New Continuous Glucose Monitoring Innovation – Dr.Casey Means

In this episode of the Empowering Neurologist, host Dr. David Perlmutter discusses the importance of metabolic fitness with Levels co-founder and chief medical officer Dr. Casey Means. Dr. Means explains why tracking glucose levels can provide unparalleled insights into health, help individuals dial in better habits, and in turn lower the chances of developing major diseases.

What is metabolic dysfunction?

Glucose has an important role in our physical existence, but it’s important to keep levels where they’re supposed to be.

Glucose is really our fundamental substrate of metabolism in our body. For every single cell in our entire body, trillions of them, to function they need an energetic currency that they can use. For so many of them that is ATP. That is created through a conversion of glucose in our cells, in our mitochondria, to this usable form of energy. So, it’s just such a fundamental sort of core part of human functioning. For most, at this point the majority of Americans, our glucose level in our bodies are not where they’re supposed to be. The way we’re processing energy is not efficient. It’s not working properly. That is fundamentally what we would call metabolic dysfunction.

Diet and metabolic health go hand-in-hand

If you truly want to dial in comprehensive health, it’s important to take metabolic fitness into account.

Just living in a normal Western life, eating a normal Western diet, we are going to be on the path towards a poor metabolism. The way we’re living these days really hijacks our system and makes it difficult for it to run properly. Really thinking about it, thinking about how to improve our metabolic health, our metabolic fitness, get our insulin sensitivity under control, get our glucose levels in a stable and healthy range, keep our metabolic processes functioning optimally is just one of I think the lowest hanging fruits we can do to improve our health just in multifarious ways. It’s not a lens that we’re orienting through commonly right now when we talk about diet. We don’t talk about diet and metabolic health in the same sentence generally, but I think we really should be.

Don’t reach for the prescription pad

Dr. Means knew there had to be a better answer than prescribing medication and performing surgery.

In terms of my personal journey to really being a metabolic health-focused physician, it started with being a surgeon. I was training as an ENT head and neck surgeon. Being so deeply embedded in the healthcare system, I was realizing that so many of the conditions I was treating as an ENT were fundamentally rooted in chronic inflammation. I was treating a lot of sinusitis, laryngitis, thyroiditis, all the “itises”, and it got me to step back and say, wow. So many of my patients are chronically inflamed. I’m reaching for my prescription pad for steroids to quell the immune system all the time. Why aren’t we talking about the triggers of inflammation? What is the root cause of inflammation? We are just talking about how to tamp down on it, but not what’s actually triggering it?

Metabolic health can be improved

It’s never to late to change course and improve the quality of your metabolic life.

We know that you can improve your blood sugar. Even if they’ve become unstable or elevated, you can move in the right direction. But it takes intentive dietary and lifestyle interventions. So, it became imperative to me to think through, what are scalable ways that we can empower people to really create consistent dietary and lifestyle choices that get our blood sugar back under control and improve what I like to call metabolic fitness? I like to call it metabolic fitness, not just metabolic health, because health sort of seems like a static state. It’s something we have or we don’t have, but fitness is something that we work to improve.

Diabetes is years in the making

You don’t just wake up one year with diabetes. Tracking your glucose can help you avoid major surprises at your annual doctor’s visit.

That seems so strange to me that you would walk into the doctor’s office, last year they said you’re fine, and this year they say, “Oh, no. You have this diagnosis,” when we know that these things are dynamically changing all the time. A diagnosis of diabetes probably started 20 or 30 years earlier. We also know that insulin resistance that leads to diabetes probably starts 13 to 15 years before our glucose levels ever really change. Just giving more information to people to understand this aspect of their biology, so they can actually stay on top of it and hopefully avoid that bomb being dropped on them in a doctor’s office out of the blue when it doesn’t have to be.

Tracking insulin is more important than calories

Calories that stimulate insulin impact the body differently than those that don’t. That’s why a fasting insulin test can be so insightful.

For anyone thinking through weight loss, or wanting to store less fat, or wanting to burn more fat, I think there’s a lot of movement in the community about talking more about insulin than talking about calories, because calories that stimulate insulin are going to have more of an effect on our ability to store or burn fat than calories that don’t stimulate insulin. There’s a lot of things that come along with insulin elevation. I think this is not in common practice now, where we’re really orienting around insulin when we think about prevention of diabetes or assessment of blood sugar issues. I think it’s happening a lot in the functional medicine space, where doctors will often order a fasting insulin test as a part of a metabolic workup. The reason that’s important is because person A and person B could have the exact same fasting glucose levels…Person B could be much farther down on the insulin resistance spectrum, and they’re having to pump out 30 or 40 of insulin and have fasting insulin levels of 30 or 40 to keep that glucose at 85.

How the Levels App works

Levels provides a steady stream of data and allows you to log your food, resulting in a score two hours after every meal.

What the Levels App does is it takes this data stream from the continuous glucose monitors, which are these wearable sensors that have a small internal probe and are measuring glucose 24 hours a day, seven days a week in response to everything you’re doing during the day, takes that raw data stream of glucose data, and our software converts it to something that’s usable and actionable and helps people make better decisions about their diet and lifestyle, orienting around glucose. The activity catalog is a feature where anyone who’s logged food, or a meal, or a set of activities will get a score after two hours.

Use meal scores to improve your health

Once you see what meals keep your glucose stable, you can replicate those meals daily to get metabolic health in line.

We create an activity catalog for you that basically shows you very easily what are all the eights, nines, and 10s you’ve gotten, basically your As and Bs. These are going to be the best meals for your metabolic response, had the least glycemic impact. Then you can scroll down and see what didn’t work so well for you. By looking through those you can start to make some inferences about what types of foods tend to keep you more stable. Again, we want to keep our glucose in a stable, fairly low, and healthy range, have small hills after meals, but not big mountain peaks and valleys. This is going to reduce the amount of insulin our body has to produce and sort of keep us on that path of insulin sensitivity.

Don’t deprive yourself of food

It’s possible to eat delicious and filling meals that also serve to keep your glucose stable, as Dr. Means has discovered firsthand.

Having used continuous glucose monitoring for the past 18 months or so and developing this software, I’ve basically figured a diet for me that I can eat huge meals, very diverse macronutrient profiles, and still keep my glucose really stable pretty much all the time. That’s just by learning the ways you can properly pair foods, time foods, the way I can use exercise to my advantage, the impact of sleep and stress on my glucose levels, all of these things, putting them together basically create a lifestyle plan that keeps glucose fairly stable without really any – there’s no deprivation or minimizing food intake. It’s just thoughtfully utilizing food to your advantage.

There is no “right” diet

Modern nutrition is a confusing space. The truth is that most diets take time to show results, and wearables can help provide immediate insight.

We have such loud voices in the nutrition space right now who are arguing with each other seemingly constantly about which is the right diet. It can be really confusing for people. We’ve never had objective data on how a diet is actually impacting us. We’ve kind of had to listen to whoever has the loudest voice at the time or trial diets and see what works for our body and see if we’re having results. But with most dieting it’s a lagging indicator. You make these investments. You try something, but you might not see a result for a long time. You might see your weight change in a few days or a week. You might see your glucose levels in six months change, but we don’t have that instant feedback on, okay, this is a good choice for me. This is not. I think nutrition wearables like this are going to be really helpful for people who have been struggling to find the right personal nutrition plan for them.

Casey Means, MD:

Glucose is really our fundamental substrate of metabolism in our body. For every single cell in our entire body, trillions of them, to function they need an energetic currency that they can use. For so many of them that is ATP, and that is created through a conversion of glucose in our cells, in our mitochondria, to this usable form of energy. So, it’s just such a fundamental sort of core part of human functioning.

Dr. David Perlmutter:

Well, hi, everyone. I’m Dr. David Perlmutter. Welcome again to the Empowering Neurologist. This might be one of the most important shows we’ve ever put on. It deals with metabolic health. What does that mean? It deals with blood sugar and insulin, which are really a cornerstone issue as it relates to some of our most pervasive and devastating issues in our society, like coronary artery disease, diabetes, obesity, Alzheimer’s disease, and even cancer. We have got to rein in our blood sugar. No matter what diet you may be on, that is your goal. That does in fact lead to downstream benefits, like weight loss, and immune balance, and reduction of inflammation, reduction of the generation of free radicals, for example.

Dr. David Perlmutter:

How do we know the effectiveness of our diets in terms of our blood sugar? And not just diet for that matter, but things like sleep, and exercise, and other lifestyle issues. Well, now we have technology, so we can moment to moment learn what are the effects of our various choices on our blood sugar. You’ve heard me refer to this before on other programs. It is called continuous glucose monitoring, or CGM. This is a wearable device, a patch, that moment to moment will give you a readout in your smartphone exactly what your blood sugar is at that moment. Incredibly valuable information. Why? Because you can take that information and learn about how various things that you’ve done affect your blood sugar.

Dr. David Perlmutter:

What’s really exciting is there is software now put out by a company called Levels that looks at this information and allows you to compare various meals, for example, levels of activity, other aspects of your choices and really give you incredible insight in terms of how lifestyle choices are affecting your blood sugar. Again, you’ve got to do everything you possibly can to rein in your blood sugar control and as such your insulin response. I can’t think of how many of our programs have been dedicated to this fundamental concept as it relates to human health, that is metabolic health.

Dr. David Perlmutter:

We’re going to talk today with the co-founder of this company, Levels. Her name is Casey Means, MD. Let me tell you a little bit about her. She is a Stanford trained physician, chief medical officer and co-founder of this metabolic health company called Levels, and she’s also the associate editor of the International Journal of Disease Reversal and Prevention. Her mission is to maximize human potential and reverse this epidemic that we are experiencing of chronic diseases by empowering each and every one of us with tools that can inform us, tools that are smart, that are personalized, and allow us to make sustainable lifestyle and certainly dietary choices as well, as they relate to regulating our blood sugar.

Dr. David Perlmutter:

Now, her perspective has been recently featured in the New York Times, Men’s Health, Forbes, Business Inside, Techcrunch, Entrepreneur Magazine, the Hill, Metabolism, Endocrine Today, and many, many more. She recently co-authored with me an op-ed in MedPage Today dealing with the politics of sugar in America. She is an award-winning biomedical researcher with past research positions at the NIH, Stanford’s School of Medicine, and at NYU. So, let’s learn everything we can about Levels and about continuous glucose monitoring.

Dr. David Perlmutter:

Dr. Means, welcome to the program.

Casey Means, MD:

Thank you so much, Dr. Perlmutter.

Dr. David Perlmutter:

I am always so glad we can work through our technology stuff when we have issues, but you’re right. The restart is the home run. Wish we had it for our bodies, right?

Casey Means, MD:

Absolutely. It worked today.

Dr. David Perlmutter:

I mentioned in the intro just how fundamental metabolism is and specifically knowing our blood sugar levels. That’s something I think a lot of people have known for a long time. They’ve gone every four months or whatever to the doctor, get a fasting blood sugar, every year or whatever. Then there came the ability of people to at least check their blood sugar at home. Mostly those were diabetics. But now it’s the dynamics of blood sugar that seems to be so incredibly valuable. Why don’t we just start off by talking about why it is that knowing not just our blood sugar levels, but how it changes, why is it so valuable?

Casey Means, MD:

Yes. Absolutely. Glucose is really our fundamental substrate of metabolism in our body. For every single cell in our entire body, trillions of them, to function they need an energetic currency that they can use. For so many of them that is ATP. That is created through a conversion of glucose in our cells, in our mitochondria, to this usable form of energy. So, it’s just such a fundamental sort of core part of human functioning. For most, at this point the majority of Americans, our glucose level in our bodies are not where they’re supposed to be. The way we’re processing energy is not efficient. It’s not working properly. That is fundamentally what we would call metabolic dysfunction.

Casey Means, MD:

Recent research out of UNC suggested that up to 88% of American adults have metabolic dysfunction, meaning this whole process of energy conversion isn’t working as optimally as it could. This is really relevant to everyone, because we see so many different symptoms and chronic conditions cropping up in our country that are becoming so, so common, heart disease, stroke, Alzheimer’s, dementia, diabetes, obesity, infertility. All of these things, they seem like totally different conditions. We look at them like isolated silos in medicine. But when we really think about the physiology of these conditions, so many of them are actually rooted in blood sugar dysregulation and resultant insulin resistance. The trunk of the tree of all these seemingly different branches is actually the same. We know that blood sugar is a contributing cause, maybe not the sole cause, but a big contributor to many of these conditions.

Casey Means, MD:

Orienting around blood sugar in our everyday lives is just such a powerful tool to improve our health in so many different ways. The beautiful thing is so many lifestyle and dietary choices can move our glucose in the right direction, can make our energy more efficient. Unfortunately, it is an uphill battle, because just living in a normal Western life, eating a normal Western diet, we are going to be on the path towards a poor metabolism. The way we’re living these days really hijacks our system and makes it difficult for it to run properly. Really thinking about it, thinking about how to improve our metabolic health, our metabolic fitness, get our insulin sensitivity under control, get our glucose levels in a stable and healthy range, keep our metabolic processes functioning optimally is just one of I think the lowest hanging fruits we can do to improve our health just in multifarious ways. It’s not a lens that we’re orienting through commonly right now when we talk about diet. We don’t talk about diet and metabolic health in the same sentence generally, but I think we really should be.

Dr. David Perlmutter:

It’s such a big, big topic, and it’s so incredibly important. I mean, I would say that of all the programs that I’ve done on so many different topics, this has got to be absolutely ranked top of top. When the World Health Organization tells us that the very chronic, degenerative conditions that you just enumerated are represented as a class, the number one cause of death on our planet, we have to take notice. We have to take notice. We have to take notice when we say that 88% of Americans have some degree of metabolic dysfunction. That does what? It paves the way for these chronic, degenerative conditions. When it relates to the brain, for example, Alzheimer’s, we have no treatment. To gain a foothold in terms of understanding these mechanisms on the front end really allows us to be a bit preventive, as it relates to things like coronary artery disease, diabetes, obesity, and Alzheimer’s, and so many others, even cancer.

Dr. David Perlmutter:

You know, there’s oftentimes the statement that, “Oh. I went to see the doctor, and he or she said that I’m not diabetic, so everything’s great.” I always envision the word “yet” hanging off of the back. I’m not diabetic yet. I think it’s really so important to consider that diabetes shouldn’t be considered binary, like pregnancy. In pregnancy, you either are or you ain’t. You know? Diabetes isn’t, well, now I have a fasting blood sugar that’s 127, I have diabetes. But when I have a fasting blood sugar of 118, everything was great. We recognize that issues are beginning already at a blood sugar of 105, 110, especially as it relates to the brain. Magically on television, “I got my hemoglobin A1C below seven, because I took X,Y,Z drug, therefore I’m in great shape.” It’s not that way. Hemoglobin A1C below a seven still needs an awful lot of work.

Dr. David Perlmutter:

What made you then, in recognizing how fundamental it is to know not just our fasting blood sugar, our A1C level, what are the dynamics of our blood sugar in relation to the choices that we make, what provoked you then to create this company?

Casey Means, MD:

Yeah. Sort of in terms of my personal journey to really being a metabolic health focused physician, it started with being a surgeon. I was training as an ENT head and neck surgeon. Being so deeply embedded in the healthcare system, I was realizing that so many of the conditions I was treating as an ENT were fundamentally rooted in chronic inflammation. I was treating a lot of sinusitis, laryngitis, thyroiditis, all the “itises”, and it got me to step back and say, wow. So many of my patients are chronically inflamed. I’m reaching for my prescription pad for steroids to quell the immune system all the time.

Casey Means, MD:

Why aren’t we talking about the triggers of inflammation? What is the root cause of inflammation? We are just talking about how to tamp down on it, but not what’s actually triggering it? I was holding that in one space in my mind, and I was also just when steroids don’t work, we go to the operating room. We bust a hole in the sinus, and we suck pus out. I was thinking, you can’t operate on the immune system, so this seems a little strange. We’re dealing with inflammatory disorders with an invasive intervention. So, that was sort of on one side.

Casey Means, MD:

I also knew, from what I was seeing in patients and also obviously what I’d learned in medical school, that so many of the chronic conditions we’re facing in our country are inflammatory in nature. We know that diabetes, Alzheimer’s, obesity, all of these represent an upregulation of the immune system, a chronic, low grade inflammatory state. What’s interesting to me is that so many of the cytokines, like the inflammatory mediators that were upregulated in ENT conditions, like interleukin-6 and TNF-alpha, they were also the same ones that were upregulated in these chronic lifestyle correlated conditions, like obesity and diabetes. It just really got me to step back and think, really focus on a more systems biology approach to the body. What is linking all of this? Why are we treating ENT conditions vastly different than obesity and diabetes, when actually a lot of the physiology seems to be the same?

Casey Means, MD:

That led me on this pretty long, intense journey to really try and understand some of the root causes of inflammation and some of these core physiologic links between so many of the diseases we’re seeing in our country. What that really led me to was metabolic disease and blood sugar, because we know that blood sugar and dysregulated blood sugar, instability in blood sugar, lots of big swings, and chronically elevated blood sugar both are big triggers of inflammation in the body. We also know that a huge proportion of the country is dealing with these issues, like you were talking about. 88% may have metabolic dysfunction. When we look at just blood sugar issues alone, 128 million Americans have pre-diabetes and diabetes. That’s getting upwards to 40% of the country. 72% of Americans who are overweight or obese. These are epidemic level conditions relating to blood sugar. We know that blood sugar stimulates inflammation, and we’re not approaching at that level.

Casey Means, MD:

It got me saying, what would it look like to step back and try and help all of these people get on top of their blood sugar? That seems very possible. We know that you can improve your blood sugar. Even if they’ve become unstable or elevated, you can move in the right direction. But it takes intentive dietary and lifestyle interventions. So, it became imperative to me to think through, what are scalable ways that we can empower people to really create consistent dietary and lifestyle choices that get our blood sugar back under control and improve what I like to call metabolic fitness? I like to call it metabolic fitness, not just metabolic health, because health sort of seems like a static state. It’s something we have or we don’t have, but fitness is something that we work to improve.

Casey Means, MD:

That’s actually the way that metabolism works. If you make consistent choices that generate elevated blood sugar, generate elevated insulin levels, that move you towards insulin resistance, your cells are going to become more insulin resistant. You’re going to go in that path down metabolic dysfunction. However, if day in and day out you’re making choices that support metabolic health, that keep glucose spikes lower and more stable, keep insulin levels lower and more stable, get our cells more sensitive to that insulin signal, you’re going to move in the other direction, towards that more metabolically optimal state. It’s just like going to the gym to build muscles. You have to do it day in and day out. You have to build adaptations. You have to put in the reps every day. Over time, results will follow.

Casey Means, MD:

That’s where ultimately my practice ended up going, towards helping people with that in a clinical way, and then where my entrepreneurial work also went, which was co-founding Levels, which is a wearable system that helps people understand what’s happening with their blood sugar in real time, how food and lifestyle choices are affecting their blood sugar, to build metabolic awareness, so that we can start to improve. It really came down to, okay, biggest epidemic we’re dealing with in our country right now is metabolic dysfunction. To me, that’s really a no-brainer. It is the biggest epidemic we’re facing both in the US and globally. It’s contributing to I think the vast majority of our healthcare costs and premature mortality in the US. Nine of the 10 leading causes of death in the US are related to blood sugar dysfunction in some way.

Dr. David Perlmutter:

Well, wait. You’ve got to slow down on that one. Nine out of 10 causes of death in America are related to blood sugar dysregulation.

Casey Means, MD:

In some way.

Dr. David Perlmutter:

That’s got to get people’s attention.

Casey Means, MD:

Yeah. Either contributed to or directly caused by. For instance, cancer is one of the top 10. We know that elevated blood sugar level and diabetes worsens outcome with cancer. Diabetes is one of the top 10, so that clearly one.

Dr. David Perlmutter:

Heart disease.

Casey Means, MD:

Heart disease, Alzheimer’s, dementia. Even one of the top 10 is suicide. We know that people with metabolic dysfunction actually have higher rates of suicide. It’s amazing. We have technology to actually measure our blood sugar in real time. This exists, and yet it’s not accessible to the average person. If we’ve got this threat, we have tools to measure it, that’s where Levels originated from was to pair those things. Let’s give technology to people, so they can understand this aspect of their health, so that you never have to walk into the doctor’s office one day and get a surprise.

Casey Means, MD:

That seems so strange to me that you would walk into the doctor’s office, last year they said you’re fine, and this year they say, “Oh, no. You have this diagnosis,” when we know that these things are dynamically changing all the time. A diagnosis of diabetes probably started 20 or 30 years earlier. We also know that insulin resistance that leads to diabetes probably starts 13 to 15 years before our glucose levels ever really change. Just giving more information to people to understand this aspect of their biology, so they can actually stay on top of it and hopefully avoid that bomb being dropped on them in a doctor’s office out of the blue when it doesn’t have to be.

Dr. David Perlmutter:

Well, you just said something I think that’s very important for our viewers. That is that insulin levels start to rise before the blood sugar levels rise. In other words, as your blood sugar level is rising and challenging itself, your pancreas will respond with higher and higher levels of insulin secretion that will tend to tamp down your blood sugar. But now, you reach a point where the pancreas, even though it’s cranking out maximum amounts of insulin, that cells become resistant to the functionality of insulin. Therefore, your blood sugar then starts to rise, but you’re well along the continuum at that point.

Casey Means, MD:

Absolutely. Yeah. I think, and you just described it quite well, about what is happening with the insulin resistance spectrum, but sort of just briefly, just to reiterate what you said, glucose spikes, the higher the glucose spike, the higher the insulin we’re going to have to release from the pancreas. That hormone, as many of our listeners know, but it’s causing the glucose to be taken out of the blood into the cells. When those spikes are happening to a high magnitude over, and over, and over again, day in and day out, year after year, the cells become numb to that insulin signal. Our pancreas has to produce more insulin to drive the exact same amount of sugar into the cells. Over time, they become more, and more, and more resistant.

Casey Means, MD:

The body is beautiful and can compensate for a long time by just pumping more insulin out and pumping more insulin out to maintain those blood glucose levels and to get that glucose into those cells, but over time, like you said, that process is going to poop out, and we’re going to see our blood sugar levels rise in the blood. That’s when you’re going to pick it up in the doctor’s office. That could be years, if not decades, after you started having actually biologic dysfunction in this whole hormonal regulatory cycle. What’s also interesting about the other side of that insulin coin is that insulin is a signal to the body that glucose is around and we need to take it up, but the secondary message of insulin … There’s many, many things that insulin does in the body, but a big one is it’s a block on fat burning. If insulin levels are high, it’s a signal to the body, we have energy in the form of glucose. We don’t need to tap into our fat stores or use fat for energy, because we’ve got tons of glucose around. It’s a block on fat burning.

Casey Means, MD:

As those insulin levels are rising over time in response to insulin resistance, we’re also putting more and more of a constitutive break on fat burning. For anyone thinking through weight loss, or wanting to store less fat, or wanting to burn more fat, I think there’s a lot of movement in the community about talking more about insulin than talking about calories, because calories that stimulate insulin are going to have more of an effect on our ability to store or burn fat than calories that don’t stimulate insulin. There’s a lot of things that come along with insulin elevation. I think this is not in common practice now, where we’re really orienting around insulin when we think about prevention of diabetes or assessment of blood sugar issues. I think it’s happening a lot in the functional medicine space, where doctors will often order a fasting insulin test as a part of a metabolic workup.

Casey Means, MD:

The reason that’s important is because person A and person B could have the exact same fasting glucose levels. Let’s say it’s in the normal range, like 85. Person A could be maintaining that glucose level of 85 with a fasting insulin of two or three. Their cells are so sensitive to insulin that they need very little insulin to keep their blood sugar levels at 85. Person B could be much farther down on the insulin resistance spectrum, and they’re having to pump out 30 or 40 of insulin and have fasting insulin levels of 30 or 40 to keep that glucose at 85. On the fasting glucose test they look the same, but on the insulin test they are vastly different. Person B is much more likely to be tipping into pre-diabetes or diabetes. It gives a wealth of information that you can’t just get from glucose.

Casey Means, MD:

One other just kind of interesting study that I was reading recently, there was a study looking at sleep and its effect on glucose levels and insulin levels. They showed that people who on average slept 6.5 hours of sleep per night versus 7.5 to 8.5 hours of sleep per night, sleep has a strong impact on our metabolic health. The people who slept the 6.5 hours had the same glucose responses as the people who slept 7.5 to 8.5, but they had to produce 50% more insulin to get that same glucose level. Just some really fascinating stuff there. I think we’re starting to become aware to it in common practice, but it’s still not a standard test that you’re going to see ordered for the average visit.

Dr. David Perlmutter:

Well, what people can have access to is having a continuous glucose monitor, if they have a forward thinking healthcare provider to prescribe that. So, people can buy the CGM device that comes with software that you have in your smartphone, but as I have. I use that and saw what it told me. It told me my blood sugar measurements at any given time, which was really helpful. But you’ve taken it to the next gen. I mean, this is a quantum leap. You just mentioned, for example, sleep. We’d like to know, for example, activity. I think we have some images we can look at. These are actual what you get on your smartphone. Let’s look at this activity catalog. Maybe you can walk us through what we’re seeing on our screens now.

Casey Means, MD:

Yeah. Absolutely. What the Levels App does is it takes this data stream from the continuous glucose monitors, which are these wearable sensors that have a small internal probe and are measuring glucose 24 hours a day, seven days a week in response to everything you’re doing during the day, takes that raw data stream of glucose data, and our software converts it to something that’s usable and actionable and helps people make better decisions about their diet and lifestyle, orienting around glucose. The activity catalog is a feature where anyone who’s logged food, or a meal, or a set of activities will get a score after two hours. Basically, after you eat something, you’re going to digest it. Glucose is going to rise in the blood. Then it’s going to hopefully come back down, if this whole system of insulin is working properly.

Casey Means, MD:

You can learn a lot from what happens in that elevation and that drop. I like to say that every glucose curve tells a story. There’s a lot of information embedded in the way that you respond to food that can tell us a lot about insulin sensitivity and glucose. How long it takes you to reach a peak and then comes back down tells us something about insulin sensitivity. How high your peak is tells us something.

Dr. David Perlmutter:

So, this person seems to be doing well. They’re getting 10s across the board, except for the fact that their iPhone needs to be charged.

Casey Means, MD:

This is my data. I took some screenshots from my app. I will say this is showing the top scores that I’ve gotten. But what’s really neat, and so what we do with the Levels App is we take a lot of that information that’s embedded in that two hour response, time to peak, delta from baseline, how quickly you return, the area under the curve, which is basically if you shaded the area under the peak, how big is that area. That tells us something about how much glucose … your exposure you’re getting after a meal.

Casey Means, MD:

We take all of that and we just put it into a score, a really easy score, a scale of one to 10, 10 being minimal glucose response, sort of an optimal metabolic response, and zero being a poor metabolic response, like a really high spike or a long time coming back. Then we create an activity catalog for you that basically shows you very easily what are all the eights, nines, and 10s you’ve gotten, basically your As and Bs. These are going to be the best meals for your metabolic response, had the least glycemic impact. Then you can scroll down and see what didn’t work so well for you. By looking through those you can start to make some inferences about what types of foods tend to keep you more stable. Again, we want to keep our glucose in a stable, fairly low, and healthy range, have small hills after meals, but not big mountain peaks and valleys. This is going to reduce the amount of insulin our body has to produce and sort of keep us on that path of insulin sensitivity.

Casey Means, MD:

People make all sorts of inferences from looking at this, like saying, “Oh. When I eat refined and processed grains, I tend to have much lower zone scores,” or, “When I add fat and protein to my fruit, like almond butter or cheese to a piece of fruit, my glucose spikes are lower. That fat and protein seems to be buffering my response,” or, “When I add fiber to my oatmeal plus some healthy fat, I have less of a response.” You start to learn these tools and these tips of what’s in your metabolic toolbox to basically achieve that lower glucose response.

Dr. David Perlmutter:

Here we are looking at the second image of the zone scores. I guess this is you, tofu, peanut butter, chia, coconut milk. That’s a big lunch.

Casey Means, MD:

It’s a strange lunch. Yeah.

Dr. David Perlmutter:

Again, you haven’t charged your iPhone. But here you’re getting a very nice glucose response measured two hours after your meal. Correct?

Casey Means, MD:

It’s a two hour window after the meal. Yeah.

Dr. David Perlmutter:

Yeah. During that window, so its area. It’s the entire curve that we’re looking at.

Casey Means, MD:

Exactly. We’re looking at how … I don’t have it right in front of me, but it’ll probably say plus some amount, which is the delta from baseline, plus five or six or something like that. Then it’ll have the score that’s more of that composite metric that takes in a bunch of different features. I’m generally shooting to now go more than above 30 milligrams per deciliter from baseline after eating something. I don’t want to go up 50, or 60, or 70 glucose points. I want to stick to 30 points of elevation or below, but ideally like 15 or less.

Casey Means, MD:

Having used continuous glucose monitoring for the past 18 months or so and developing this software, I’ve basically figured a diet for me that I can eat huge meals, very diverse macronutrient profiles, and still keep my glucose really stable pretty much all the time. That’s just by learning the ways you can properly pair foods, time foods, the way I can use exercise to my advantage, the impact of sleep and stress on my glucose levels, all of these things, putting them together basically create a lifestyle plan that keeps glucose fairly stable without really any … there’s no deprivation or minimizing food intake. It’s just thoughtfully utilizing food to your advantage.

Dr. David Perlmutter:

Now, the next image looks at a comparison feature, where you’re able to look at your response of two different versions of something, I think in this case it’s yogurt, side by side. Can you walk us through that?

Casey Means, MD:

Sure. Absolutely. The compare feature is to show you two or more different versions of a meal or an activity and see which one had the least impact on your glucose. An example of this would be, okay I’m having unsweetened yogurt, and I’m going to add fruit to one. I’m going to add fruit and nuts to one. I’m going to add fruit, and nuts, and chia seeds to one. In that first permutation, it’s mainly adding a carbohydrate addition, fruit, sugar. The second one, it’s adding fruit and fat. The third one, it’s adding fruit, and fat, and fiber. You can compare all your results to those three different experiments and see which one had the least glycemic impact on you. Most likely, it’s going to be that third one, the one that has fiber and fat in addition to the carbohydrate. But each person’s body is different, and each person will respond differently to these different things. But-

Dr. David Perlmutter:

This is incredibly, incredibly valuable information. In the fourth image, you’re looking at a comparison between Element, which is an electrolyte supplement added to water, mainly used I think in people on the ketogenic diet, and then comparing that to the blood sugar surge, which you see in the white curve, of Gatorade. This is pretty remarkable. This is like your own science kit right on your smartphone.

Casey Means, MD:

Totally. Yeah. It’s like a little lab on your arm. Element is this great athletics electrolyte drink. It tastes good, and it’s all natural. It gives you what you need in terms of replenishment from a hard activity. Many people are still using something like Gatorade, which is filled with high fructose corn syrup and a bunch of refined sugar stuff. Someone might think, “Oh, Gatorade’s normal. That’s fine to drink.” If that’s what you want to do, that’s perfectly fine, but to know that there are other options that are going to give you that same electrolyte boost, but with no glucose response, as opposed to a 50, 60 point glucose response, that’s really important information to know. Because those spikes day after day, week after week, year after year, that’s going to affect your physiology.

Casey Means, MD:

We did a similar experiment, one of our customers, wish protein bars, like athletic protein bars. They found that there were certain bars, like the H.V.M.N bars and the ThinkThin bars, that basically caused no glucose spike at all. A Clif bar had an 80 or 100 point spike. All things being … Walking into a grocery store, you might just grab a Clif bar and think that’s fine, and for some people it might be fine. It might not cause a big glucose elevation in certain people. But knowing that information and just sort of reframing from, oh, they’re all the same, they all have some carbs, to, wow, these are two totally different responses for my body, I personally think that’s very helpful information.

Dr. David Perlmutter:

Well, the last section, the last image here, is from the learn section. I think this might also be one of the most valuable things that you offer, which is frequently updated. What kinds of things are you presenting in this section?

Casey Means, MD:

Yeah. We’re working with just a variety of the key thinkers in this space about producing content that’s going to be really relevant to the average individual trying to optimize their metabolic health. Right now, if you search glucose or metabolic health on the internet, most of what you’re going to find is about diabetes and pre-diabetes or scientific research papers. But there’s very little for individuals who are otherwise healthy, who are sub-diabetic, they don’t have a diagnosed metabolic condition yet, but want to learn how all these things are relevant to their own health, their current performance, their current day to day living, and then their avoidance of future disease. That’s really the niche that we’re filling is translating this research for people that are looking to orient their diets and their lives around improving metabolic health.

Casey Means, MD:

It’s just a vast array of great information. How does glucose affect our inflammation? How does sleep impact our metabolic health? How does exercise impact our metabolism and our glucose control? On the flip side, how can different types of fueling improve our athletic performance? A lot of it is about chronic disease and about avoidance of these conditions and really about what we were talking about in the beginning of the podcast, but a lot of it’s also about current performance, because what’s so interesting about glucose is it’s kind of at the nexus of our day to day lives and improving our sort of lived experience of our current lives, but then also avoidance of disease.

Casey Means, MD:

It’s not just about sort of keeping things in check now, so we don’t get sick in the future. It’s also about making our day to day lives better. Really I think the way to look at this is when there’s variability in our glucose, we often feel variability in our day to day lives. When glucose shoots up and then crashes down, that’s a process called reactive hypoglycemia. When we get a really high glucose spike, we produce a ton of insulin, and sometimes our body can overshoot in taking that out of the blood stream. That period of overshooting, when your glucose is actually low after a high spike meal, people can feel jittery. They can feel anxious. They can feel like they have brain fog. That variability in our glucose curves really does map onto variability in our sort of psychological experience of the day. I feel that more stability in our glucose levels day in and day out translates to more stability in our energy, our mental health, our brain performance.

Dr. David Perlmutter:

Those of us who are in this field, where we are doing our best to stay current with scientific literature related to the nutritional recommendations that we make, we know that there are broad stroke recommendations. You and I just put out an op-ed in MedPage about just the issues related to sugar consumption. That’s kind of a broad sort of recommendation. What you’re describing here is as personalized as could be. You are the N of one getting this instant feedback with respect to how your unique body with of the nuances from your genome, your microbiome, your current state of metabolic health, et cetera, how your body is responding to various challenges, whether it’s almonds versus cashews or aerobics versus strength training. It couldn’t be more specific in terms of the information that’s good for me as the N of one.

Dr. David Perlmutter:

I’ve learned that almonds are good and cashews with me are worse in terms of my glucose response. I would never have known that. It’s those subtle things that can be in the aggregate changed to bring about better blood sugar control, which to get to the beginning of our time together today, is really the key. It’s the key to … Metabolic health opens the door to being healthy across a very, very wide spectrum of being, as it related to the things that we fear the most, cancer, coronary artery disease, Alzheimer’s, diabetes, obesity, and a whole host of inflammatory conditions. Not to mention … Why do people say not to mention and then they mention it, which is a contradiction? But I will mention it. Risk of bad outcome as it relates to COVID. Having said that, we know that people on the diabetic scale, certainly Type 2 diabetics, have a bad response, and we know that there’s an immune play here that is influenced by blood sugar control.

Dr. David Perlmutter:

So, again, to get that information is so valuable moment to moment, not in the doctor’s office. What you’ve done is quite dramatic. It’s really going to move the needle. But to be sure, things are going really well with Levels. I think that your growth numbers are absolutely phenomenal. Tell us a little bit about how the company’s doing.

Casey Means, MD:

Yeah. I mean, things are going great. We’ve been around for about 18 months. We have been really excited to see just a huge interest in this space, which to me is really hopeful, because it means that it’s starting to get into the zeitgeist how much sugar is affecting our health, our future health, but also our current performance. We’ve got all sorts of demographics who are interested in this, which is also great to see, ranging from keto enthusiasts, people who already are sort of following a low carb diet and really want to optimize and learn what foods are actually okay or not okay to keep them in ketosis. We’ve got lots of people in the weight loss community who are interested in understanding wight loss more through that metabolic lens, the hormonal insulin related lens, not just about calories in, calories out, but really focusing on keeping that glucose and insulin more stable.

Casey Means, MD:

We’ve got a lot of pro athletics who are really looking to get that extra advantage on fueling. They want to make sure that they’re staying metabolically flexible for their sports. What that means is that they are good at burning both carbohydrates, but also fat, during their events. They want to be able to tap into all the energy in their body and not just glucose. Like we were talking about earlier, when our glucose and insulin levels are constitutively high, it’s blocking our ability to burn fat. If you’re an athlete and you want to get the maximal amount of sort of energy from your body, being able to switch back and forth between fat and carb burning is helpful. So, many athletes are interested in fueling through that lens, but also we know that high glucose spikes impact inflammation and may impact recovery. People also want to make sure that in the recovery state, they’re not potentially causing unnecessary spikes that are going to sort of impair the recovery process.

Casey Means, MD:

Yeah. Keto, weight loss, athletics, but then we’ve of course got people who are generally interested in nutrition and finding the right diet for them. We have such loud voices in the nutrition space right now who are arguing with each other seemingly constantly about which is the right diet. It can be really confusing for people. We’ve never had objective data on how a diet is actually impacting us. We’ve kind of had to listen to whoever has the loudest voice at the time or trial diets and see what works for our body and see if we’re having results. But with most dieting it’s a lagging indicator. You make these investments. You try something, but you might not see a result for a long time. You might see your weight change in a few days or a week. You might see your glucose levels in six months change, but we don’t have that instant feedback on, okay, this is a good choice for me. This is not. I think nutrition wearables like this are going to be really helpful for people who have been struggling to find the right personal nutrition plan for them.

Casey Means, MD:

Then of course there’s people who are more in the camp of wanting to focus on longevity and actually focus on staying healthy for the long run. It’s a whole spectrum of different people who are interested. We have 95,000 people on our wait list right not. We’re in a beta phase right now and really trying to just get our product as perfect as possible before we launch to sort of the onslaught of people. But I’m just heartened to see that there’s interest in this and it’s becoming more I think a part of the cultural zeitgeist, a lot in part to you and your books that you’ve written that have really nailed home these messages for years, and years, and years. We’re kind of just trying to support that same ideologic message and continue to get it out into mainstream.

Dr. David Perlmutter:

Yeah. We’ve been at that for quite some time, and yet there’s still such pushback from mainstream. I recall last year, actually it was probably two years ago now with the lost year of COVID, being on a program, a CBS morning show, where they said, “You know, you’re telling people that they should control their blood sugars and not eat sugar to be good to their brain, but we reached out to the sugar industry.” I’m not kidding. On national television they … “They said that sugar in moderation is perfectly wonderful for your health. That’s okay.”

Dr. David Perlmutter:

It’s why you and I just wrote that op-ed, because it’s not okay. It’s not good for your health. It’s something in the human diet that has never been there. There’s nothing natural or speaking to our genome appropriately about consuming excess sugar or added sugar. It is a powerful metabolic signal that’s telling the body that caloric scarcity may be in your future, that winter is coming and you need to make fat. You need to increase your inflammation. You need to become insulin resistant, because that will allow you to survive during times of caloric scarcity. That’s not our modern world. We’ve certainly got an abundance of calories, though we may not have necessarily an abundance of nutrition. That’s for sure.

Dr. David Perlmutter:

But anyhow, before we close, what’s down the range for Levels? What are you planning for the future near term, and long term, and on the wish list? Where do you think it’s going to go?

Casey Means, MD:

Many, many directions. I think, first and foremost, our core focus is generating metabolic awareness in a really effective way at scale, so helping people learn about how not only diet, but also lifestyle, affects their glucose levels. Building a product that does that is our core focus right now and hopefully changing our customers’ lives for the better. We’ve talked a lot about food, food combinations, and things like that in this episode, but it’s amazing how much else affects our glucose levels. How much sleep we’re getting very much affects our insulin and glucose levels. How much stress we have, and how we respond to stress, and our stress hormone levels in our bodies significantly impacts our glucose levels.

Casey Means, MD:

Our exercise of course impacts glucose, with really any form of exercise being good for our metabolic health and our insulin sensitivity. It seems like the more consistently we move throughout the day, the better for our metabolic health. So, actually moving for a few minutes every half hour seems to be better for metabolic health than just doing one half hour workout a day. Consistency is important. Microbiome has a huge impact on our metabolic health. And micronutrient status, so not just our macronutrients, but our micronutrients, our B vitamins, manganese, alpha-lipoic acid, zinc, vitamin C. These things all impact our enzymatic reactions for metabolic health.

Casey Means, MD:

With all of that in the model of how to keep glucose stable, building a product that really gives people that holistic understanding of how to live a holistically healthy life. It’s not just about eating low carb and avoiding foods. It’s about building a body over time that through all of these mechanisms has a readout of glucose that is positive. That doesn’t just mean avoiding carbohydrates. It means building a body that processes healthy carbohydrates properly. That’s really our product roadmap is teaching people how to do that.

Casey Means, MD:

Part of that is involving other data streams, so heart rate data, heart rate variability data, step data, sleep data, merging that with the glucose data stream to be able to give people higher level insights. Then down the road potentially looking at multianalyte sensing. Right now, only continuous biomarker we have possible is glucose. That’s the only sort of on the body lab test that you can do at home 24 hours a day. There’s nothing else. It’s a great one, because it’s our key metabolic substrate. But I think we’re going to see huge movement in the industry towards other analytes being senses in a continuous fashion as bio feedback, which I think is going to really change the game for personalized nutrition. We’re very much involved in helping to look into that, and research that, and hopefully be a part of moving in that direction.

Casey Means, MD:

We’re working a lot with our research partners. We have partnerships with Brigham Young University, soon to be Thomas Jefferson University, University of South Florida, doing a number of academic research collaborations to really understand metabolic health better. So, that’s just kind of the beginning, but we’re just really excited to move forward. Hopefully, I think a side goal for us is to also make this hardware just massively more accessible. Right now, it’s a high price device. It’s prescription only. Currently, these devices are mostly used in the Type 1 and Type 2 diabetic community for monitoring their conditions. We’re bringing this more to the wellness market. But at the end of the day, these could really benefit anyone.

Casey Means, MD:

They’re a lifesaving technology for the Type 1 community. They’re a very helpful adjunct for the Type 2 community. Then of course they’re for more optimization and health maintenance for the wellness community. But end of the day, the price of these need to come down massively, and they need to be widely accessible for all populations who need them. We’re hoping to be a part of that movement as well.

Dr. David Perlmutter:

The irony is that this keeps you from, if you implement the data, this keeps you or helps prevent you from becoming a Type 2 diabetic. So, why not? There was a time when you couldn’t have a PSA test done unless you had prostate cancer. Why not? The next question would be how reluctant are let’s say mainstream allopathic physicians? How reluctant are they to prescribed a continuous glucose monitor for someone who’s not diabetic or not even really close?

Casey Means, MD:

Yeah. From what I’ve just seen anecdotally, it’s certainly not common practice now. I’ve seen it very common practice in the function medicine community and the longevity community, but not so much in the mainstream allopathic medicine, although generally when I have a conversation about this with doctors, by the end of the conversation they’re like, “Oh. I should be doing this, especially for conditions that are very metabolic related and difficult to treat, but we don’t have good treatments for them.”

Casey Means, MD:

For instance, I have a number of OB/GYN friends who treat polycystic ovarian syndrome all the time. Polycystic ovarian syndrome is the leading cause of infertility in the United States. It is, from a hormonal perspective, we see an abundance of androgen or male type hormones in the female body, which causes menstrual irregularities, infertility, and other symptoms, like hair growth, hirsutism, acne, and other symptoms, central obesity. We know that people with PCOS, half will be diabetic by the time they’re 40. It’s just astronomical the overlap between the infertility and the metabolic derangements. The thought about this is that as insulin resistance in the body develops in these women, the insulin, the elevated insulin that results from insulin resistance stimulates a particular cell type in the ovary, the theca cells, to produce more testosterone. That’s really the root.

Casey Means, MD:

If we can get insulin levels down, take the accelerator off the theca cell androgen production, you can actually improve PCOS symptoms. There’s been a number of dietary and lifestyle studies showing that low glycemic diets and ketogenic diets, both low carb diets, improve PCOS symptoms, all sorts of metabolic biomarkers, and infertility rates. However-

Dr. David Perlmutter:

There’s one study that I quote that looked at the institution of the ketogenic diet in … it was a group of five, one with PCOS. I think three of them actually became pregnant. We know that there is a huge microbiome issue there as well. Interestingly and to your point, probably the number one pharmaceutical intervention for these women is metformin, a drug that is in general used for diabetes, although we could talk about the other aspects of that that may relate to correcting metabolism through being that way. But nonetheless, I have been very much looking forward to chatting with you today. I’m, as you know, very thrilled with what you’re doing. I’ve expressed it to you in phone calls before. I’m delighted to be able to participate in an advisory role, because I think this is really so very, very important. I want to thank you for your time today.

Casey Means, MD:

Thank you so much for having me, Dr. Perlmutter. It’s just such an honor and pleasure to get to work with you. Thank you so much for having me on the podcast.

Dr. David Perlmutter:

Great. Well, we’ll talk soon. As I stated in the intro, nothing is more fundamental than controlling our metabolism, controlling, balancing our blood sugar, balancing our insulin response. Now, we have the technology to know moment to moment what is the effect of our lifestyle choices, our exercises, the foods we eat, the stress that we experience, the amount of sleep we get, what is the effect on our blood sugar? That is vitally important and extremely empowering information that is brought to you now from Levels, an incredible software that utilizes the information that is put out by your continuous glucose monitor. I hope you enjoyed the program today. Thank you again for joining us. I’m Dr. David Perlmutter. Bye for now.