Optimizing Blood Sugar: A Deep Dive

Whether we realize it or not, we’re all riding a rollercoaster. The rollercoaster is our health – specifically, our blood glucose levels. While this number fluctuates throughout the day, a healthy individual will keep their glucose level well under 140. That’s not the case for most Americans.

Dr. Casey Means is a Stanford trained physician on a mission to improve metabolic health. The co-founder of Levels, she is helping to introduce innovative biowearable technology for tracking metabolic fitness. In this conversation with the Biohacker Babes, Dr. Means explains how glucose impacts health and quality of life, the importance of a well-functioning metabolism, and how to optimize lifestyle choices to perform at your best.

• Check out Levels
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• Check out the Biohacker Babes Podcast
• Connect with Lauran Sambataro on Instagram
• Connect with Renee Belz on LinkedIn

05:16 – 90% of people with prediabetes don’t even know it

Glucose is vital for energy production in the body. However, it can also cause metabolic dysfunction and diseases like diabetes.

“I think a lot of people, like you said, tend to think of glucose very much in the realm of disease. We think about it really mostly in the context of type two or type one diabetes, which are diseases of overt, metabolic dysfunction, where the body really has a difficult time processing glucose. But what we’re really learning is that metabolic dysfunction is really so much more of a spectrum. it’s not an on and off switch where all of a sudden, one day you’re totally fine with how you’re processing glucose and then the next day you’re diabetic. It’s really much more probably a multi-year, if not decade march towards these processes just not working effectively. And so there’s really a huge opportunity to intervene and to optimize much earlier on in this process before you really have this sort of overt fulminant manifestation of disease. So currently right now in our country, metabolic dysfunction is really epidemic proportions. We have 128 million Americans with prediabetes or type two diabetes. Of that 128, 90 million are prediabetic, meaning they’re on the way towards diabetes. And of that 90 million, 90% of people have no idea that they have this problem.”

6:50 – Stable glucose improves quality of life

When glucose levels constantly rise and fall rapidly, that instability can affect mood, energy, and overall performance. Keeping level will help optimize energy and performance.

“So we know that when you eat food, basically you’ll eat some food and your glucose will naturally go up probably a little bit. Unless you’re eating zero carbohydrates whatsoever in your meal, but it’s natural to have a little elevation. But when that elevation becomes a sharp spike followed by a sharp dip, that process can have a lot of ramifications for your day. That spike and dip, more like a mountain and valley than a gentle rolling hill of glucose, can lead to fatigue. It can lead to a little bit of anxiety. It can lead to brain fog. And these are things that people walk around with thinking this might be normal, to be super lethargic after a meal, or to have really fluctuating mood throughout the day. But what’s really interesting is that when you can see this on your continuous glucose monitor and realize that these subjective experiences are actually really linked to this up and down with your glucose, and identify what food or activity is actually leading to that, you can start having so much more granularity and actionable insights into these pain points of our day-to-day living.”

11:10 – ‘Normal’ isn’t optimal

Research shows that the current recommended glucose levels may be too lenient, and that a narrower glucose range results in better health outcomes.

“What more research is suggesting is that catch all for ‘normal’ is probably not actually accurate. It’s probably more likely that upwards to 90-100, that’s a much higher risk range than if you’re down in the 70-90 range. So based on my review of the literature and the studies that have been done about risk ranges within the normal category, it really seems that 72 to 85 is actually the range that we should be shooting at for fasting glucose. And while these criteria put out by the ADA, the American Diabetic Association, are the catch-alls for population-based data, we really should probably be shooting for a narrow range. There’s some really interesting studies out there. There was a big study in the New England Journal of Medicine that looked at a lot of healthy men and basically categorized anyone under a hundred fasting glucose and separated them into quartiles. So it was 70-78, 78-85, 85-92 and 92-100 or something like that. And the people in the lowest quartile versus highest quartile of normal, the highest quartile had a five times hazard ratio for developing diabetes in the future. So it seems like as you move along, even in the normal range, you’re setting yourself up for potentially developing prediabetes and diabetes.”

13:41 – You can’t fit it all in a 15 minute conversation

There are so many factors to metabolic health that doctors do not have time to be concerned if the current measures, like fasting glucose, are within normal ranges.

“This is talking about precision nutrition, personalized diet, exercise, stress management, and autonomic nervous system regulation. Exercise type, frequency. You can’t fit all that into a 15 minute conversation, which is pretty much what the average primary care doctor is getting. So if you can see a 99 fasting glucose and say, Oh, I don’t need to worry about diabetes, pre-diabetes, nothing, stamp of approval, out. That’s unfortunately, I think that’s kind of where we’re at. Because the system is just so overburdened right now, we have such a massive amount of chronic disease. You’ve got 74% of Americans overweight or obese. You’ve got 128 million people with metabolic dysfunction And then a bunch of other lifestyle and dietary related chronic conditions. You’re trying to diagnose, prescribe a pill, get people out. And so to really have these super nuanced discussions about moving your fasting glucose from 99 to 85, I just don’t think it’s the priority right now.”

16:08 – Lifestyle choices lead to health or disease

Diet, activity, stress, and sleep all contribute to metabolic health. These are all things we have control over. With technology, it is easier than ever to observe and change behaviours to optimize health and prevent disease.

“Ultimately the diseases that are bankrupting the health and the economy of our country right now are diseases rooted in dietary and lifestyle choices. So I think it’s a really great point. This is not necessarily the thing that ultimately should or can be fully motivated by the doctor. This is something that has to come from people wanting to make the choices day in and day out that ultimately create the conditions in the body that lead to the expression of good health. So the question really becomes, is this even something that doctors should be necessarily focusing on if it’s more of a behavioral thing, and this is a choice based thing? And so that’s where I think digital health can be really cool, because fundamentally it comes down to we have hundreds of decision points every day. Whether we stand up, whether we walk, what we choose to put in our mouth, when we choose to go to bed, how we choose to emotionally respond to the stressful email we got, this happens like a million times a day. And every single one of those actions ultimately stacks up to become metabolic health. And so apps and tools that really harness that, the motivation and the biofeedback and the behavior change.”

19:08 – You’re not going to die because you’re not vegan or keto

There is no one size fits all approach. Studies are finding that everyone reacts differently to food. One person might see a huge glucose surge after a banana, while another stays flat.

“We are kind of told that there are these diets that probably work for everyone, but on a biological level, that’s probably not true. And so to be able to not only feel empowered that you’re kind of forging your own path, but to also be shaping a diet and a lifestyle that works best for your physiology, is positive on twofold. There was this very interesting paper that is part of what really motivated our company, which was out of the Weizmann Institute. It was published in 2015, and it was called Personalized Nutrition by Prediction of Glycemia Responses. And basically they looked at hundreds of people, healthy individuals, non-diabetic individuals, put CGMs on them and then fed them standardized meals that are standardized snacks, like cookies and bananas. And what they found was that two people will respond, to potentially have equal and opposite reactions to the exact same food. So I could eat a banana, Lauren can eat a banana, Renee can eat a banana. I could go up a hundred points on my glucose. Renee could go up 50 points and Lauren could go up not at all. So the banana is probably not a good idea for me and a good idea for Lauren. And so I think it’s super exciting to have this tool that can help you stand in the face of so much conflicting nutrition information, really loud voices in this space saying, this is right or this is right.”

22:37 – It’s all personal

The glycemic index currently used does not take into account the context food is eaten in. How food is paired, when it is eaten, personal tolerance and how that varies each day will all change the glycemic response to food.

“The traditional idea of a glycemic index was people would basically eat 50 grams worth of carbohydrates of a specific food, and then see how high the glucose rose in the blood. So this is problematic to start with, because we don’t often eat 50 grams of a specific carbohydrate of food. 50 grams of carbohydrates of watermelon is a lot of watermelon, versus table sugar it might be a very small amount. So it’s impractical in the sense that we just don’t often eat that kind of quantity of foods. The second thing is that we don’t generally eat foods in isolation. So we don’t just eat straight white pasta. We eat pasta generally with some sort of fat source on it, like an alfredo sauce. And all those interactions between foods is going to change the glycemic index of a food. So those are reasons why even fundamentally it sort of isn’t super practical…So really what we should probably be doing is moving towards personalized glycaemic indices for ourselves. So you actually test different amounts of carbohydrates and then different carbohydrates in combination with other macronutrients, like protein, like fat, and then other things like fiber, other insulin sensitizers like cinnamon or vinegar or things like that. And actually just see what happens to you and kind of create your own glycaemic index.”

32:34 – Mountains and valleys on the road to insulin resistance

Big surges of glucose cause the body to release insulin. The more often this happens, the less responsive cells are to insulin, and dysfunction develops.

“So what you really want I would say first and foremost is to be minimizing variability. You want a flat as you can, stable line without huge mountains and valleys. So those big spikes and dips are what we call glycemic variability or glycaemic excursions. And those are problematic because every time you have a big glucose surge in the blood, your body is releasing from the pancreas a bunch of insulin. And that insulin is required for the glucose to be taken up by the cell and processed by the mitochondria. And when that insulin is getting stimulated in a huge amount, over and over again, with these big spikes, the cells, they’re seeing all this insulin in the blood and it’s having to bind all these insulin receptors on the cell. And over time, this all gets overwhelmed and it sort of becomes numb to it.”

36:24 – Big glucose surges stresses the body and even causes wrinkles

Too much glucose in the blood leads to inflammation, glycation, which can cause skin to wrinkle and oxidative stress in the cells.

“So the three main things that you really need to worry about with these big glucose spikes. It triggers inflammation. So the body sees all this glucose and it asks why is there so much glucose in the bloodstream? Is there a problem? Is the liver dumping this out because we’re under threat and we need to be running from a lion, what is happening? And so it tells the body something might be wrong and that triggers inflammation. So one is inflammation. The second is that high concentrations of glucose in the blood causes a process called glycation, which is glucose sticking to things all over the body. It can stick to blood vessels, it can stick to cell membranes, it can stick to proteins. And when sugar sticks to things, it causes some dysfunction. Those proteins aren’t going to work as well in the body. Things are going to get rusty essentially. So you don’t want glycation, it underlies a lot of problems. One fun example is actually it promotes wrinkling of the skin. So when you glycosate your collagen in the skin, it cross-links it. And when the collagen is cross-linked, it produces wrinkles. So it’s not surprising someone who’s just generally unhealthy is more likely going to move down that aging spectrum on all accounts. And one of those may be the way their skin appears. So inflammation, glycation, and then the third would be oxidative stress. So when you dump all this glucose into the body, you’re having a lot of strain on the energy producing pathways of the body.”

41:47 – Getting off the carbohydrate rollercoaster can lead to fat burning

When insulin is constantly being released to soak up glucose, the body stops burning fat for fuel as it sees there is enough glucose to use.

“That’s the roller coaster that many Americans are on for decades. Right? I’m sure carbs, insulin, spike, crash, carbs, insulin, spike, crash and that all that exposure to insulin is causing problems and it’s exhausting. Your pancreas gets exhausted and your cells get exhausted. And you know, it really fundamentally is what underlies our obesity crisis too. Because when your insulin is high, it’s telling the body that there’s tons of glucose energy on board. So it tells your body we don’t need the fat to be burned for fuel because we have all this glucose. And so what that signals to your cells is stop all fat oxidation, stop fat burning. And so when your insulin is elevated, you’re essentially not able to burn fat for energy for performance or energy for weight loss. So in terms of weight loss and why it may at scale have been essentially a failure, why diets often just don’t work, I think is because we’re not actually focusing on insulin as the root.”

43:19 – A smaller eating window could improve metabolism

Studies have found that eating the same amount of food within a smaller time frame could improve metabolic health, glucose and insulin levels.

“I see a lot of articles that are like, you need to eat in the morning to get your metabolism going to rev up. Physically causing me pain to see that because when you’re getting your metabolism going, that’s just all, so you’re getting your insulin going if you do that, which theoretically is getting your glucose burning going. But it’s shutting down your ability to burn fat, which is ultimately the goal for probably around 74% of Americans who are overweight or obese. And so certainly eating carb free, a handful of nuts or something like that’s one thing going to have a very low insulin response. But since our food pyramid for many years said eat 6-11 essentially grain servings a day, that’s not what people were reaching for. It wasn’t a vegetable or a handful of nuts or things that aren’t going to spike insulin. So there’s actually one really fascinating study that I looked at. What happens when you give two different groups of people the same amount of calories in the exact same amount of food, but one of the groups eats between eight and 2pm and then stops eating for the rest of the day. And then one group eats between 8amand 8pm. So essentially full day feeding or time restricted feeding…the people in the shorter feeding window group 8am to 2pm had much better metabolic parameters, lost weight, better fasting insulin, better fasting glucose, and so same amount of calories, same food and just when you ate. So for most people, I would say restrict the amount of time you’re eating each day to a shorter window.”

55:38 – Varied workouts will use different fuels

High intensity exercises will release glucose into the bloodstream to be used by the big muscle groups, whereas endurance and low intensity like walking will trigger the body to use a mix of fat and glucose for energy.

“So with a power sport or high intensity interval training where you’re going above 80% of your VO2max on the hiit training, those are both things that are going to cause your body to think that you’re under stress. It’s going to translate hormonally into catecholamine release and we need to run from the lion type of thing. So that’s going to signal to your liver, which stores your short-term energy stores, your really quickly accessible glucose. It’s going to say we have a problem, dump that into the bloodstream so that we can feed the muscles to run away from the lion… So they don’t seem to be damaging in the same way that a food induced glucose spike is. It’s different physiology. And then with endurance training, just like you said, we do often see a slow either a flat or a slow decrease in glucose. So at lower intensities, you’re going to be doing more of a mix of fat burning and glucose burning. At the higher intensity you’re going to, as you move up in terms of the intensity, you’re preferentially burning glucose over fat. But at walking, hiking, a slow jog, it’s going to be much more this mix of fat and glucose.”

68:00 – Continuous glucose monitors for the health conscious

Dr. Means sees CGMs as an important tool for everyone to improve their health. The people using Levels right now are people who care about optimizing their health and performance like athletes and people trying to lose weight.

“I think it is going to be something that everyone uses at least for a short term period to basically figure out what their optimized diet is and gain those insights. I think it’s valuable for everyone. So right now I think it’s really the early adopters and the performance enhancement people like us biohackers who love this..We did this small pilot with Justin Mares, one of the founders of Perfect Keto, where basically people were asked to keep their glucose under 140 for the entire month. Which is pretty lenient, it’s not that hard to stay under 140 for most of the day. And they lost on average nine pounds over 28 days just by keeping their glucose under 140 and using the app to learn what would keep them under 140. So that was really cool. So weight loss. Performance athletes. We’ve got NBA players wearing Levels and they have been in with 13 professional sports teams who want that extra fueling edge and to know what they actually should be eating for highest performance.”

71:10 – Metabolic fitness is the most important measure for health

Metabolic fitness underlies a vast array of diseases, conditions, and lifestyle factors like mood and energy. Dr. Means believes that metabolism will become the focus of health for the future.

“While we know it’s related to the really overt diseases like diabetes, obesity, stroke, heart attack, non-alcoholic fatty liver disease. These are all diseases that are the big heavy hitters of metabolic dysfunction. And Alzheimer’s, now people are calling Alzheimer’s type three diabetes. Insulin resistance in the brain may be really linked to dementia. But there’s also a lot of more subtle things that we don’t realize are actually very much associated with metabolic dysfunction. And I think as that awareness gets greater, the more people will realize how this could benefit them…I think we’re going to start seeing it in the zeitgeists of health, like metabolic health is health. So every cell in the body needs energy to function properly. So basically where metabolic dysfunction crops up in terms of cell type is where you’re going to get symptoms. And so in terms of a root cause, centralizing focus of all of these symptoms and diseases we’re seeing in epidemic proportions, it is the lowest hanging fruit to swat at to achieve multiparous health improvements. But that’s not widely known. So I think that the next five years we’re going to start seeing a lot more emphasis on that and people understanding how it could benefit such a wide range of things.”

Intro: [00:00] We’re digging deep and asking the questions we need to ask. Years of stress and not just emotional. I was depleting my body. I was malnourished. I’m working out like crazy. I’m eating all these healthy foods. How could I not be well? We have to get back to the basics. We can change the way our genes are expressed. Anyone that wants to improve their health or upgrade their health. They should be biohacking. My name is Renee. And I’m Lauren. We are the Biohacker Babes. We’re sisters, and we’re joining forces to empower you to become your own biohacker and upgrade your life. The Biohacker Babes podcast aims to create insight into the body’s natural healing abilities, strengthen your intuition and empower you with techniques and modalities to optimize your health and wellness, because life is too short to not feel your best every single day. This podcast offers health, fitness and nutritional information, and is designed for educational purposes only. You should not rely on this information as a substitute for nor does it replace professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional.

Thank you for joining us and welcome to the show.

Host: [01:20] Welcome to the Biohacker Babes podcast. This is Renee, and I’m here with my sister Lauren today, as well as a guest. We have Dr. Casey Means, and I could not be more excited about this episode today. We really could have talked to her for just hours and hours. She is a wealth of information. I mean, the studies and science she has, to back up, everything that she’s talking about was just mind blowing. And I think a lot of really great practical information that you can all start applying today. So, we’re talking about CGM, so continuous glucose monitors. You’ve probably seen Lauren and I on Instagram posting pictures of these little monitors on the back of our arms.

So, we’ve had a lot of fun with that. And we also did an episode pretty recently, about what we’ve learned from those. So today, we jump into a lot of the science. So, before I bring Dr. Casey on, let me give you her bio here. So, Dr. Casey Means is a Stanford-trained physician, chief medical officer and co-founder of metabolic health company Levels and associate editor of the International Journal of Disease Reversal and Prevention. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech enabled tools that can inform smart, personalized, and sustainable dietary and lifestyle choices.

Dr. Means’ perspective has been recently featured in Forbes, Entrepreneur Magazine, The Hill, Metabolism, Endocrine Today, EndocrineWeb, Well And Good, and Dr. Michael Greger’s video series. And he is the author of How Not To Die. She is also an award-winning biomedical researcher with past research positions at the NIH, Stanford School of Medicine and NYU. Amazing background, and she was such a pleasure to talk with, so stay tuned. Help me welcome Dr. Casey. Alright. So, welcome Dr. Casey. We are so excited to talk to you today. We did a previous episode about our CGMs, but we really want to get into the science behind it, today.

You have a wealth of information, and actually, not just about the science, but about the social aspect and the community aspect and the accountability. There’s so much that goes into this technology and this tool to help metabolic dysfunction. So welcome. We’re so excited to talk to you today.

Dr. Casey Means: [03:39] I am so excited to be here.

Thank you so much, Lauren and Renee. I have been a longtime fan of your podcast, so I am really thrilled to be here.

Host: [03:47] Amazing. Aw, thank you. What a fun day. Yeah, I mean, we were already just chatting away before we hit record, I was like, Oh gosh, this is getting too good. Let’s go. Yeah. We could talk to you all day.

Dr. Casey Means: [04:01] Absolutely.

Host: [04:03] So since we already did sort of a basic introduction to CGMs, can you just go a little bit further and tell us how a healthy person can benefit from using a CGM?

Because up until now, I think the population just thought of them as something that diabetics used. Can you address that?

Dr. Casey Means: [04:19] Yeah, absolutely. So, you know, just kind of, for a review for anyone who maybe hasn’t, you know, heard about CGM, so continuous glucose monitors are these wearable devices that you put on your arm. They measure your glucose 24 hours a day.

They basically stick on there for two weeks and they’re sending data to your phone every 15 minutes automatically. So, it’s this incredible continuous data stream about this core metabolic bio marker- glucose. So, you know, when we eat food, we digest the carbohydrates. They go into our bloodstream as glucose, and then our cells take them up.

And the mitochondria process that glucose into energy that we can use for our cells’ ATP. And when that process is going super smoothly and, you know, we’re processing glucose really efficiently, we call that metabolic fitness or metabolic health. And when that process is not going well and our cells are not taking up or processing glucose effectively, we call that metabolic dysfunction.

And I think a lot of people, like you said, tend to think of glucose very much in the realm of disease. We think about it really, mostly, in the context of Type 2 or Type 1 diabetes, which are diseases of overt, metabolic dysfunction, where the body really has a difficult time processing glucose. But what we’re really learning is that metabolic dysfunction is really so much more of a spectrum.

You know, it’s not an on and off switch where, all of a sudden one day, you’re totally fine with how you’re processing glucose and then the next day, you’re just diabetic. It’s really much more probably of a multi-year, if not decade, march towards these processes just not working effectively. And so, there’s really a huge opportunity to intervene and to optimize much earlier on in this process before you really have this sort of overt, fulminant manifestation of disease.

So currently, right now in our country, you know, metabolic dysfunction is really like epidemic proportions. We have 128 million Americans with prediabetes or Type 2 diabetes. Of that 128 million, 90 million are prediabetic, meaning they’re like, they’re on the way towards diabetes. And of that 90 million, 90% of people have no idea that they have this problem.

They’re walking around with impaired glucose tolerance, and they are not aware. And so, that’s a huge population right there, of people kind of moving on this spectrum, but even earlier on in the spectrum, so not even pre-diabetes, you know, normal fasting glucose, normal responses to oral glucose tolerance tests, there’s still room for improvement.

So, and the sort of optimization, even in the normal level, can really improve quality of life. So, we know that when you eat food, basically, you’ll eat some food and your glucose will naturally go up, probably, a little bit, unless you’re eating, you know, zero carbohydrates whatsoever in your meal, but it’s natural to have a little elevation.

But when that elevation becomes like a sharp spike followed by a sharp dip, that process can have a lot of ramifications for your day. It can cause, that spike and dip, sort of more like a mountain and valley than a gentle rolling hill of glucose, can lead to fatigue. It can lead to a little bit of anxiety.

It can lead to brain fog. And these are things that people kind of walk around with, thinking this might be normal, to sort of be like super lethargic after a meal, or to have sort of really fluctuating mood throughout the day. But what’s really interesting is that when you can see this on your continuous glucose monitor and realize that these subjective experiences are actually, really linked to this up and down with your glucose and identify what food or activity is actually leading to that, you can start, you know, having so much more granularity, and sort of actionable insights into these pain points of our day-to-day living. And so, there’s really like cool opportunities for essentially working to get the glucose line as stable and flat as possible, and just sort of seeing your day kind of, and your performance just sort of uplevel.

So that’s, I think, a really exciting opportunity for more, the optimization and performance side of things and yeah. So, I’d love to hear about your guys’ experiences using this, and if you’ve kind of felt any of that, you know, during your CGM experiences?

Host: [08:34] Yeah. Because I think we’re really both, in the realm of optimization. I am curious, real quick, so you said a lot of people are walking around, that maybe are pre-diabetic and they don’t know, or just have glucose intolerance and they don’t know, why do people not know? Are they not going to the doctor? Or doctors not testing A1C?

Dr. Casey Means: [08:52] Yeah. So, there’s three main ways to test for pre-diabetes or diabetes.

So, the first is checking a fasting glucose, which for most people will be done yearly, but certainly not everyone, not every young person is going in for a, you know, for a glucose check every year. So, in terms of ranges, so fasting glucose of less than a hundred is going to be considered normal, fasting glucose of a hundred to 125 is prediabetic, and 126 or above, milligrams per deciliter of glucose in the blood, is considered diabetic. You can also test by doing a hemoglobin A1C test, which is a blood test that’s looking for essentially, a 30-day average of blood glucose. So, that’s looking at red blood cells and how much glucose is stuck to them. So that’s called glycosylated hemoglobin (hemoglobin is in the red blood cells) and how much sugar is stuck to it. You can measure this and determine what range you fall into. And then there’s also a more dynamic test, which is where people will chug this really nasty glucose drink that either has 50 or 75 grams of glucose in it. And then you get a blood test at 60 minutes and two hours, baseline 60 minutes and two hours, and see kind of what happens afterwards. And based on those thresholds, you know, you’re categorized as normal, pre-diabetic, or diabetic. And so, for the average healthy person, they’re not going to be getting a hemoglobin A1C or an oral glucose tolerance test because there’s just, those are, you know, more invasive and you’d have to have some clinical suspicion that there’s a problem going on to get those.

So, for those people, it’s mostly the fasting glucose test. And, you know, it’s a good question of why 90% of those people walking around with prediabetes don’t know it, it may be that it was a little bit elevated, and their doctor didn’t think it was maybe worth really focusing on or mentioning or mentioned a few, you know, dietary and lifestyle tweaks, but not really necessarily like a plan or make it really obvious.

It’s also interesting because it can kind of bounce around day to day, and I’ve definitely noticed this in myself. Like fasting glucose can, you know, be a 10point difference some days, based on what I’ve eaten or how I’ve slept or whether I’m stressed out or whether I’ve been exercising a lot that week.

So, there is some of this dynamic nature to it, and I think that really highlights sort of the spectrum nature of it, you can move backwards and forwards sort of frequently. So, there’s that. And then I think another thing that’s kind of interesting about the fasting glucose thing is that, right now, we lump everyone under a hundred, into the normal category.

But what more research is sort of suggesting is that that catch-all for quote unquote normal is probably not actually accurate. It’s probably more likely that, like upwards to 90, to 100, that’s like a much higher risk range than if you’re down in like the 70 to 90 range. So, based on my review of the literature and the studies that have been done about risk ranges within the normal category, it really seems that 72 to 85 is actually the range that we should be shooting for, for fasting glucose.

And while these criteria put out by the ADA, the American Diabetic Association, are sort of the catch-alls for like population-based data, we really should probably be shooting for a narrow range. And there’s some really interesting studies out there. There was a big study in the New England Journal of Medicine that looked at a lot of healthy men and basically categorized anyone under a hundred fasting glucose and separated them into cortiles.

So, it was like 70 to 78, 78 to 85, like 85 to 92, and 92 to a hundred, or something like that. And the people in the lowest cortile versus highest cortile of normal, the highest cortile had like a five times hazard ratio for developing diabetes in the future. So, it seems like, as you move along, even in the normal range, you’re setting yourself up for potentially developing prediabetes and diabetes.

And the same is true for stroke and cardiovascular outcomes, even in the normal range. As you move higher towards a hundred, your risk of ischemic and hemorrhagic stroke significantly go up. That exponential sort of rise starts far before a hundred. So, we really should probably be thinking deeper about these fasting glucose levels, and not just shooting for normal, but shooting for an optimal range. But consensus on that in the medical community or even discussion of that, is not happening right now. So.

Host: [12:57] And that’s probably for. Is there not any movement towards recategorizing those standards? Like, what is the resistance there?

Dr. Casey Means: [13:05] I think in conventional medicine right now, we’re kind of just like playing triaged catch up. Like, it’s like, if you are in the normal range, like we’re not going to worry about you. Like, we have so much.

Host: [13:16] We don’t have time for you.

Dr. Casey Means: [13:17] We don’t have time for this and also, within that, well actually, within any range like, to really get people to improve these numbers, it’s a very nuanced discussion. I mean, this is talking about precision nutrition, personalized diet, exercise, stress management and, you know, autonomic nervous system regulation, exercise, you know, type frequency.

That’s not, you can’t fit all that into a 15-minute conversation, which is pretty much what the average primary care doctor is getting. So, if you can sort of see a 99 fasting glucose and say, Oh, I don’t need to worry about diabetes, prediabetes, nothing, stamp of approval out, you know. Unfortunately, I think that’s kind of where we’re at because the system is just so overburdened right now. We have such a massive amount of chronic disease.

You know, you’ve got 74% of Americans are overweight or obese, you know, you’ve got this 128 million people with metabolic dysfunction, like, and then a bunch of other lifestyle and dietary related chronic conditions. You’re trying to like, diagnose, prescribe a pill, get people out. And so, you know, to really have these like super nuanced discussions about moving your fasting glucose from 99 to 85? I just don’t think it’s the priority right now, unfortunately. Even though I think the ROI on prioritizing that would be absolutely massive, So. Yeah.

Host: [14:36] Yeah. And I think that’s an issue with all lab testing, right, I mean, that’s where functional medicine really thrives. It’s like, you’re not looking at normal ranges, you’re looking at optimal ranges.

So, whether it’s glucose or TSH or cholesterol or whatever, I think, like you said, Okay, your normal go. You’re fine. Not optimal.

Dr. Casey Means: [14:56] Yeah, absolutely. There’s this amazing researcher out of Harvard, Todd Rose, who wrote the book called The End of Average, that talks about averages and threshold-based diagnoses in medicine and how, you know, on a population level, these things are helpful.

They help us triage. They help us categorize people into buckets for treatment and for diagnosis and for billing and all of this stuff, but on the individual level, it’s fairly irrelevant, you know? So, moving away from that into more the n of 1, personalized approach to medicine is, I think, where we absolutely need to go.

But, and again, I think it would be in the long run, probably cheaper, you know, assess people really in a detailed way, really optimize their diet and lifestyle, keep them healthy for the long-term. Ultimately, that’s high value. Outcomes over cost is going to be the right ratio there. But right now, our system’s not set up for that, in the way that we bill and the way that we practice medicine. So.

Host: [15:50] But you also need the patients or clients to be proactive and, you know, be taking responsibility for their health. So, it’s not just the healthcare and the medical side, it’s, you know, the US population. A patient wanting to make change, I guess.

Dr. Casey Means: [16:06] Yeah. I think that’s so true. Yeah. Yeah. And that’s where I think, you know, what you guys are doing and what digital health is doing is so important. Because ultimately, the diseases that are bankrupting the health and the economy of our country right now, are diseases rooted in dietary and lifestyle choices.

And so, yeah, so I think it’s a really great point. Like this is not necessarily the thing that is, ultimately, should or can be fully motivated by the doctor. This is something that has to come from people wanting to make the choices day in and day out, that ultimately create the conditions in the body that lead to the expression of good health.

And so, the question really becomes like, is this even something that doctors should be necessarily focusing on, if it’s more of a behavioral thing, and this is a choice-based thing. And so, that’s where I think digital health can be really cool. Because fundamentally, it comes down to, we have hundreds of decision points every day: like whether we stand up, whether we walk, whether what we choose to put in our mouth, when we choose to go to bed, how we choose to emotionally respond to the stressful email we got. This happens like a million times a day and every single one of those actions ultimately stacks up to become metabolic health, to become health.

And so, you know, apps and tools that really harness the motivation and the biofeedback and the behavior change, things that we know, engage people and sort of help them gain buy-in to these choices, I think, is really where medicine should be moving. Because, you know, as a doctor, I’d love to be on someone’s shoulder 24 hours a day, you know, helping guide them with each decision point, but it’s not possible.

And even coaching like that, coaching is expanding hugely in medicine and I think that’s a great move. But even with coaching, you still can’t be with a patient 24 hours a day. But their phone, or their Oura ring, or their CGM, you know, or their WHOOP strap, these things can be with them. And so, as much as we can get doctors and professionals really working on these tools to help make them as high impact as possible for like optimizing those micro-optimizations with everybody, you know, every, you know, decision point, I think the more we’re going to move in the direction of health. So, I’m a huge proponent of doctors channeling some of their energy away from one-to-one clinical practice and more into these scalable behavior-change solutions, because I think that’s where we’re going to see, you know, the most return on investment, in terms of reversing the tide of the chronic disease epidemic.

Host: [18:34] Yeah. Really putting the power in the hands of the people, and personalizing this, right? Like, I feel like a huge complaint from people that are starting their health journey, is that they’re just overwhelmed. They don’t even know where to begin. It’s decision overwhelmed. There’s so many opinions. But when we give the individual the power with objective data and then also personalize it, it’s so empowering.

And then, what I really love about the CGM is that I can sort of like take ownership of what works for my body. And instead of doing what everyone else is doing, I’m like, I feel really proud that I’m doing something different.

Dr. Casey Means: [19:10] I love that. Yeah. And it fits so much with also, what we probably should be doing, in terms of our health, because there is no one size fits all.

We are kind of told that there is like these diets that probably work for everyone, but on a biological level, that’s probably not true. And so, to be able to, not only feel empowered that you’re kind of forging your own path, but to also be shaping a diet and a lifestyle that works best for your physiology, is like, you know, is positive on twofold.

And you know there was this very, very interesting paper that is part of what really motivated our company, which was out of the Weizmann Institute. It was published in Cell, in 2015, and it was called Personalized Nutrition by Prediction of Glycemic Responses. And basically, they looked at, you know, hundreds of people, healthy individuals, non-diabetic individuals, put CGMs on them and then fed them standardized meals that are, standardized snacks, like cookies and bananas.

And what they found was that, you know, two people will respond to potentially, have equal and opposite reactions to the exact same food. So, like, I could eat a banana, Lauren could eat a banana, Renee could eat a banana, and we could like, I could go up a hundred points on my glucose, you know, Renee could go up 50 points, and Lauren could go up, not at all.

So, the banana is probably not a good idea for me and a good idea for Lauren. And so, I think it’s super exciting to have this like tool that can help you stand in the face of so much conflicting nutrition information, really loud voices in this space saying, This is right. This is right. You know, 80% of consumers are confused about nutrition advice.

There was like a survey that had happened a couple of years ago.

Host: [20:45] I’m sure.

Dr. Casey Means: [20:46] And conflicting information. Yeah. Let me just go on Instagram, it’s like, you know, there were people saying like, You’re going to die if you’re not vegan and you’re going to die if you’re not keto, it’s like, what is a person to do? So.

Host: [20:58] So extreme. Yeah.

Dr. Casey Means: [20:59] Right! And so, it’s so, I think, empowering to have that tool. And, so like, one to just be able to stand up with all this information and then also, to walk into a grocery store, and like everything’s marketed as healthy and, you know, you can test things out and be like, Oh, okay, this is marketed as healthy, but it’s clearly not healthy for me.

And an example of that, that we see a lot in our customers and even on our founding team is oatmeal. Oatmeal is marketed as heart-healthy and yet, amongst our user base, we have seen spikes of like, 85 to a hundred, which is basically going into like diabetic levels. And, you know, that, Sure, like it’s got whole grains and it’s got fiber, a little bit, which are associated with cardiovascular health, but that big of a glycemic fluctuation is going to cause, you know, endothelial dysfunction, inflammation, glycation of your cell walls, of, you know, various proteins in and cell membrane, and like, it’s going to cause all of this physiology that’s very bad for cardiovascular health, oxidative stress. And so, we are just like, Oh my gosh. Like, oatmeal is an overt example, but you can think about all the smaller examples to, you know, keto, PowerBar-type things, like exercise bars that say they are keto, but then spike people 30, 40 points. Like, it’s just so, I think it’s really empowering to have that tools in the box.

Host: [22:20] Yeah. So, can you speak to the flaws of like glycemic index and glycemic load? Because for years, that was the Bible of blood sugar.

Dr. Casey Means: [22:31] Yeah.

Host: [22:31] I remember like trying to memorize the foods, like back in school. Oh gosh. What a waste of time!

Dr. Casey Means: [22:37] No. And like, you know, I think all of us went through that phase, where we’d like, try and do a low-glycemic diet, and eat things under 40 or 50 on the glycemic index. So, yeah. Yeah. So, the traditional idea of a glycemic index was, people would basically eat 50grams worth of carbohydrates, of a specific food, and then see how high the glucose rose, in the blood.

So, this is problematic to start with, because we don’t often eat 50 grams of a specific carbohydrate of food. Like 50 grams of carbohydrates of watermelon is like a lot of watermelon, versus of table sugar, it might be a very, very small amount. So it’s impractical in the sense that we just don’t often eat that kind of quantity of foods. The second thing is that, we don’t generally eat foods in isolation. So we don’t just like eat straight white pasta, you know, we eat pasta generally, with some sort of fat source on it, like a, you know, Alfredo sauce or whatever, and all those interactions between foods is going to change the glycemic index of a food.

So, those are kind of reasons why, even fundamentally, it sort of isn’t super practical. And then what we’ve learned, more recently, like through this study that I mentioned from the Weizmann Institute and then a number of follow up studies that have essentially reconfirmed that information is that, people are going to actually respond differently to the same carbohydrate load based on their physiology.

So really, what we should probably be doing is moving towards personalized glycemic indices for ourselves. So, you actually test, you know, different amounts of carbohydrates and then different carbohydrates in combination with other macronutrients, like protein, like fat, and then other things like fiber, other insulin sensitizers like cinnamon or vinegar or things like that, and actually just see what happens to you, and kind of create your own glycemic index, which is really what my company is trying to do for people, is like let people develop their own. And what’s also interesting about it is, not only is there inter personal variability with the glycemic index, so all three of us will have a different glycemic index for oatmeal, for instance, but there’s also intra personal variability. So, even within myself, day to day, it’s going to be different. On a Monday versus Tuesday, I might have a totally different response to oatmeal. And that could be because of all the other factors that feed into metabolic health, like sleep, exercise, stress, microbiome.

In that paper that I mentioned, they looked at all these different responses to food and then took a lot of other data from these individuals, like BMI, body fat percentage, they took a bunch of stool samples and looked at their microbiome, and they basically figured out an algorithm to predict how someone would respond to a particular carb load.

And some of the key things in there were things like physical activity, anthropomorphic features, so like, how much visceral versus subcutaneous fat someone had, which is kind of a proxy of insulin sensitivity, and then microbiome composition and things like the Bacteroidetes and the Firmicutes bacteria in the gut, the ratios of these things can have a strong impact on how we respond to food.

So, you know, digestion and metabolism is so complex, and so a carb in the mouth is not glucose in the blood. There’s a huge amount that goes on between that, that changes day to day and, you know, might lead to different responses. So, for all those reasons, I think we got to move past the standard glycemic index.

Host: [26:05] Yeah. And you just mentioned microbiome and I know, I think, Casey, you and I talked about this on the phone a couple of weeks ago, Lauren and I have both done the Day 2 tests, and we’ve been able to compare our results from that to the CGM, and I mean, it’s very comparable?

Dr. Casey Means: [26:21] Really?

Host: [26:21] Yeah. I haven’t seen anything that contradicts.

Dr. Casey Means: [26:24] That’s so interesting. So, you basically, they gave you a list of foods that they thought would be good for your glycemic control and they’ve pretty much matched?

Host: [26:33] Yeah. I mean. In a scale of 1 to 10, so if you’re a 10 this food is not going to be stressful. It’s not going to spike your blood sugar excessively. And low on the list are things that you really need to watch out for.

And we have pretty different ones, between the two of us.

Dr. Casey Means: [26:48] Really?

Host: [26:49] Yeah. Yeah. Well, so Laura and I were together a couple of weeks ago and we both had pineapple, and my CGM went so high, and I was like, Oh no, let me go check my Day 2, and pineapple for me, was like 1.2 out of 10.

Dr. Casey Means: [27:04] Wow.

Host: [27:05] And mine was like an 8, and it didn’t affect my CGM.

Dr. Casey Means: [27:08] That’s so cool. And you sent stool samples to Day 2, and did you guys send in any other lab data as well? Or just the stool?

Host: [27:18] A1C. I think that was the only thing they needed.

Dr. Casey Means: [27:20] It’s very cool. And that company, you know, was founded by the people who did that study at the Weizmann Institute. So that was kind of their consumer product spin off of that.

So, it’s super cool to see the, like the very much like, bench research, you know, turning into then, a direct consumer product that has actual, real clinical applicability. So yeah, it’s interesting to see that intersection. Yeah, and then there’s other cool companies coming down the pipeline, that are actually, trying to really hit the microbiome piece.

There’s a company called DayTwo. I don’t know if you guys have been in touch with them, but they’ve made an FDA approved probiotic that has been clinically shown to lower hemoglobin A1C in Type 2 diabetics. So, you know, I mean the probiotic market is all over the place in terms of quality and in terms of clinical data, but theirs is super tight.

Host: [28:16] Is it like a genetically modified probiotic? Or is there a real probiotic alive today, that does that?

Dr. Casey Means: [28:22] There is. Yeah, there is. Like, they’re using, I forget the main strain that they’re using, but it’s one that has been associated with, you know, improved glycemic control. And then the other two that have been big in sort of showing metabolic impact is the Bacteroides and Firmicutes family, and they have a relationship with both metabolic function and obesity. So, you can look at the Bacteroidetes to Firmicutes ratio and basically predict sort of propensity for obesity or metabolic dysfunction. So, yeah, reduction in Bacteroides tends to be associated with an increase of risk for diabetes. So, really interesting stuff there.

Host: [29:03] I’ve heard about them doing that on rats, where they have the obese rats, they take the microbes, they put it in the skinny rats, then they get fat.

Dr. Casey Means: [29:11] Yep, exactly.

Host: [29:13] I’m curious what the protocol is. Is the idea that you’re just changing the terrain after like, Oh, one run of this supplementation? And then you’re like, long-term your blood sugar will be affected.

Dr. Casey Means: [29:25] I don’t know what the duration of time that they’re putting people on these for, to see the clinical effect. I’d have to look into their clinical research data a little bit more deeply. Yeah. You know, I’m not a hundred percent sure. From my standpoint, you know, what I’ve, in terms of using probiotics in my own practice like, I tend to think of probiotics as sort of like, very much a transient booster.

So like, a lot of studies have showed that they don’t necessarily seed your microbiome with like, change the population long-term, but while they’re moving through your gastrointestinal tract, they interact with food in a positive way to create more short-chain fatty acids and create more of these healthy byproducts that are good for the body.

So, while you’re taking them, they’re going to have this beneficial effect, but then when you stop, you don’t necessarily see long-term changes in the microbiome. So typically, what I try and do, is use them for like a 3 to 5-month period, to help basically, improve gut lining, you know, function, you know, try and get as much sort of butyrate production and short-chain fatty acid production, as I can, out of these bacteria that I’m adding in with the probiotic.

And then, while doing that, get people to really improve their microbiome on their own, through dietary strategies. So like, lots of, you know, addition of fiber, eliminating unnecessary antibiotics, eliminating pesticides, you know, reducing animal protein consumption, not necessarily eliminating, but trying to get it down to like sort of a normal level. Not, you know, dozens of ounces per week, but more like a few, very thoughtfully chosen animal protein sources, and those interventions where it’s really more dietary-based, are going to lead to like the more long-term fundamental changes in microbial biodiversity. So, how Pendulum approaches that in terms of time, of course, I’m not a hundred percent sure if they have a dietary strategy along with that, but it’s cool to see like solid clinical research coming out of, you know, the space, in terms of supplements. So, yeah.

Host: [31:21] Well, that makes a lot of sense. So, the company’s called Pendulum? Is that what you said?

Dr. Casey Means: [31:25] Pendulum. Yeah. Yeah.

Host: [31:26] Cool. I’ll have to look into that.

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Host: [32:28] I have a question, when we’re looking at the CGMs, what are we aiming for? What do we want our day to look like?

Dr. Casey Means: [32:36] Such a good question. Yeah. So, what you’re going to kind of see as the output, like for people who haven’t used these before, is essentially, you can imagine you’re getting every 15minute data points and ultimately, that’s going to lead to a graph essentially, of your 24hour glucose period.

And so, what you really want, I would say first and foremost, is to be minimizing variability. You want a flat, sort of, as flat as you can, stable line without huge mountains and valleys. So, those big spikes and dips are what we call glycemic variability or glycemic excursions. And those are problematic because every time you have a big glucose surge in the blood, your body is releasing, from the pancreas, a bunch of insulin, and that insulin is required for the glucose to be taken up by the cell and processed by the mitochondria.

And when that insulin is getting stimulated in a huge amount, like over and over again with these big spikes, the cells, they’re seeing all this insulin in the blood and it’s having to bind all these insulin receptors on the cell, and over time, this all gets overwhelmed and it’s sort of becomes numb to it.

It’s like, there’s so much glucose. We are shuttling so much glucose across the cell membrane, the mitochondria have too much to do. We need to stop. Like, we need to like hold up. And so, the cells sort of, as a protective mechanism, become insulin-resistant, and they sort of stop responding to a signal as well.

So now that pancreas has to produce more insulin to overcome that sort of numbness. And so then, you get what’s called insulin resistance, which is essentially the first part of moving down the spectrum of metabolic dysfunction, because you can imagine, you know, the pancreas is producing more and more insulin.

The cells are becoming more and more numb to it. So now, the glucose can’t get in a cell and it’s starting to rise in the blood. And as it starts to rise in the blood, that’s when you see the fasting glucose sort of start to rise over time. So, this insulin elevation actually probably, predates the glucose elevation in the blood by a long time, probably years. And most functional medicine providers are going to be testing fasting insulin on people, to see how they’re doing, in terms of this early marker of metabolic dysfunction, but in conventional practice, you don’t really see anyone checking fasting insulin yet, but I think that’s a marker, that we’re probably going to see come online, as an early marker of metabolic dysfunction.

So ultimately, that’s the problem with these big spikes and dips, is that you’re just essentially, telling the body to move down that pathway of insulin resistance and metabolic dysfunction. And the more you can tighten those spikes and dips, the more you’re just letting the pancreas settle down, letting the insulin be in a normal level, you’re still getting plenty of glucose to power energy, to power the muscles.

You’re just not getting this huge excess. And then separately, from the insulin resistance stuff, those glucose elevations alone can trigger physiology that’s problematic. So, the three main things that you really need to worry about with these big glucose spikes is, it triggers inflammation, so the body sees all this glucose and it’s sort of like, Why is there so much glucose in the bloodstream?

Is this a problem? Like, are we, is the liver dumping this out because we’re under threat and we need to be like running from a lion? Like, what is happening? And so, it tells the body something might be wrong, and that triggers inflammation. So, one is inflammation. The second is that, high concentrations of glucose in the blood causes a process called glycation, which is glucose sticking to things all over the body.

It can stick to blood vessels, it can stick to cell membranes, it can stick to proteins. And when sugar sticks to things, it causes some dysfunction, like those proteins aren’t going to work as well in the body. Things are going to get, you know, rusty, essentially. So, you don’t want glycation, and glycation underlies a lot of problems.

One fun example is actually, it promotes wrinkling of the skin. So, when you glycate your collagen in the skin, it cross-links it. And when the collagen is cross-linked, it produces wrinkles. So that’s, and it’s not surprising. Like, someone who’s just generally unhealthy is, you know, more likely going to move down that aging spectrum on all accounts, and one of those may be the way their skin appears. So, inflammation, glycation, and then the third would be oxidative stress. So, when you dump all this glucose into the body, you’re having a lot of strain on the energy-producing pathways of the body, like the mitochondria we talked about, and a number of others.

And when you’re doing all of this sort of metabolic processing and cleanup, it generates these metabolic byproducts called free radicals, and free radicals are these, you know, byproducts in the body that are reactive and they have generally, an unpaired electron that wants to go around and kind of bind with things in the cell.

And they can just bind to things and doing that cause damage. And so, high glucose, like, so insulin, inflammation, glycation, oxidative, stress, it’s all stuff you don’t want, that you can avoid by figuring out what foods don’t spike you, what food combinations help minimize your glycemic excursions and keep it really tight and narrow.

So that’s sort of what you want to be shooting for, like long story short, is flatter. And over time, as you keep those excursions lower, you’re going to get your insulin sensitivity moving in the right direction and then you’re sort of baseline or fasting glucose will likely start to come down, as you tighten up the curve, over time. If that makes sense.

Host: [37:54] So you’re saying flatter, but you don’t want it, do you want to completely flat? Like you should have some spikes, right? I’m under the assumption that you want to have a little bit of elevation, postprandial, that would be normal, and then come back down, but it’s about how much, and how much is healthy.

Dr. Casey Means: [38:10] Yeah, absolutely. Yeah. I mean, like, sort of the hills versus mountains is how I would say it, you know. And on the Levels blog, we have this post that’s called like What’s Normal: The Ultimate Guide to Healthy and Optimal Glucose Ranges, that’s really sort of this look at this from not the standard like practice, sort of ADA guidelines, but like looking at the literature, what should we probably be shooting for, based on looking at sort of increased risk for various glycemic trends. And so, if you look at populations of healthy people, essentially, for 90% of the day, they should be between 70 and 120 milligrams per deciliter on their glucose. So in like the healthiest populations, that tends to be where people spend the majority of time.

So, fluctuating post-meal, between like 70s, or if you’re in the 80s or 90s at baseline, up to about 120, seems to be normal and fine. Going like way up to 150, 180, 200, that’s going to be where you’re going to start to see these problems. So, some gentle rises and falls is totally physiologic and normal, and when you eat carbohydrates, you are going to have a little bit of an elevation. Looking at the research, it looks like, yeah, trying not to get above about 120 post-meal, and trying to not have an excursion more than about 15 milligrams per deciliter after a meal, is probably ideal. This is not like standard criteria.

This is more of just a holistic assessment of what seems to be lowest risk. If you look at more criteria for dysfunction, so if you have a normal person take an oral glucose tolerance test, what is considered dysfunctional is that they would go up and then not be under 140, 2 hours after the meal. That’s what the ADA says. If you drink the 75 grams of glucose and then, you know, you’re going to have a huge glucose swing, most likely, and then if, after two hours, you’re under 140, that’s considered normal. And I think that’s egregiously too high. I can’t remember the last time I’ve been above like 120, you know, on my glucose.

So, the idea of being 140, 2 hours after a meal, to me, just seems like so lenient. I think it should be much, much, much tighter range. So, on our app, we have people basically, our green zone is 70 to 110. We want people to sort of be really shooting for that, for the vast majority of the day. And if you go above that, that’s fine, but the higher you go, probably the more you’re moving into these physiologic occurrences that are detrimental. But absolutely, Lauren. Like, a little bit of up and down is fine. It’s really just trying to tighten up those swings.

Host: [40:53] Got it. It makes sense.

Dr. Casey Means: [40:54] And the other thing, just one last thing, like, when you go higher and you release more insulin, you can potentially get into what’s called reactive hypoglycemia, which is like, you produce so much insulin that the body sucks up all the glucose really, really fast, and then you actually go, you, you know, plummet and go below your pre-meal baseline. So, you’ll see this shoot up into the red, drop down into the red, and that reactive hypoglycemia, we know, is really associated with a lot of subjective sort of complaints that we hear from people commonly, like fatigue, brain fog, anxiety.

So, just avoiding those spikes to try and avoid the dips is also, I think, an important piece of it as well.

Host: [41:33] Right. A lot of those dips are like the people that run to the vending machine in the afternoon. Like they need like a candy bar or a cup of coffee, right? It’s probably like that drastic drop.

Dr. Casey Means: [41:42] To kind of get it back up, yeah, and feel good again.

Host: [41:44] Right. And then it just keeps going and going and going. Like it’s a vicious cycle.

Dr. Casey Means: [41:47] Right! And I think that’s the roller coaster that like, many Americans are on for decades. Right?

Host: [41:53] Yeah, I’m sure.

Dr. Casey Means: [41:53] Like, you know, carbs, insulin spike, crash, carbs, insulin spike, crash, you know, and all that exposure to insulin is, yeah, is causing problems and yeah, it’s exhausting, and your pancreas gets exhausted and your cells get exhausted. And you know, it really, fundamentally, is what underlies our obesity crisis too, because when your insulin is high, it’s telling the body that there’s tons of glucose energy on board. So, it tells your body, Oh, we don’t need the fat to be burned for fuel because we have all this glucose. And so, what that signals to your cells is, Stop all fat oxidation, stop fat burning. And so, when your insulin is elevated, you’re essentially not able to burn fat for energy, for performance, or energy for weight loss.

So, you know, the kind of, in terms of weight loss and why it may, at scale, has been essentially, a failure, like diets often just don’t work, is I think a lot, because we’re not actually focusing on insulin as the root of why we’re not able to burn fat. And if we can get our insulin down, we can unlock those pathways that tell our body like, you know, Burn fat. We need the fuel. There’s not enough glucose on board. So.

Host: [43:03] That’s huge. Because I think a lot of people still think, you know, eat six times a day, and they’re not really maybe focusing on what they’re eating. So, if they are eating six times a day, it’s spiking. So, it’s like, your insulin just ends up being high all day and then they don’t know why they can’t lose weight. Ugh, yeah.

Dr. Casey Means: [43:19] Exactly. It kills me when I hear, you know, you got to, Oh my gosh, I see a lot of articles that are like, You need to eat in the morning to get your metabolism going, to rev, I feel like it physically causes me pain to see that. It’s because when you, you know, getting your metabolism going, that’s just false, you’re getting your insulin going, if you do that, which theoretically, is getting your glucose burning going, but it’s not. It’s shutting down your ability to burn fat, which is ultimately, the goal for probably around 74% of Americans who are overweight or obese. And so, it’s, I mean, certainly eating carb free, like a handful of nuts or something like, that’s one thing going to have a very low insulin response, but since our food pyramid for many years said, eat 6 to 11, you know, essentially, grain servings a day, that’s not what people were reaching for. It was like a vegetable or a handful of nuts or things that aren’t going to spike insulin. So, there’s actually, one, a really fascinating study that I loved, looked at what happens when you give two different groups of people, the same amount of calories in the exact same amount of food, but one of the groups eats between 8:00 and 2:00 PM and then stops eating for the rest of the day, and then one group eats between 8:00 AM and 8:00 PM. So essentially, full day feeding or time restricted feeding. And that’s sort of kind the example of the people who are snacking, eating six times a day, the 8:00 AM to 8:00 PM people, versus people who are maybe just eating breakfast and lunch, a late lunch, and then that’s it.

And the people in the shorter feeding window group, 8:00 AM to 2:00 PM like, had much better metabolic parameters, lost weight, better fasting insulin, better fasting glucose, so, same amount of calories, same food, and just when you ate. And so, for most people, I would say, A, restrict the amount of time you’re eating each day, to a shorter window, I mean, stopping at 2:00 PM is pretty darn extreme, like, I wouldn’t recommend that for most people because it’s very challenging, but, if you’re going to narrow your window, put it in the early part of the day, because that’s when we tend to be most insulin sensitive, and just stop eating a little bit earlier than you would, each day.

Ideally, maybe around 4:00 to 6:00 PM, for your last meal. Because once things get dark outside, and melatonin starts being produced, melatonin actually has an impact on our insulin sensitivity and our ability to produce and respond to insulin. And so, you’re going to get much more metabolic bang for your buck, eating it earlier in the day, than late in the day.

So, you know, I tend to get people to try and orient around eating their higher glycemic stuff, higher carbs stuff earlier in the day, when they’re going to be more insulin sensitive. There is variability. We have customers like, Levels customers who actually don’t find that to be true, in their own personal experience, when they test this out, but on the research side of things, that is what tends to be true. So.

Host: [46:13] That makes sense. Two of my biggest lessons so far, from my CGM, have been about frequency and meal timing, not necessarily what I’m eating.

Dr. Casey Means: [46:22] Interesting.

Host: [46:22] I’ve never been like a huge snacker, but I have cut out the snacking since I got my CGM, because I just could not get steady levels.

It was like kept spiking, kept spiking. It’d be like doing a workout every hour. It’s like, my body was getting exhausted. So now that I’ve just really focused on solid meals and also eating earlier, which I’m always trying to do, but we know it’s really.

Dr. Casey Means: [46:44] So hard.

Host: [46:45] Especially when you’re eating with friends or family like, it’s hard to get everyone to be on your schedule. When I do it, I have steady levels. It’s really awesome. And also, I’ve experimented with some fasting. And it’s crazy how just not eating will keep it nice and steady.

Dr. Casey Means: [47:04] It’s so effective!

Host: [47:05] Yeah.

Dr. Casey Means: [47:06] It’s hard! I mean, it’s like the miracle of like, fasting and time restricted feeding, like eating, I feel like the last couple of years, the research has just really coming out about this, and especially with regards to weight loss and metabolic health, but it’s hard, you know. Like, I think it’s, we’re so used to eating late, in our culture, and, you know, we’re not comfortable with hunger. We’ve been basically, trained to want, that hunger is like a scary thing. And so, I’m excited about the different digital health tools coming down the line, to just help support people, in this regard. I think CGM is one of them. I think heart rate variability tools is another one, so like Oura, WHOOP, Leaf Therapeutics, Heart Math, because eating late at night can sometimes totally throw off your heart rate variability overnight and so that’s another way of sort of seeing the feedback of what’s actually happening when you eat. Seeing that spike in glucose throughout the night is very de-motivating to eating at night. And then these apps like Zero, like you know, Peter Attia’s company like that do the fasting. I think I’ve seen you, have you guys posted Zero stuff? Or which fasting?

Host : [48:06] You use a fasting app. Oh my gosh, what is it called? Oh, LIFE. I use LIFE.

Dr. Casey Means: [48:10] Okay, cool. But all these things, like I think, add just that extra piece of like motivation when it’s really hard to do it on your own. And sometimes, there is, feels like there’s a social cost to it? So like, adding in this extra dimension of community and biofeedback, I think it’s really exciting. So.

Host: [48:26] So, I have a selfish question. I mean, I love fasting. And like, for me, over the years, I have found that 14 hours of fasting overnight, like seemed to work well. I thought I was sleeping well, my Oura ring is happy, digestion is good with that, but since I had my CGM, I saw my blood sugar was dropping in the middle of the night. Like sometimes into the 50s.

Is there a number that’s too low while you’re sleeping? Like, cause I, then I started doing a snack before bed. I was doing one tablespoon of nut butter with a teaspoon of raw honey, and then my blood sugar would stay at 70, the whole night. Then I’m losing my fasting window. So I’m like, what’s the balance there?

Dr. Casey Means: [49:09] Yeah. I mean, I think the real answer is, we don’t know.

Host: [49:13] Okay.

Host: [49:13] Like, this has been, there haven’t been studies that basically, have said like, one, we have not had many studies where we put CGMs on healthy, and not just healthy, but like, very healthy optimizer people, and seeing what normal overnight glucose is, I mean, there’s some research on this, but to say like, if you go below 50 it’s going to cause X, Y, and Z outcome, not known.

So, I think this is a, we’re entering an exciting era, where we’re going to be able to start figuring these things out, because so many more healthy individuals, non-diabetic individuals are using this technology, and the data is going to, we’re going to start to be able to have some outcomes data on this.

So that’s sort of big picture. Like it’s hard to, I can’t give a exact number. But a couple of things that are important to keep in mind with the sensor, so, first thing is that during REM sleep, our glucose does drop, glucose tends to be like 5 or percent lower during REM sleep, so you may, I don’t know if you’ve noticed any correlations between your Oura ring data and your glucose data, but sometimes there is.

Host: [50:12] I have.

Dr. Casey Means: [50:13] And do you see a dip during the deep sleep and the REM?

Host: [50:16] My glucose dips line up with wakefulness.

Dr. Casey Means: [50:20] Oh, interesting.

Host: [50:22] And I don’t always remember waking up. So, like sometimes, I’m like, Oh yeah, I did wake up and go to the bathroom at that time. Other times, I don’t remember. So maybe I just kind of rolled over, but I see that little like, light. That must be at the tail end of your REM, right? You’ve dipped and then that will go up.

Dr. Casey Means: [50:35] Virtually. That’s possible.

Host: [50:37] Oh! Oh, maybe. I got to keep playing with that.

Dr. Casey Means: [50:40] Yeah. And then the second thing is, in these studies, like I was mentioning where they just like put CGMs on a bunch of healthy people and you kind of see where people fall during the day and I mentioned, you know, 91% of the day there’ll be between like 70 and 120, that extra 9%, you know, like when they’re not between 70 and 120, you do find that people do spend some percentage of the day between the 50s and 70s, whether that’s problematic, these were more observational studies, so we don’t actually know. But it is not abnormal, based on these population observational studies spend some time between 50 and 70. One additional, kind of interesting thing is that, there was a study that showed that with cardiovascular and stroke outcomes, looking at fasting glucose, that lower is not necessarily the best. So below 72, for fasting glucose, risk of disease actually went up. So, it was like a J shaped curve. So, the lower you are, a little bit more risk. The lowest risk, seem to be, between like 72 and 85, and then it starts to go up after that. So, the reason for that might be because the body releases some stress hormones when the glucose is too low and like chronic catecholamine or stress hormone release may, kind of, trigger cardiovascular issues, endothelial dysfunction.

So, that’s like very limited data, but that’s actually why, on our recommendations for fasting glucose, we say between 72 and 85, because there is some research to suggest really low on fasting glucose could actually, kind of, generate like a stress response. But so much more research needs to be done there. And then the last, oh.

Host: [52:14] Yeah. So, we could test our cortisol while we’re sleeping, and test our blood sugar in our HRV, all at the same time.

Dr. Casey Means: [52:24] And inflammatory markers. Yeah, I think that would be so cool.

Host: [52:27] Now where’s that tech. Let’s go. Maybe in like 2030, we’ll see that.

Dr. Casey Means: [52:32] The one other just, sensor-error type thing to keep in mind is that, there is something called pressure-induced sensor error, which is where when you lay on the sensor, it can cause erroneous values, sometimes really deep dip.

So, they did this study where they put CGMs like all over, this is kind of sad, but they put them all over pigs, and then they had the pigs like roll from side to side, and when they were on the sensor, like there was significant glucose drops. So, it could be interesting too. I don’t know how you would test that, like videotape yourself during sleep or something, but like to see if you’re rolling on it. And then the last thing is that, at lower values, the sensor is more inaccurate. So, these sensors are optimized to be most accurate at values that are going to be most relevant to someone with Type 2 diabetes, so really, between like the 80 and 200 range. So, at much lower values, like below 80, you’re going to start to see more divergence between the sensor value and actual blood value. It’s, you know, still quite accurate, but when you start to get into like the 60s, for your glucose, there may be more of a delta between what’s actually going on in your blood and what’s happening on the sensor. And the newer generation sensors that are coming out, like the FreeStyle Libre 2, which was just FDA approved, are going to be more accurate at lower values. But those are just all things to keep in mind, when you think about low values. You know, naturally lower in REM, probably not abnormal to be spending some time, as a healthy individual, between 50 and 70, could be pressure on the sensor, you know, could be sensor error. So.

Host: [54:05] Okay. Yeah. I had a weird experience when I was flying, a couple of months ago. It dropped. It was between like 30 and 50, for hours. Like, while I was in air, on the plane, it was like dangerously low. Does that have anything to do with the pressure error? I was like, there’s just absolutely no chance that that’s correct. So, I wasn’t stressing about it. But I was like. Yeah, I mean, you were conscious, right? Like. Yeah, and I was eating. I was like, 30? Come on.

Dr. Casey Means: [54:35] I have no idea. I mean, this could be.

Host: [54:37] I think I ended up getting rid of that sensor or I was like, something’s wrong with that. I’ll just start over.

Dr. Casey Means: [54:40] Yeah. I mean, in those moments, anytime I like, go super low, I generally do a finger stick, just to like, double-check, and oftentimes, it’s like way off at a super low value.

So, that’s one thing to try. I do tend to carry around a finger stick, ketone, glucose monitor everywhere, just because, you know, I love checking these things. But, you know, and then sometimes, I’ve been low blood sugar because I’ve done really big endurance workout or whatever, I’ve, you know, have been hiking all day and hadn’t, didn’t have a lot of glucose, and then I come back, and I’m actually feeling a little bit hypoglycemic. And then I see my glucose and it’s like in the 60s and I finger prick, and then it’s like actually in the 60s. And so, you know, I think it’s, checking, sometimes, is helpful, with a finger stick, but yeah.

Host: [55:28] So, I have some questions about working out.

Dr. Casey Means: [55:30] Yes.

Host: [55:30] So, my experience has been with endurance stuff, it goes down, and with strength, it goes up. What are the benefits of each? And like what is a healthy range for those?

Dr. Casey Means: [55:40] Yeah. So, every type of exercise is going to have a little bit of a different reaction on your CGM. And I think, probably, for the purpose of the conversation, like talking about doing this fasted, is the best way to do it. Because if you add in like a big pre-meal snack, like that’s going to change the data. But, with power sports, like lifting and high intensity interval training, these are both sports that are probably going to cause a glucose elevation on your CGM. And it sounds like that’s what you saw? Is that right? How high did you see?

Host: [56:12] It would get to like 120. And I was fasted. So doing like pretty intense kettlebell stuff or, you know, just lifting pretty heavy.

Dr. Casey Means: [56:14] Yeah. Awesome. Yeah. So that is pretty normal, from what we’ve seen. And the physiology of it is pretty interesting. So, with a power sport or high intensity interval training, where you’re kind of going above 80% of your VO2 max, on the HIIT training, those are both, things that are going to cause your body to think that you’re under stress. Like, it’s going to translate hormonally, into catecholamine release and, you know, we need to run from the lion, type of thing. So that’s going to signal to your liver, which stores your short-term energy stores, your, really, quickly accessible glucose, it’s going to say, We have a problem. Dump that into the bloodstream so that we can feed the muscles to run away from the lion, i.e., the kettlebells or the high intensity interval train and workout. So, the body typically is going to tell the liver to put it like, more than it needs, than the muscles actually need, and that mismatch is why you see a glucose elevation. So, it’ll do like eightfold what you need, and the muscles need about five-fold higher, and so you’re going to see that little bit of increase. So, it’s kind of interesting to know, it’s almost like a new gauge to see like how intense your workout is, you know? Like, we’ve seen people do CrossFit fasted, and have a 50point glucose elevation. And so, it’s like this strange metric for like how stressful or intense is your workout, not necessarily a good thing, but it is interesting to see that.

And, you know, in terms of, is that damaging, like, is that sort of like a food induced spike? It doesn’t appear that it is, in the same way. We know that high intensity interval training and power sports both, actually are insulin sensitizing. You’re more insulin sensitive the day after those workouts and, doing long-term, ultimately, is going to be very good for metabolic health and insulin sensitivity.

So, they don’t seem to be damaging in the same way that a food induced glucose spike is. It’s different physiology. And then with the endurance training, just like you said, we do often see sort either a flat or a slow decrease in glucose. So, at lower intensities, you’re going to be doing more of a mix of fat burning and glucose burning. At the higher intensities, you’re going to, as you move up, in terms of the intensity, you’re preferentially burning glucose over fat, but at like a walking, a hiking, a slow jog, it’s going to be much more this mix of fat and glucose. So, you can imagine, you’re using a little bit of the circulating glucose in the blood and that’s going to kind of keep you steady or kind of go down, your liver is going to be probably a little teeny bit of glucose coming out, to sort of refuel the bloodstream, and then you’re also going to start tapping into your fat sources for energy. So, that’s really, those are great for metabolic health as well, by being able to tap into both fat and glucose for energy, you’re gaining metabolic flexibility, essentially, the ability to flip-flop between what energy sources you’re using, which is associated with sort of an adaptable metabolism, which we want.

So, that’s what you’d be probably expecting. There’s been some great research showing, even with walking, a really low intensity sort of, you know, endurance-type activity, walking for just two minutes, every 30 minutes, throughout the waking day, can significantly lower 24hour glucose exposure, even more so than a big chunk of walking.

So, they basically had three groups, one that walked for 30 minutes before all three meals, one that walked for 30 minutes after all three meals and one group that walked for two minutes, every 30 minutes throughout the waking day. So, in total, they all walked the same amount of time, but, you know, it interjected in at different times of the day.

And the group that did that every 30 minutes was, by far, the lower 24hour glucose levels. So, it seems that activating these big muscle groups regularly throughout the day seems to be what’s most important. And that, you know, again, hard to practice, but any reminders we can do on our apps and our wearables that kind of get us to just like walk around and do the two minutes of squats or walking, I think is really high value. Yeah.

Host: [01:00:20] Yeah. That’s fascinating. Yeah. So, the people that are sitting at their desk for eight hours and then going to the gym for two hours.

Dr. Casey Means: [01:00:28] Right.

Host: [01:00:28] Are kind of SOL.

Dr. Casey Means: [01:00:30] Well, and not going to, I don’t want it to like, poo-poo on that, like, anything is great, like movement, do it, you know, but I would.

Host: [01:00:39] Yeah. Just get up every 30 minutes.

Dr. Casey Means: [01:00:41] Yeah. Exactly! And I would love to see workplace environments that take this research into account, you know, and how cool would it be if every office just had like a couple of treadmill desks and a couple of ellipticals and a couple pelotons just like scattered throughout the workplace so that you could, it was just so easy to like, jump on for two minutes. It doesn’t interrupt the workday, probably would increase productivity massively, but like, I just want to see this scientific research actually, starting to go into like how we develop these built environments and, you know, ultimately. Yeah.

Host: [01:01:12] The ideal workspace. Yeah.

Dr. Casey Means: [01:01:16] Absolutely.

Host: [01:01:16] Okay, I’m going to start walking more often. So, sorry, I just want to go back for two seconds, just to recap. So, it’s okay that, when I’m doing those power-type exercises, for it to go up, as long as it comes back down, and I guess a part two question is, is that sort of categorized as a Hormetic stressor? Because I know like, if I do a cold shower or infrared sauna, my glucose goes up. As long as it’s coming back down, that’s okay? It’s okay to have that stress?

Dr. Casey Means: [01:01:41] Yeah, I would say so. And again, this is like with the caveat that like, we don’t know a hundred percent for sure, like, because we haven’t been studying super healthy people with CGMs for a long period of time.

Host: [01:01:50] Right.

Dr. Casey Means: [01:01:52] So, but I would say yes. I think it falls under the category of like that Hormetic stressor and you know, under a very different physiology than a carb-load glucose spike.

So, yes, agree. And you would not want to see your glucose going up during a workout, and just staying elevated. That would be a little bit abnormal. You might see that if you do a very hard workout and then have a recovery drink or something afterwards, you might see it in that scenario, but ultimately you never want to see the glucose going up and just floating in a higher range for like more than a couple of hours.

And then, I think just one other kind of interesting point to emphasize is that, you mentioned that you were doing some of this in a fasted state, and I think that’s a topic that, you know, is really interesting right now, thinking about exercising in a fasted state, it’s something we have never been taught traditionally.

It’s always like, you know, You’re going to pass out if you don’t eat before a workout, some people who lift, like you need a high calorie, high glucose fuel before a workout to spike the insulin so that you can get your biggest like muscle gains and things like that. But I think that there’s now, this movement towards more like the ketogenic workouts and things like that.

And I think there’s like really some interesting stuff to it, because if you’re working out in a high insulin state, it’s going to tell your body not to burn the fat for energy during a workout. So, you’re going to be dependent on glucose and you only have about two hours of glucose for a workout. And in a really high intensity workout, it might be less than that.

So, the glucose that’s stored in your muscle cells and your liver, that’s like all you got for quick short-term glucose. So, if you work out fasted, you’re going to burn through that pretty quickly, and then your body’s going to be forced to burn fat, unless you have really high insulin on board, and then your body’s not going to be able to burn that fat, so all of a sudden, you’re going to get to the end of that, you know, your glycogen glucose stores, and you’re going to hit a wall. You’re not able to tap into that fat. So, by training your body in this like low insulin state, sort of fasted state for working out, you really flex those fat burning pathways.

And over time, are going to likely see that you can work out for longer and longer and longer fasted, because you’re just becoming like a pro fat oxidizer. So, once you burn through your glucose, you just flip the switch, and you can start burning fat. And, there is marathon runners, we are working with this great athlete, Anthony Kunkel, who’s a national champion endurance ultramarathoner. And he’ll do 15, 20 miles with zero exogenous glucose, no gels, nothing, totally fasted because he’s basically, just burning through fat during his workouts and he’s been training in a low-carb state for a long time. So, it’s interesting to experiment with. But you know, ultimately, yeah, you want to manage your fueling in sort of this nuanced way, to get the most out of your, you know, fat and carb burning. So.

Host: [01:04:45] Yeah. It’s interesting that you said you would hit a wall if you had supplemented or eaten before, and that probably just perpetuates the cycle. Because I know a lot of people, they’re like, Well, I just can’t. I just can’t. Because that’s all they’ve ever done, they’ve never pushed past that, and they’re not able lift that clutch.

Dr. Casey Means: [01:05:01] Yeah.

Host: [01:05:02] So it sort of claims the psychology, I guess, a little bit. Yeah.

Dr. Casey Means: [01:05:04] Yeah. And one thing to clarify, like I would say, if you’re just someone who’s like always been having a protein shake, you know, with carbs in it, before a workout and all of a sudden you’re just like, Oh, I’m going to workout fasted and go, and run 15 miles, like, probably not going to go well, right? Because you might not be fat-adapted yet, where you can really harness that fat oxidation pendulum. And it’s possible that you’re a little bit hyperinsulinemic, like you have high insulin at baseline because of being on this metabolic spectrum and so, it’s hard for you to burn fat. So, I would say it’s really like a journey of easing into being able to be a fat adapted person, and that journey starts with keeping those glucose spikes low, you know, doing some intermittent fasting, just training your body to live in a state where you’re not just burning carbs all the time. So. But it’s not something that’s going to be able to like turn on, the first time you try it, and probably will be torture, the first time you try like, working out in a bit of more fasted state. So.

Host: [01:06:01] Right. Yeah, I’ve heard Ben Greenfield talk about training his endurance athletes, where like, they will train in a fasted or keto state, and then when they actually go to compete, they do carb load. That’s interesting.

Dr. Casey Means: [01:06:13] Yes. Yeah. It’s a really cool concept like, called carb cycling is one term that’s sometimes used for it. There’s an awesome article on Geoff Wu’s website, Human, H V M N, it’s a really good blog. But there’s a really awesome research-based article on carb cycling that I recommend, which is basically what you’re talking about. Like, get your metabolic flexibility on point, so that you can use either substrate, fat or glucose, during a workout, but then when you really need to perform, like give this quick acting energy that you can use really fast. And it’s going to kind of be like extra potent, and you’re still, you know, at any point in a workout, no matter what VO2 max you’re at, it’s going to be some balance between fat oxidation and glucose.

Like the curves, essentially like, intersected around 50% VO2 max, when carbs exceed fat oxidation, but even at 80, 90%, you’re still burning some fat. Even at those really high amounts. And as you fast adapt, the curves actually shift a little bit, so even at those higher VO2 maxes, you’re burning more fat than someone who’s not fat adapted.

So, the carb cycling is cool because you get all this quick acting fuel, but you’re still in that, you know, 20, 30% of, that’s coming from fat, doing that really, really well, like, you’re burning that fat efficiently. So, I think it’s a really cool concept. Yeah.

Host: [01:07:35] I love that. Yeah. Oh my gosh. I could talk to you for like the entire day. I just want to follow you around, Casey.

Dr. Casey Means: [01:07:41] This is so much fun. Yeah.

Host: [01:07:44] Will you come back? Because I would love to talk to you more about food specifically, we didn’t even really get into that, so we’ll have to do a part two. Yeah.

Dr. Casey Means: [01:07:50] Absolutely. Yeah. After you’ve used the app and everything, like we should totally dig into the specific foods and stuff more.

Host: [01:07:57] Yeah. Yeah. So, I’m curious. I mean, before we let you go, where do you see the future being, with Levels, with CGMs, like, is this something everyone’s going to have one day?

Dr. Casey Means: [01:08:10] I think it is. I think it is going to be something that everyone uses at least for a short-term period, to basically, figure out what their optimized diet is, and kind of gain those insights, I think it’s valuable for everyone. So right now, I think it’s really the early adopters and the performance enhancement, you know, people who, like us, you know.

Host: [01:08:31] Biohackers.

Dr. Casey Means: [01:08:33] Biohackers who love this. The segments of the population that we’ve seen be like super early organic adopters, you know, the people who it’s like, We’ve done virtually no marketing, and they have just come out in hordes, I would say is the weight loss community, we did this small pilot with Justin Mares, one of the founders of Perfect Keto, where people were asked to keep their glucose under 140 for the entire month, and they lost, on average, which is pretty lenient, like it’s not that hard to stay under 140 for most of the day, and they lost on average nine pounds over 28 days, just by keeping their glucose under 140 and using the app to learn what would keep them under 140, so that was really cool. So, weight loss performance athletes, you know, we’ve got NBA players wearing Levels and they have been in talks with like 13 professional sports teams who want that extra fueling edge, and to sort of like, know what they’re actually, should be eating for highest performance.

So, pro sports, weight loss, and then the bio-optimizers, and the people who want that sort of like, especially mental performance edge. So, a lot of, you know, Silicon Valley executives and people who just need brain function to be like, so on point, the post-meal slump, the brain fog, the anxiety and fatigue during the day, is just really, has huge consequences, so anything to get that extra edge. So, those have kind of been some of the organic traction, but then, you know, I think that as awareness expands about how important metabolic health is, that is going to become a lot, more segments are going to become interested. Metabolic dysfunction, like while we know it’s related to the really overt diseases like diabetes, obesity, stroke, heart attack, non-alcoholic fatty liver disease, these are all diseases that are like, kind of the big, heavy hitters of metabolic dysfunction, and Alzheimer’s, you know, now people are calling Alzheimer’s Type 3 diabetes, insulin resistance in the brain may be really linked to dementia, but there’s also a lot of more subtle things that we don’t realize are actually very much associated with metabolic dysfunction.

And I think as that awareness gets greater, like the more people will realize how this could benefit them, so that’s like the things like infertility, you know, polycystic ovarian syndrome- the leading cause of infertility in our country, is ultimately a disease of metabolic dysfunction.

It’s thought that maybe some insulin resistance at the level of the ovaries causes increased testosterone production and that really underlies the menstrual dysfunction that you see in PCOS. Same thing with something like erectile dysfunction, microvascular disease caused by metabolic dysfunction leads to problems with erections.

And so, like even something like that is linked to metabolic disease. Lots of other things, you know, chronic pain, chronic fatigue, anxiety, depression, acne, wrinkles, it sort of has its finger in everything, like metabolic dysfunction. And so, I think we’re going to start seeing it in the zeitgeist of just like health, like metabolic health is health.

So, every cell in the body needs energy to function properly. So, basically, where metabolic dysfunction crops up, in terms of cell type, is where you’re going to get symptoms. And so, in terms of a root cause, sort of centralizing focus of all of these symptoms and diseases we’re seeing in just sort of epidemic proportions like, it is the lowest hanging fruit to swat at, to achieve multifarous health improvements.

And so, but that’s not widely known, you know? And so, I think that the next five years we’re going to start seeing a lot more emphasis on that, and people understanding how it could benefit such a wide range of things. But, yeah.

Host: [01:12:07] Yeah. It affects everything. And I know some physicians are now saying like cancer is a metabolic disease. I think that’s one people really don’t link. So.

Dr. Casey Means: [01:12:18] Yeah. And I think that’s huge. And there’s like a lot of research going on with fasting and ketogenic diets with cancer and seeing really interesting results because fundamentally, you know, cancer as a metabolic disease, we’re getting more and more evidence that’s the case. You’ve got, even with a lot of genetic diseases like the BRCA mutation or Huntington’s disease, like these diseases don’t, even if you have the gene and the mutation, not a hundred percent of people get diseases.

Sometimes there’s like 80% penetrance or, you know, penetrance is a term for like how often a disease is expressed in a person who has the offending gene, and a lot of what might be the difference in that penetrance is underlying metabolic factors. And so I think, yeah, really, really interesting stuff. Cancer is a big one and yeah, exciting things are in store for metabolic health.

And then I think the biggest piece is going to be showing that, in healthy people who are not diagnosed with prediabetes or diabetes, that this actually lowers costs, over time. Because for insurance companies and hospital systems and payers to be, you know, reimbursing this technology for just the average person looking to optimize their diet, it’s going to ultimately have to be cost saving, and I believe there’s zero question that it will be cost saving. You know, someone with diabetes is, you know, the cost of their healthcare, compared to someone without, is significantly higher, per year, to a health insurance company than, and so, the cost of the technology, which is only going to become cheaper over time, is kind of a drop in the bucket, compared to actually treating the disease.

Host: [01:13:58] Right. It’s really exciting. And now, I mean with COVID, I think more people are talking about metabolic issues, so. There’s our part 3 in this interview.

Dr. Casey Means: [01:14:06] Part 3, yes. Huge. Yeah.

Host: [01:14:07] I won’t go into that. I’ll just leave that out there. But that’s a big, I think, the average person is hearing that this matters. Right. Yeah,

Dr. Casey Means: [01:14:14] Absolutely. Yeah. I mean, obesity, diabetes, some of the biggest risk factors for COVID mortality and, you know, these are largely, preventable and reversible diseases.

So yeah. You know, there was a fantastic article that came out last week by Bill Frist, former house senate majority leader, who’s also a physician, and he was in CNN. It was, I think called like the US food system is killing Americans, period. Like, it was just very, very direct article, and it talked a lot about COVID, and like, this is what we know about COVID like, diabetes and obesity will make it be lethal, and this is what our food system and our food policy is doing, you know, the way that we truly have policies that promote these diseases at the federal level, the way we do farm bill spending, and the way we do snap fund allocation, you know, a lot of different factors in policy that promote these diseases.

And so, if we want to battle COVID fundamentally, and future diseases that will be worsened by metabolic disease, we need to be changing our fundamental policy around food and healthcare. So, it was really powerful. I highly recommend it, but yeah.

Host: [01:15:22] You have so many great resources. Oh, this study, this like.

Dr. Casey Means: [01:15:26] Oh, thank you!

Host: [01:15:27] We’ll have to share those in the show notes, as many of those as we. Yeah! So, Dr. Casey, until everyone gets a CGM, can you give our audience one piece of advice, something that they could start working on today, to help their metabolic health?

Dr. Casey Means: [01:15:41] Yes, absolutely. I would say there are so many in the metabolic toolbox, you know, exercise every day, get good sleep, you know, manage your stress well, you know, eat foods that are good for your body, but I think one piece of low hanging fruit that’s pretty much applicable to everyone is, increase fiber in your diet. You know, I think somewhere around 50 to 70 grams of fiber per day, is really optimal for microbial diversity in the gut and for optimal metabolic health. In almost every study, increased fiber is shown to be associated with lower glycemic excursions and lower A1C.

And why I mentioned it is, because it’s somewhat counterintuitive, because fiber typically comes from carbohydrate sources, but it often, for a lot of people, does not cause a glycemic excursion, because it’s fiber, it’s carbohydrates that the bacteria in the gut are going to digest and turn into all these very helpful metabolic byproducts.

And so, what’s actually seen by your body is much less, in terms of carbs. So, I’d say, you know, in terms of fiber sources- beans, legumes, nuts, seeds, chia is an awesome thing to sprinkle on top of stuff to get easy, easy fiber, like two tablespoons have like 10 grams. The average American is getting about 12 grams of fiber per day, and I would shoot for 50 to 75. So. And of course test it, like on CGM, you know, maybe eating straight beans will spike your glucose, but beans with some, you know, tahini and some nuts and other stuff like may blunt that spike, so you got to be thoughtful about it. But overall, fiber is a friend, in terms of metabolic health.

Host: [01:17:18] Fiber is your friend. Yes. Awesome. Well, thank you so much for spending time with us. This conversation was everything I wanted it to be. It was motivating, educational, it was fun, and we would love to have you back, but we really appreciate your time.

Dr. Casey Means: [01:17:33] Thank you guys so much.

Host: [01:17:33] And we’ll send our audience to you. Can you just tell them how they can find you online or in person?

Dr. Casey Means: [01:17:39] Yes, absolutely! So, the CGM side of things, so, you can find us at www.levelshealth.com, for way more information about the nuances of metabolic health you can go to www.levelshealth.com/blog. You can find us on Twitter and Instagram at unlock levels, and you’ll see a lot of fun, like, you know, customer, you know, glucose examples and lots of really interesting stories there on our social. And then me, personally, I’m at Dr. Casey’s kitchen, so drcaseyskitchen on Instagram and Twitter. And I do a lot of plant-based, metabolic-friendly meal examples on my Instagram. So, yeah, come check us out. And if you’re interested in getting a CGM, people can sign up for our waitlist at levelshealth.com and we’re excited to get these rolled out to anyone who’s interested.

Host: [01:18:33] That’s amazing. Amazing. Yeah, I ate some of your meals. I may make one tonight, for dinner.

Dr. Casey Means: [01:18:38] Ooh awesome!

Host: [01:18:39] Yeah, they’re so beautiful.

Dr. Casey Means: [01:18:41] Thank you.

Host: [01:18:41] Like, can you just deliver to my house? That would be great.

Dr. Casey Means: [01:18:45] I’ve been following your guys’ a squatting and ice bath challenge, and I’m like, I need to ask you more about that. That’s pretty incredible. It’s so badass. So.

Host: [01:18:56] Thank you. I love it. Well, we will definitely chat again. And thank you so much for today.

Dr. Casey Means: [01:19:03] Bye guys.

Host: [01:19:04] Yeah. Thanks for everyone, for tuning in.

Intro: [01:19:08] Love this episode of the Biohacker Babes podcast? Head over to Apple podcast to subscribe, rate, and leave a review. We truly appreciate your support. Until then, happy biohacking.

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