifically.

Jennifer Cohen: [00:25:10] And how often would you say do you hit training? Because it’s not a great thing to do every day.  Everything in moderation. I’m not a very moderate person, I’ll be honest with you, because I’m much more of the high-intensity person everyday. But I will say, you do plateau and you do break down your body much quicker. That has a lot of other cons to it. So where is that happy medium from all your research?

Josh Clemente: [00:25:33] It’s a good question. I think it’s something that we still need more data and we need to continue to interpret it to understand where the ideal balance is. But I think the biggest component of this is recovery. So if we’re going 110% every day, it’s impossible for our bodies to adapt and recover to that. It’s too much. We’re asking too much. And so I agree, every day is not the right cadence for high-intensity training.

Now where exactly that balance is? It is going to definitely depend on the individual. I think people like Whoop, who are doing some really good work around recovery are helping to highlight exactly how your body’s responding to the training you’re throwing at it and that connection between good recovery and specifically good sleep and metabolic control is really strong. For example, we can show in our dataset that if one person has five hours of sleep versus nine hours of sleep, they’ll have a completely different day in terms of blood sugar control. And there have been studies that have showed that just six hours of sleep, so basically cutting off two hours from a normal eight-hour night of sleep, can increase your insulin levels by 40%. And so for someone who’s trying to improve insulin resistance, that acute stress of having short nights of sleep can continually compound and increase the negative effects of small decisions you make. So after a short night of sleep, you indulge in that same meal, it’s going to have a much worse impact than two days ago when you had eight hours of sleep. And so this is one of the key things, especially if you’re someone who’s trying to train to lose weight or to improvement metabolic health. No. You don’t want to be going 110% and not recovering because that can have the same stress effects on your body as a poor night of sleep. It’s basically incomplete recovery. And so these things can stack on themselves and you might think you’re doing something that’s beneficial for you, but it could actually be working against your goals.

Jennifer Cohen: [00:27:15] I think sleep is so important. I think sleep is so underrated. People think, okay, if I sleep for five hours, that’s good enough. But I think what you said is so accurate. I know. I did a red-eye and I didn’t sleep for two days and it threw me off for a good six days after. It really did, because number one, like you said, even subconsciously you don’t even think you’re doing it, your decision-making is much more lax in terms of what you’re eating. You’ll end up eating more carbs, more sugary foods, things that are bad for you unintentionally. That’s just the first part. But then you’re also saying, what it does is it’s also how your body actually responds to those foods. Your insulin is much more peaked. Beyond just the bad decision-making when you’re actually eating the food is actually your levels are completely out of whack.

Josh Clemente: [00:28:05] Yeah. The hormonal response is different. It’s really important to understand the context of our choices. And there are basically four big levers. You have diet, exercise, sleep, and stress, and these are the choices we’re making every single day. And it’s really key. We’re starting to learn that when you’re compromised on one of those vectors – So let’s say sleep-compromised, because maybe you just had a baby and you’re not getting good sleep, or maybe you switched jobs or something like that. All of these things now will cascade down. So when you’re compromised on one of those four levers, it’s even more important to be mindful and make better choices on the other three. So when sleep is compromised, diet, exercise and stress, you should do what you can to improve mindfulness and get some movement in day after day and choose meals that are better for you. So we’re starting to see with better data in real time. We’re starting to close these feedback loops and understand how much context matters. This is not something that you just do the same thing day in and day out and you’re going to get the same results. And this is, I think why for so many, the traditional diet concepts have just failed because for someone who is living a very stressful life or has much worse sleep hygiene, perhaps they have sleep apnea or something like that, they might try the exact same lifestyle choices as someone else who lost 25 pounds effortlessly. And it doesn’t work for them. That’s because they’re in a more compromised situation. We’re all individuals with different hormonal environments and so there is no one-size-fits-all. We all have to have contextual information to drive our choices and it can feel overwhelming, but the beauty is technology is getting us there.

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So with your company, Levels, is it a wearable technology then? Is that really what you’re doing? You’re doing the continuous glucose monitoring for a wearable device?

Josh Clemente: [00:32:10] So what we’re doing is we’re taking the continuous glucose monitors that were originally developed for diabetes management and we’re bringing them to the world of health and wellness, general information on health and wellness. And to do that, we’re building the platform, basically the behavior change software on top of these devices. And so now using Levels, you log your diet, exercise, sleep, and stress and we use machine learning to interpret the raw blood sugar levels that are coming into the system, and then tell you how to make better choices.

So we just surface insights so that you can see that effect of short sleep, or you can see the effect of a walk, or you can see the effect of a good streak of exercise on your blood sugar control, and then you can connect that to quality of life. So I can then see over time after making these little micro optimizations, I can see the receipts, that is how I like to describe it, for those choices. And that might be better meal order. That might be more activity. It might be better sleep hygiene. But now I have the blood sugar data in real time to close that feedback loop for me so I can actually see the benefit and not just try and feel emotionally through it.

Jennifer Cohen: [00:33:12] Can you see? You could track your exercise and see if you’re working out too intensely, too often. Can you tell if you’re spiking way too high, to come back down at a normal or healthy pace?

Josh Clemente: [00:33:24] Yeah. You can see some really interesting patterns with different types of exercise. So with those really intense workouts versus the Zone 2 training I was describing. And so there’s this virtual effect where, for me personally, it’s at about 85% of my maximum heart rate. So when I’m going more intense than 85% for at least 20 minutes, my blood sugar will skyrocket and that’s my body turning on cortisol, turning on adrenaline and basically unleashing a lot of blood sugar for me to fuel that workout. Whereas when I’m below that threshold, let’s say I do a two-hour bike ride at only 65% of my heart rate, my blood sugar will just decrease slowly over time. I will use that glucose that’s available in my body, both stored and currently in my bloodstream and it will just decrease monotonically and it’s a completely different effect from that high-intensity interval training.

And so the valuable thing there is to understand, depending on the type of training I’m doing, I should fuel completely differently. And so a lot of people, they just approach, if I’m going to work out, I need to have a bagel and a banana before I go. It doesn’t matter whether it’s jumping on the bike for two hours or going for an intense CrossFit workout. When I see the data, I realize for that CrossFit workout, my body’s producing all the energy I need from the stores available on my body, the body fat I’m carrying, the glycogen in my body. So my liver will produce that glucose. I don’t need to eat anything before the gym. Whereas if I’m jumping on the bike, that slow decrease in blood sugar, I will eventually run out and basically outpace my liver’s ability to produce it.

And so if I want to avoid bonking, which is that infamous term of running into a wall and losing energy, I can time additional fuel perfectly because I can see it happening in real time and I can get additional calories, if I need it, before I hit the wall. So it’s really valuable to see the delta between two different types of exercise.

Jennifer Cohen: [00:35:04] Is it complicated or is it pretty easy to use? It sounds like there’s a lot of data and even the way your vocabulary and talking and explaining things, for the layman person, it can seem a little bit complicated maybe to really grasp and understand. Is there a way to dumb it down for people who are not normally, who would ever use this thing?

Josh Clemente: [00:35:25] So Levels is – The entire goal is to develop sustainable behavior change. And so right now, although the concepts sound complex, we, the entire Levels thesis is around developing simple scores that show you the effects of choices you’re making both whether positive or negative. We combine all of this under the hood, research and data science and concepts into simple scores. So for example, you eat a meal and you take a walk and then you eat that same meal the next day, and you don’t take a walk. You’re going to get two different meals scores for those events and you’re going to see a report which compares them. And so you can see without doing any research, without knowing anything about physiology, you can see the benefit of that walk on the meal that you chose to eat twice. And so you can now understand that my decisions stack together and very simply I get a report card that tells me, okay, I should optimize towards this type of pattern, not that one.

And this happens for exercise. It happens for diet choices. It happens for sleep. In some cases we can track stress. That one’s a little bit trickier to really quantify still to this point. But we can start to do it in ways, like we can detect when your blood sugar starts to rise but you’re not working out and you didn’t log a meal. So if your blood sugar starts to rise in the absence of those two things, we can basically surface that insight and say, hey are you really stressed out right now because you’re not exercising and you’re not eating. And he might say, oh yeah, I am actually. I’m preparing for this big meeting. I’ve been panicking all day. I’ve been rushing. And we can say, okay, this is the effect of this stress. Maybe take a few minutes to practice some mindfulness. Sit down, close your eyes, take some deep breaths. And you can see your blood sugar recover from that stress-related increase. And so it’s all about just minimizing the cognitive overhead, we call it. So the amount of thinking and research you have to do in order to understand how to make better choices.

Jennifer Cohen: [00:37:09] One thing we didn’t touch upon yet, which I want to for sure, is the diet aspect because that’s a big one. What do you think right now especially, there’s so many fads? The keto diet, the paleo diet, the intermittent fasting, the other fastings. There’s so many different diets, vegan. Do you see a pattern? What is your take on this? How do you eat number one? And what do you see as the best way to eat in all these fads.

Josh Clemente: [00:37:39] I’m really glad to be asked this question because it’s actually key to Levels that we do not adopt a specific dietary philosophy because the data shows us that there really isn’t a one-size-fits-all and we’ve seen in our dataset that people who eat completely differently on the, let’s say, the dietary ideology spectrum can have really excellent blood sugar control. For example, my co-founder Dr. Casey Means, she is a hundred percent plant-based, so she’s fully vegan. She eats a lot of carbohydrates and much of them, many of them are starchy, so would traditionally think that this is going to be a high blood sugar diet. The reality is that she has some of the best blood sugar control in the entire dataset. And then you’ve got people who are on the ketogenic and carnivore end of the spectrum. They basically avoid carbs at all costs. The realization that both of these philosophies can be grounded in objective data is what we gravitate towards. So we meet people wherever they are. If you have a dietary philosophy, you should embrace it, but it should be grounded in data. You shouldn’t make an assumption that the choices you’re making are objectively healthy for you, unless you have some evidence of that, because again, every person is different and so something that works for someone else may not work for you.

So I myself, I’m extremely carbohydrate sensitive essentially across the board. It doesn’t matter really how high in the Glycemic Index, if I eat carbohydrates without eating them in a mixed meal with fat and protein to balance them, I will have a very extreme blood sugar spike, and it will last – I’ll have these oscillations for hours. I didn’t know this, of course, until I started measuring my data in real time. And so it led me to bias myself towards a high protein, moderate fat, a relatively low carb diet. I still eat carbohydrates. I eat a lot of nuts and seeds. I eat berries. I eat oftentimes specifically with mixed meals. I’ll have chia seeds and oatmeal and things like this, but in a very balanced context. So I’ll never eat oatmeal unless I mix in some almond butter and have some berries in there and maybe add some chia seeds. And all of that fiber and fat helps to modify my blood sugar response. And again, it’s all context and it’s all individual. But what I know is that it’s not necessary for us to leverage, like everyone has to go ketogenic in order to be healthy. We don’t truly believe that. We know that true health goes well beyond just blood sugar control and although blood sugar control is really important, especially in modern society where we have so much dysfunction. It’s also something that can be achieved with many dietary philosophies. That’s really a beautiful thing, I think.

Jennifer Cohen: [00:40:00] It’s interesting because I was going to ask you about fruit because there’s such controversy around fruit. People are saying, “Oh, it’s terrible to eat fruit because of the sugar content.” Other people say, “It’s great to eat fruit because it’s a natural thing.”

People talk about the order of the foods you eat it in. Does it matter if you eat your food, if you eat protein first or carbs first or eat them separate? Some people say you shouldn’t be eating your proteins, if you’re going to be eating your protein, don’t eat fruit with that because that would do all sorts of different things. Do you have any data on those things too?

Josh Clemente: [00:40:31] Yeah. So fruit –

Jennifer Cohen: [00:40:32] What’s your opinion on fruit?

Josh Clemente: [00:40:34] Again, it depends. A lot of people have much better management of fruit than others and that’s like that banana and cookie experiment.

Jennifer Cohen: [00:40:40] Exactly. It’s all individual. That’s why, when I asked the question, I hesitated.

Josh Clemente: [00:40:44] Yeah. I know. But what I do think is important though, is that the context again is really, really valuable to understand. So let’s say a lot of people think, okay, fruit is just healthy so we should have as much of it as possible. And the way that we accomplish that is smoothies, pressed juices. So instead of eating an orange, we’ll take [inaudible] and we’ll strip out the pulp. So now we can see data. So for my personal data, one of the biggest blood sugar spikes I’ve ever seen was I was in New York. I had just gotten off a train and actually it was basically a red-eye train and I was going to a meeting and I wanted to – I was relatively new on this whole CGM thing and didn’t really understand the effects of these different decisions. So I went to an organic juice cart and I got what was called Health Drink. This was a green apple, carrot and celery and it was a pressed juice. And that was it. There was no added sugar there. I watched the woman press all of these fruits and vegetables into a cup and give it to me. And I drank this during the meeting thinking I was making a healthy choice. My blood sugar was in the diabetic blood sugar range for about an hour after that. It was well over 200 and anything over 140 is considered abnormal. That specific example demonstrates that you can then go and eat those whole fruits. So instead of drinking the pressed juice you eat the whole fruit, which has a lot of pulp and fiber in it and see exactly how much worse that pressed juice example is for you. If you want the vitamins and minerals of fruit, eat a whole fruit, because the context matters. We have historically throughout all of humankind’s development, we have been foraging for foods and eating them in their whole form. We haven’t been pressing them into these refined, essentially sugar bombs and stripping out all of the fiber that is necessary for us to digest them effectively.

And so that I think is one of the key lessons is that I don’t think that fruit is bad. I just think that for all things, there is a balance. And so we should be mindful of that and I think eating the way that these foods were historically eaten.

Jennifer Cohen: [00:42:37] I never understood the juice craze, to be honest with you, because it didn’t – Do you remember Jamba juice and all those things?

Josh Clemente: [00:42:43] Yeah.

Jennifer Cohen: [00:42:43] I never got it. Here you are, you’re having over a thousand calories in these juices. It’s sugar. At the end of the day you’re taking out all the pulp and all the fiber and people think that they’re doing themselves a service, because like you said, if you think that it’s healthy because fruit is healthy, you think, instead of having one orange, let’s have 36 of them and just put it all in a cup because more is better. And it’s a fallacy. That was one thing I never got that juice thing ever. I still don’t. People still do it like crazy and it never makes much sense to me.

Josh Clemente: [00:43:15] I agree. I think we see that though across all different dietary philosophies, which is that you have some is good, more must be better. And we see this, I think, with the ketogenic craze, which is that, okay, we have learned that fat is probably not as unhealthy as we thought back in the eighties and nineties. So yeah, I think fat, healthy fats should be consumed as a normal part of diet. It’s a great calorie to consume, but some people take that to the absolute extreme and you’ve got people who are going on heavy cream diets who are just eating heavy cream and butter and everything. And I think, again, there are limitations on every end of the spectrum. And what’s really important is that we realize that there should be balance across the spectrum. We need to have good data. We need to have a good understanding of the effects of our choices, so that we’re not just taking one data point and extrapolating it to everyone into infinity and just saying this is the golden standard of how everyone should eat. And yeah, I think the pressed juice is one example, but it’s not to say that fruit is bad for you. I just think that the way we eat it, or at least the portion sizing of that pressed juice is really also important. So if you want to have the pressed juice, maybe have a quick shot or a small one, rather than having a 16 oz drink, like I did, which can cause the same blood sugar effects as having a milkshake or drinking a soda for some people.

Jennifer Cohen: [00:44:23] So when you say blood sugar. So when your blood sugar spikes like that and your insulin spikes, does that automatically mean that you are getting it stored as fat or you are going to store the sugar and you will gain weight. Isn’t that basically what it is? And that’s why I went – I was taught many years ago in my space about having to stabilize your blood sugar. It’s all about stabilizing your blood sugar. So I feel like what you’ve done is create a system where you basically figure out how to stabilize your blood sugar for optimum, not just for health or weight. How about for mood and for brain alertness and cognitive –

Josh Clemente: [00:45:00] Yeah.

Jennifer Cohen: [00:45:00] Is it also – I mean –

Josh Clemente: [00:45:01] It’s all very closely connected. Yes. So the amount of variability in blood sugar is closely tied to a ton of downstream negative effects, and many of these are cognitive. Oftentimes when you have a very large blood sugar spike and then your blood sugar is coming crashing back down that’s when people feel the lowest mood, feel shaky, fatigued, tired, hungry, all of those hanger like effects. And that can often happen up to two hours after a meal. So this is a delayed onset. And so for many of us, like myself, you don’t connect that directly to the meal. But that glucose variability is actually very inflammatory as well. So it introduces a lot of inflammatory cytokines, hsC-reactive protein, IL-6, TNF alpha, all these things that you may be hearing about that are very closely connected to our immune system are also triggered by large blood sugar elevations and specifically, variability.

So this is happening over time. It can lead to very long-term effects, as well as that short-term qualitative experience of unhappiness, mood dysfunction and fatigue. What we’re really trying to control when we’re saying blood sugar stability is not just that quality of life in the moment of managing blood sugar levels so that you don’t have those ups and downs and feel the effects of them, but also insulin and insulin resistance. So if you’re constantly spiking your blood sugar, you’re actually also constantly spiking your insulin. And if insulin is constantly spiked up and down, it can create over time, this numbing effect called insulin resistance. And when tissues in the body become insulin resistant, the consequences are pretty devastating and it is ultimately what introduces Type 2 diabetes, pre-diabetes heart disease, PCOS, all of those in the brain. Alzheimer’s disease is now being called Type 3 diabetes because it has these symptoms of brain insulin resistance. And so the insulin is really, I think, the nebulous secondary effect that we want to control by controlling blood sugar.

Jennifer Cohen: [00:46:52] This is so fascinating to me. How about fasting in general? When people are doing these three-day fasts, two-day fasts, what is it doing? How does your blood sugar stay stabilized when you’re doing that to your body?

Josh Clemente: [00:47:06] It’s pretty interesting, the fasting thing. There’s a lot of controversy about fasting as well. And actually there was a paper published, I think yesterday that showed that intermittent fasting did not have better effects than continuous eating for weight loss. Intermittent fasting is you’re still eating every day, so it’s not this extended fast. However, there are –

Jennifer Cohen: [00:47:24] Intermittent is so popular now. Every second person I meet they’re like, “Oh yeah, I do intermittent fasting.” And I feel like I’m the only person in LA who has not been part of this clan so far because I like food too much. And I do feel, like you said, I feel like I’ve been around the block a lot enough to know that, like everything that has a backlash, people learned to do this for a while and then in 10 years it’s going to be, “Oh, actually intermittent fasting causes you to gain weight because it’s causing starvation mode.”

Josh Clemente: [00:47:52] Yeah. I think that the metabolic flexibility component of this is really key. So working out fasted, this doesn’t mean that you have to fast every day, but let’s say working out in the condition of not having eaten yet requires your body to derive energy from somewhere. And so that energy is going to come from what’s on our bodies. And for the average human, we’ve got about 2000 calories of stored sugar, which is called glycogen, we have about 80,000 calories of fat, and that’s a person with about 15% body fat at around 160 pounds body weight. So that’s a ton of fat energy and this person is not even overweight. So imagine all of that energy should be available. However, most of us don’t ever tap into it because we’re constantly eating and running our energy mechanisms off of the food we eat. So by doing exercise in the fasted state, you’re teaching your body to tap into the energy stores that are on us already and available. So I think there’s really something there in terms of metabolic flexibility and training ourselves to tap into those sources. For the longer term fasts-

Jennifer Cohen: [00:48:49] It’s a big thing right now. It’s very popular, very trendy right now.

Josh Clemente: [00:48:55] Yeah. It definitely is, especially for athletes who are, who want to do longer duration exercise. So you imagine if you’re trying to run a hundred mile race, you either have to carry all that food with you or you can somehow figure out how to increase the efficiency of your body’s metabolism and its ability to tap into those fat stores. So I think there’s definitely something there.

In terms of fasting, intermittent fasting may end up not being that valuable, but I think that the really interesting stuff is the longer duration fast. So what that does is if you’re not consuming calories, you no longer are bringing in these blood sugar spikes. You no longer are causing insulin elevations. And so that will allow your body to basically bring your insulin levels down to the minimum. And then you don’t have, you’re like cleaning out the insulin background, so to speak, and allowing yourself to tap into your fat stores.

And I think there’s also these cellular mechanisms, which work – It’s really hard to measure right now. There’s one called autophagy. You might’ve heard that one getting kicked around a lot. But basically it’s your body recycling cells that are not operating at their peak efficiency. So it basically triggers this mechanism that says, all right, this cell’s not working very well. We’ve got to be very efficient right now. We’re going to recycle that cell and use it for energy for the other cells. And this doesn’t happen for an intermittent fast. I think it only kicks in after 30 or 36 hours of fasting. Again, there’s not a ton of objective data on this yet. It’s conceptual, but it wouldn’t surprise me if there is something like that, where when food is not readily available, humans historically would have to become more efficient and it could really bring some benefits. I’m still optimistic that fasting could have some place in general health, but I don’t want to say that everyone should do it every day.

Jennifer Cohen: [00:50:29] I think to your point earlier in the podcast, you were saying that it’s all individual. Again, why should this be any different than anything else? Maybe fasting would work great for you, but it would do damage to me. It’s not a one-size-fits-all type of situation. Could you tell those things by doing this CGM?

Josh Clemente: [00:50:49] Yeah.

Jennifer Cohen: [00:50:49] Continuous glucose?

Josh Clemente: [00:50:51] There are some people like – Dr. Jason Fung is one. He wrote The Obesity Code and Diabetes Code, and he really goes into the effects of insulin, the hormonal theory of weight gain and how fasting can really be beneficial for people who specifically need to reverse some metabolic dysfunction. And I think this is exactly what you were just saying. It’s all individual. If you’re someone who has rampant insulin resistance and is struggling every day with weight balance and energy and fatigue, it could be one of the best mechanisms to, again, allow your body to clear out your insulin background, reduce the blood sugar spikes you’re causing and the metabolic rollercoaster thereafter and really start to tap into those energy stores and train your body to use them effectively and basically even out your hormones. And this seems to be really evident in Dr. Jason Fung’s work and at his obesity clinic where he uses fasting primarily.

So I think when you have a specific reason to need to get metabolic control quickly, it’s a really promising mechanism. For everyone else who’s looking for longevity or to sharpen the point on their health, I think there’s a little bit to be determined if it’s a really strong mechanism. I have experimented with it myself, but yeah, I totally agree, it’s very individual.

Jennifer Cohen: [00:52:01] And what happened? Okay. So the paper, the journal that you were talking about yesterday. You were reading about the intermittent fasting. What did it say? Did it just say that it’s not necessarily the benefit that people think it is basically?

Josh Clemente: [00:52:13] So I think what they did is they had two different – They had an intermittent fasting group and they had a control group, which was a group of people who did not – Basically the intermittent fasting group could only eat in an eight hour window every day. So basically they were fasting for 16 hours and then they were allowed to eat, I think, ad libitum, which means as much as they want in that eight hour window. And then the other group was –  They were supposed to eat just three square meals every day distributed throughout the entire day. What the study showed is that, although the intermittent fasting group lost very slightly more weight as a whole, it was not significant, meaning, it was within the noise of the study and that shows that there’s really no significant benefit to use something like this 16 and 8 intermittent fasting over just general calorie control with distributed meals.

I think it was interesting. I don’t think it kills intermittent fasting as a concept. There are a bunch of different things you could do, like maybe add exercise in or different macronutrient ratios. Maybe if intermittent fasting is done with specific meal content, it might have a difference. But overall yeah, definitely something that, again with all this stuff, when new data becomes available, it’s really important to take it into account and not be dogmatic and say, “Oh no! I’m going to ignore that because it doesn’t tell my story.” And we just have to constantly update with new information.

Jennifer Cohen: [00:53:31] Are there any ways that you’ve found that are hacks to level out your glucose? I’ve heard cinnamon’s really good for this. Apple cider vinegar I heard was very good to stabilize your blood sugar. What do you think of those and do you have any other ones?

Josh Clemente: [00:53:47] To me, the biggest hack is more exercise, and it doesn’t have to be intense. It’s more movement allowing your body to use your muscles to maintain blood sugar control instead of just hormones like insulin. It’s really amazing to see how beneficial a simple walk is. It’s not something that just clears your mind, it also clears out your blood sugar levels in real time. So that’s the biggest one. Anytime you have an opportunity to take a 5 minute, 10 minute walk, even if you’re pacing around in your living room, that’s a huge benefit for metabolic control.

A few other ones. So I haven’t seen much benefit from cinnamon personally. There is some research that says that it is valuable to help maintain glucose, but this might be another individualization effect.

Vinegar does have a lot of benefit. I like to put vinaigrette on everything. I actually have a strange personal love of vinegar. I just really love it. And so it’s interesting to see that it also seems to have a positive effect on my post-meal blood sugar levels. I tend to put it on a lot of things and that is also one that’s been studied quite a bit and it also shows a significant benefit in these research trials.

Beyond that, I think sleep is really powerful. And then because of that alcohol control. Even if you don’t drink every day, it only takes one day of having alcohol late at night to completely obliterate your sleep and essentially introduce that vicious cycle that we talked about earlier, where poor sleep introduces acute insulin resistance and every decision you make, every meal you eat for the next day, two days, sometimes even up to a couple of days until you’ve restored that sleep. That can be much worse for you. And especially for people that need to improve metabolic dysfunction or want to lose weight, alcohol, especially in the evening is really damaging to sleep. And that has all these downstream effects on blood sugar control and weight management. So those are the three big ones for me.

Jennifer Cohen: [00:55:34] For vinegar, does it matter what kind of vinegar? Is it apple cider vinegar? Does it matter? Balsamic vinegar, light vinegar?

Josh Clemente: [00:55:41] So it’s a good question. I don’t have a ton of data on specific different vinegars. I’ll put a vinaigrette on basically every salad I eat and oftentimes just in other meals. And I do know that apple cider vinegar specifically is the one I’ve tried this with. But having a shot of vinegar before you eat an indulgent meal seems to have a completely different blood sugar effect. So I don’t do this very often, but I have tried it once or twice where if I know that I’m going to eat something like pizza or pasta, I’ll experiment by having a shot of apple cider vinegar beforehand and comparing it to times in the past when I haven’t. And again, I don’t have enough data to say that this is a really powerful effect, but I’ve only done that with apple cider vinegar because it’s one of the most palatable. Taking a straight shot of white vinegar might be too much for most people.

Jennifer Cohen: [00:56:23] I think apple cider vinegar is gross too, but that’s not the point. It’s not delicious, let’s put it that way. Did you see a huge difference in your glucose then, your levels when you do that?

Josh Clemente: [00:56:35] I saw a significant difference. I wouldn’t say that I had no blood sugar response. It was just that it was more stable, so slower, and the peak of the blood sugar spike was much lower. It’s a similar effect to what we see when you have a mixed meal instead of having a carbohydrate by itself. For example, like that oatmeal example, where a lot of people will eat it on its own, and you don’t even add brown sugar and your blood sugar will go something like – 70% of people in the Levels dataset, their blood sugar goes into the pre-diabetic, oftentimes diabetic blood sugar zone after plain oatmeal. Many people have then modified that by adding almond butter and some chia seeds and that fat and fiber takes that sharp spike and turns it into a slow, steady increase in recovery. And that again is introducing a different hormonal response. So even though the amount of carbohydrates may be very close to the same, because the rate of increase in your blood is much lower, you don’t have to produce as much insulin as quickly. And that will prevent that hormonal spike and crash effect where, as your blood sugars crash, you’re feeling very uncomfortable and oftentimes hungry again. And so –

Jennifer Cohen: [00:57:34] [inaudible]

Josh Clemente: [00:57:36] Yeah. So that mixed meal effect is very similar to the vinegar effect, where it just changes the shape of the blood sugar response and the time.

Jennifer Cohen: [00:57:44] Okay. I’ll wrap it up in two minutes. I just want to ask a couple other questions about the oatmeal thing. You’re saying that when you add the fat and when you add the fruits, fat, everything else, people’s first thing is, “Oh my God! That’s going to be so calorie dense.” But if it does stabilize your blood sugar, does it impact your weight gain or weight loss? Will you lose weight because you did that stabilization factor, even if you’re having more calories?

Josh Clemente: [00:58:09] This is the million dollar question I think. The calorie balance does matter. Calories are a unit of energy. And we do need to maintain effective energy balance versus the energy we’re expending. The problem is again, that the hormonal environment really will affect how our bodies distribute that energy. So if I’m causing a blood sugar spike, my body has to produce that insulin spike to keep my blood sugar in a comfortable zone. And so that insulin spike will just pump that glucose into my fat stores. And that is the situation for people who want to maintain weight loss. That’s the situation where a more balanced meal will help control that insulin response.

Now to your point about adding additional macronutrients, that is more calories and those have to go somewhere, right? So I think the best result here is do both. So rather than just taking a portion of, for example, oatmeal and adding in almond butter and protein and fiber, let’s instead reduce the portion of carbohydrates and turn it into a balanced meal by then adding the fats and proteins and fibers. Don’t just take a portion and add a whole bunch of other calories, I think, to compensate for it. And that’s probably the best approach. It’s respecting the thermodynamics of energy balance. Calories do matter, but it’s also respecting the hormonal effect of the meals we’re eating.

Jennifer Cohen: [00:59:27] One of the foods, the tumeric. Is there nothing? You didn’t see anything on tumeric?

Josh Clemente: [00:59:30] I haven’t done much turmeric. I usually eat turmeric in a curry or a stew that typically is higher in protein. It doesn’t have any carbohydrates anyway. And so I haven’t really seen much there. But that’s a really good question. I’m not sure. I’d have to look into that one.

Jennifer Cohen: [00:59:43] And then, okay. So I’m very curious. So how do people try this? They go to the Levels website. What’s the process for someone like me? I’ve never tried this. I’d like to try it myself. I want to try it.

Josh Clemente: [00:59:54] Yeah. We’ll definitely get you connected. We can basically produce a link. So right now, we’re still in what we’re calling beta mode. So we’re in this early access phase where we’re rapidly developing the app and introducing new features all the time. And so we don’t currently – Because we’re so interested in getting maximum feedback from everyone who is using it, you can’t currently go on the website and just order it today. It’s invitation only, essentially. That being said, I’d love to get you a link that you can use, and your entire listenership can also use to sign up if they’d like to try the early access program. We’ll be continuing for a few more months and then we’ll be rolling out the full program where you can basically just order this online and it’ll come straight to your door. As of right now, we do have a limited number of slots per month for this early access program and I’m looking forward to rolling this out again very soon.

Jennifer Cohen: [01:00:40] Wow. So how many people have actually done this with your program? Thousands? Hundreds?

Josh Clemente: [01:00:45] About 2000 people have gone through the program thus far and we have many, many more on a wait list who are very eager to get their chance to join. And we’ve been opening up these invitation only slots and just learning as much as we can from each person. So we’ll oftentimes do phone calls and interviews to understand how the features are helping them make better choices in the moment because that’s the only metric for success. It’s not just getting people to purchase the product. Is this creating sustainable behavior change?

Jennifer Cohen: [01:01:11] And what have you seen in the 2000 people so far, more or less?

Josh Clemente: [01:01:15] We’ve seen really positive benefits and the biggest thing is just redefining the relationship to food and lifestyle choices. So people, they really feel like they were flying blind before and now they have a closed loop feedback where I make a choice, I sit down, I’m going to eat lunch. What am I going to eat and why? I now know what I’m going to eat with confidence, because I have data from my own body telling me this food works well for me and that one doesn’t.

And so that experience of just having your body speak back to you and tell you what to do and when, is really powerful. And traditionally we’ve only had the bathroom scale or the mirror to tell us if we’re making good choices and now it can be 10, 15 minutes after a meal, you have that response.

Jennifer Cohen: [01:01:54] Wow! So where do people go? Can you give us some information of where to find you and Levels?

Josh Clemente: [01:01:59] Yeah. levelshealth.com, that’s the website. I definitely recommend the blog. So you’ll see that right on the homepage. And on the blog, we write a lot about metabolic health, metabolic fitness, which I’ll describe in just a second here. But all of the concepts that bring together these new theories of hormonal weight management, energy management, and specifically how it affects each person differently.

I was listening to your TED Talk and you talked about boldness and how wellness, a lot of people think it’s something that you either have or you don’t have, and that’s not the case. It’s something that you have to work towards.

Metabolic fitness is the same. So a lot of people think, I’m either metabolically healthy or I’m not. Nothing I can do about it. The reality is it’s very much like physical fitness where you don’t have it, you have to build it. And that takes focus, effort and repetition. And real-time data can show you whether the effects of your choices are positive or negative and which direction you’re heading.

Jennifer Cohen: [01:02:51] I love the fact that –

Can you hear me or no? You hear me or no?

Oh, I was just saying that I love the fact that you actually listened to my TED Talk and I appreciate that. So basically you’re saying that you got to practice anything and if you’re not good at something, that’s not a good enough reason just not to do it. You just need to get good at it and there’s no other way to get good at it except just doing it over and over and over again. Repetition.

Josh Clemente: [01:03:16] Right. And having a data stream to tell you the positive or negative effects of the choices you’re making makes that possible. It can show you, again, those receipts for the little micro optimizations you’re making and give you that feedback that says, ” That might’ve been a very small choice to get up and take a walk after that meal, but it made a significant difference in how your body responded and if you keep that up, you’re going to see long-term benefit. And many of our early customers have lost upwards of 20 pounds since starting this just by having the feedback loop. They haven’t adopted some crazy new diet. It’s just mainly eating and living for metabolic control and it’s producing this metabolic fitness.

Jennifer Cohen: [01:03:50] I also think, like you said, just tweaking your lifestyle just a little bit every day, just little habit change. Little habits make big change overall. It doesn’t have to be something vast and overwhelming, “I’m going to fast for five days and go on a water diet.” It could be something just – It can be just looking at your lifestyle and just making little moderate tweaks goes a long way.

Thank you, Josh. This has been very, very informative. I love this. And I wish you guys a lot – It doesn’t sound like you need any luck, because you guys have a waitlist, for crying out loud, to even use it. I don’t even know if – Will you please allow me to even try the program?

Josh Clemente: [01:04:23] We will absolutely get you in. Yeah. I don’t know that I mentioned it, but for anyone who wants to at least follow along, please check us out on Instagram and Twitter @Levels. That’s our handle and then again, levelshealth.com. And Jennifer, we definitely want to get you the link. We’ll get you signed up ASAP and we’ll also get one that your listeners can use if they’d like to join the early access program.

Jennifer Cohen: [01:04:42] That’s great. Thank you so much, Josh. I so appreciate you being here and hopefully next time we can do it out on a treadmill, wherever it is you decide to live. And if you ever come to LA after you figure out where you’re going to live.

Josh Clemente: [01:04:53] Looking forward to it. Thanks so much for having me on.

Outro: [01:04:56] Habits and Hustle. Time to get it rolling. Stay up on the grind. Don’t stop. Keep it going. Habits and Hustle from nothing into something. [inaudible] hosted by Jennifer Cohen. Visionary [inaudible] you can get to know. Be inspired. This is your moment. Excuses we ain’t having that. The habits and Hustle Podcast powered by Habit Nest.