The Top Lab Tests to Determine Whether or Not You’re Actually Healthy with Dr. Casey Means

How do you know whether you’re really healthy? Once-a-year lab tests can only show you so much when it comes to your health. If you really want to know what’s going on, you have to keep a closer eye on your numbers. In this episode, Levels co-founder Dr. Casey Means explained what metabolic health is, which lab tests tell you the real story, and how to use those results to get to better metabolic health.

03:52 – What is metabolic health?

Dr. Means explained that metabolic health is the process of making energy in the body, and poor metabolic health means your body is not properly processing energy.

Metabolic health is really this process of how we make energy in the body. Every single one of our 37 trillion cells in the body needs energy to function properly. And right now, we are in an energy crisis in the United States, where again, 88% of Americans are not processing energy properly. And the reason for this is because our modern Western diet and lifestyle is totally hijacking the processes in the body for which we just make, and process, and use energy. And that’s a problem. And so, metabolic health is the term for what’s going on in this fundamental pathway that drives life in the body, and which right now is in crisis in the average American body, because of the way that we’re eating, chronic over nutrition, especially refined carbohydrates and sugars, of our sedentary lifestyles, our chronic low-grade stress, and our poor sleep. These things are taking over these systems that are fundamental for every cell to function properly.

09:19 – Lab work doesn’t tell the whole story

Oftentimes a person’s symptoms will tell them something is wrong even if their lab work comes back okay.

What’s so interesting about the energy story is that right now we’re dealing with so many people just don’t feel good. They have FLC syndrome, as Mark Hyman says, feel like crap syndrome. We feel tired. We feel anxious. We don’t have the pep in our step that we want. We know something’s wrong. And we’re often going to the doctor and hearing, “Oh, your labs are normal, nothing to worry about.” We know, in our gut, that that’s not good enough, that there’s got to be something more that we can figure out about how to optimize our health. What’s interesting is that this way we’re feeling today, even when we’re young, maybe just not enough pep in our step, not enough energy, that’s the same process that’s going on that will ultimately lead to chronic disease. These symptoms, in a sense, are a gift, because they’re showing us that something is off right now, something is not optimal. And that is a gift, because we can do something about it. But unfortunately, as you alluded to, right now in our system, we don’t take action or intervene until things are really flagrantly wrong on our lab testing.

14:02 – Get healthy before you get sick

Pre-disease is when the body is not in a good metabolic state but no disease has occurred yet, is the optimal time to work on getting healthier to prevent problems in the future.

Knowing that most of the symptoms that are facing people today and diseases are actually diseases that develop over decades. That whole window of pre-disease is where we need to focus energy, and where we don’t in our conventional medical practice right now. And so, because of that reality, and because of the way the system is set up, the onus is actually on us to stop outsourcing our judgment to other people who are focused more on the black and white, no disease or disease state, and to actually start understanding for ourselves what some of these biomarkers of predisease are so that we can take action and have agency in our own lives. So, that’s where education is really important.

26:59 – What numbers should you look at?

Dr. Means recommended looking at triglycerides if you want to optimize your health. Triglycerides can show you if you’re ingesting too much sugar.

To get down to brass tacks for people who are like, “What numbers should I shoot for?” I think really for triglycerides, which again is the numerator of the triglyceride HDL ratio, triglycerides, if you’re over a hundred, you should really start to be thinking about how can I cut out some of these refined sugars, grains, fructose in the diet. The standard lab panel will say, if you’re under 150, you’re fine. But actually it looks like lower than that is better. So definitely shoot for lower than a hundred, ideally less than 70 for your triglycerides. In terms of the triglycerides to HDL ratio for that, there is no standard guideline on what this should be. Because again, we haven’t really focused on this ratio, even though there’s good research to suggest it’s very predictive of our metabolic health status and heart disease risk.

33:46 – The liver is crucial for metabolic health

The liver is the center of a lot of your metabolic health, so it’s important to be mindful of what in your diet could affect the liver directly.

The liver is really the center of where a lot of this is happening metabolically. And what’s interesting is that… So the pancreas delivers insulin directly to the liver, and the liver, unfortunately, because of our huge amount of fructose that we’re eating in our diets… Which is fructose, now high fructose corn syrup is just making its way into so many of the packaged foods we’re eating. Of course, there’s a large fructose load in juice because it’s essentially concentrated fructose. And of course it’s filling sodas. Because we’re eating so much of this fructose and it’s overwhelming the liver, the liver is essentially converting this excess sugar into fat. So we’re getting fatty liver disease, which we talked about earlier. 45% of American adults have now, and that fatty liver disease makes the liver insulin resistant. So then the pancreas is sending insulin to the liver, and it’s seeing all this insulin resistance that’s caused by the fat building up because of this excess refined fructose carbs and sugar. And it’s having to do so much more.

40:29 – Don’t wait too long for testing

Testing on a more frequent basis can give you a more accurate depiction of which lifestyle choices are making a difference and which ones aren’t.

I think it’s another testament to why actually testing maybe on a more frequent basis can be really helpful because if you make a dietary intervention, if you wait until maybe a year until you retest some of these things, you may not actually be able to create that one to one relationship between the intervention and what actually happened. So for many people, like for instance, if you’re adding more saturated fat or adding more plants or cutting out refined sugars and grains, retesting after one to two months on some of these metabolic health tests can be a great indicator of whether you’re moving in the right direction and can be extremely motivating. So the more we can tighten up those feedback loops, I think the better. And of course, the continuous glucose monitor is the ultimate in the biofeedback loop, because it’s just that really instant feedback on each thing you’re eating.

44:36 – Be the CEO of your health

Being in charge of your own continuous glucose monitoring can help you be the CEO of your own health.

This is just really allowing you to be more of the CEO of your own health. This is allowing you to not have to outsource all the judgment about what’s going on inside your body and let you really start to take some ownership. And the cool thing is you can order these as frequently as you want. You could get them once a year. You could do them every month if you want. You could do this panel three months after starting a dietary intervention. You can start to see how what you’re learning on your continuous glucose monitor is impacting these other metabolic labs. So it’s really up to you. And so that’s a new offering that we have with Levels that I think is going to give people a lot more context on what’s going on with their continuous glucose numbers. And I’m thrilled to see how people respond to it.

51:33 – The body is a complex system

Dr. Means said that because the body is such a complex system, every person will react differently to different types of food.

The reality is the body is this incredible complex system with many redundant pathways. Also each body is different, of course, genetically, microbiome, everyone responds to foods differently. You know, you and I could eat the exact same piece of bread and have totally different glucose responses to it. So, everyone’s different. We’re also different day-to-day as our own bodies, like we were talking about with the insulin story. Insulin could be 30 and three months later could be 5. And so you’re going to respond to food differently in those two different states. I really like to think of the body as this incredible dynamic entity that is kind of like a shape shifter. It’s different literally day-to-day, based on how you’re living, what you’re doing and what you’re putting into it, based on the amount of sleep you got the night before, the amount of cognitive stress you’re under, what you ate the day before, whether you moved your body a lot or a little, it’s a different body. Even the thoughts that we have create a whole different hormonal milieu in our body day-to-day. And so it’s just it makes it seem totally nonsensical to say that there is one particular diet or lifestyle for everyone.

01:12:31 – Exercise changes everything

Exercise can have a drastic impact on how your body absorbs nutrients and whether you have a healthy metabolic process.

The thing about exercise is it changes everything. Muscle is a huge glucose sink. It pulls glucose out of the bloodstream and uses it and disposes of it. It also clears out the liver of excess fat and stored glucose in the form of glycogen because you’re putting the body under a stress where it needs more energy. It pulls it out of its stores and the liver is one of the big stores. It really can change the game, like you said, week to week and be able to see those impacts. I mean, I imagine that was motivating to you to keep on doing those three workouts a week.

Dr. Casey Means (00:00:00):

88% of American adults have at least one biomarker of metabolic dysfunction. So, it’s really important to get the right labs and then understand how to interpret them and know what is optimal.

Dhru Purohit (00:00:12):

Casey, welcome back to the podcast. It’s a pleasure and an honor to have you here. We’re going to jump right in today. We’re talking about optimal lab ranges, specifically in the category of metabolic health and the metabolic health panel. Tell us why, big picture, we should be caring about the topic of metabolic health, and specifically getting the right blood test to determine whether or not our metabolic health is headed in the right range. And if you wouldn’t mind, two parter, it’s a lot, maybe three, three of the top lab tests that people should be getting today, if they truly care about this area of their health.

Dr. Casey Means (00:00:52):

Thank you so much for having me back Dhru. I’m thrilled to be here, and I will jump right in on this. The reason we all need to care about what’s going on with our metabolic lab test is because 88% of American adults have at least one biomarker of metabolic dysfunction. And the average person doesn’t really know where they stand on the spectrum of metabolic health. So, it’s really important to get the right labs and then understand how to interpret them and know what is optimal. If I’m looking at all the different metabolic health tests out there, the ones that I think are really critical for everyone to know about for themselves, I’d say, first would actually be a ratio of tests, triglyceride to HDL ratio. So these are two pieces of our standard cholesterol panel. And when we put them into a ratio, triglyceride to HDL ratio, it’s a great surrogate marker of whether we are insulin resistant. So, that’s a key one that we need to focus on that I don’t think the average person is really aware of right now.

Dhru Purohit (00:01:47):

And by the way, we’ll talk about why, but a lot of doctors don’t talk about this ratio. They’re not educated on this ratio. So, we’ll get into more about why that’s the case and how to increase that education. But that’s a great first one.

Dr. Casey Means (00:02:00):

The second one is fasting insulin. Another test that is not often ordered in conventional practice, but it’s one that you can ask for, and it’s critical. Because, fasting insulin rises in our bodies before our fasting glucose actually changes or goes up, and it can actually change almost a decade or even more prior to our fasting glucose budging. So, it’s really helpful to see a fasting insulin to see what’s going on with metabolic dysfunction earlier than our standard lab tests, like glucose. And the third one I would say is hemoglobin A1C. This is a test that a lot of doctors will order for their patients. And this is basically a three month average of what’s going on with your glucose. There’s some limitations to it, because it doesn’t show you the variability in your glucose day to day. It’s an average overtime, but it can give you a broad snapshot of where you stand in terms of your average glucose levels.

Dhru Purohit (00:02:54):

So the first time you were on the podcast, we did a deep dive into glucose and how it plays into metabolic health. And the long of it is, the long and short of it is, that when we have an elevated blood glucose level, that increases the risk factor of so many different things that we’d experience in life. Give us a couple of those things and extend elevated blood glucose to poor metabolic health panel. If you have a poor metabolic health panel, your lab results come back, and partly is this is about, is your doctor ordering the right lab results, but let’s say it comes back, they’re not in the optimal ranges, which we’re going to talk about what those ranges are generally, what are you more likely to have happen? What kind of diseases that we all know and have heard about are we more likely to develop in our life and what kind of symptoms would be people having when they have poor metabolic health?

Dr. Casey Means (00:03:46):

Yeah. The first thing that might be helpful to define for people is just briefly touching on, what is metabolic health? Metabolic health is really this process of how we make energy in the body. Every single one of our 37 trillion cells in the body needs energy to function properly. And right now, we are in an energy crisis in the United States, where again, 88% of Americans are not processing energy properly. And the reason for this is because our modern Western diet and lifestyle is totally hijacking the processes in the body for which we just make, and process, and use energy. And that’s a problem. And so, metabolic health is the term for what’s going on in this fundamental pathway that drives life in the body, and which right now is in crisis in the average American body, because of the way that we’re eating, chronic over nutrition, especially refined carbohydrates and sugars, of our sedentary lifestyles, our chronic [inaudible 00:04:43] and stress, and of our poor sleep. These things are taking over these systems that are fundamental for every cell to function properly.

Dr. Casey Means (00:04:51):

Now going to glucose. So, glucose is one of the energy substrates in the body. Our body takes in glucose and it converts it to an energy currency that we can use in the body, namely a molecule called ATP. And that’s done in the mitochondria. Takes in glucose, converts it to something we can use. And that process, right now, is broken for many of us. That leads to essentially erratic glucose patterns. We see our fasting glucose going up. We see more variability in our glucose day to day, so more ups and down swings, when in reality, we want more gentle rolling hills. When our mitochondria are working great, we see more of that flat and stable glucose in a healthy and normal range. But that’s not what we’re seeing in most Americans today. We see this overtly in the rates of prediabetes and type two diabetes in our country with 128 million Americans having overt glucose dysregulation, prediabetes, or type two diabetes.

Dr. Casey Means (00:05:49):

And we also know that nine of the 10 leading causes of death in the United States right now are either directly caused by poor blood sugar control or are worsened by poor blood sugar control. So, this is things like, of course, type two diabetes, but also heart disease, stroke, Alzheimer’s, dementia, which of course is now being called type three diabetes, cancer, many other conditions. And so, it’s really important us to understand what’s going on with our glucose and then understand the metabolic context around that.

Dr. Casey Means (00:06:24):

That’s where other lab tests can be really, really helpful, other lab tests that give us a signal about what’s going on with the energy story in our body. That’s what we’re talking about when we talk about a metabolic lab panel. This is looking at other tests that deal with energy.

Dr. Casey Means (00:06:41):

This is things like our cholesterol panel, which is looking at total cholesterol, HDL, LDL, and triglycerides, different forms of transporting energy substrates in the body. It’s looking at things like fasting insulin, which is of course the hormone that allows you to take up glucose out of the bloodstream. It’s looking at things like inflammatory markers, like CRP, which inflammation and metabolic health are closely intertwined with erratic glucose and poor metabolic health driving inflammation, but inflammation also making blood sugar worse. And so, it’s really taking all of these things into context, so we can get a full story about what’s going on with how we’re making, processing, and storing energy in the body. It’s so important for us to know this for ourselves and learn how to have our own judgment about these tests, because it is so fundamental to to our health and to the chronic epidemics, the epidemics of chronic disease that we’re facing in the country right now.

Dhru Purohit (00:07:47):

Well, I’m excited because we have a bunch of tests that we’re going to walk through. And we’re going to talk about why they matter, and big picture, how people can think about them. But to add to the foundation, before we jump into those tests, I think it’s important to talk about a lot of people go to their yearly physical, if they’re fortunate enough they have insurance, they have a doctor, everything like that, they go to their yearly physical, and they typically get the answer of, “Hey, everything looks good,” little pat on the back. Maybe some cases of, “Maybe lose a little weight, exercise more,” and then you’re on your way. But they don’t feel good, or they don’t feel like they used to feel, or they feel like something’s off, or wrong, or other stuff. And sometimes the doctor might say, “Hey, your cholesterol’s a little high. You should make some changes and some cuts.”

Dhru Purohit (00:08:37):

But there’s not a lot more unless there’s something blatantly wrong. That’s where our medicine and industrial medical complex is great. There’s something blatantly wrong where they need to really jump in, they can handle that situation and save you from a heart attack that you’re having right now. So, I think this episode is going to be really great, because it helps people understand that there’s this area in between that we don’t have to wait till we literally have heart disease to make interventions. We can start paying attention now to these labs that we’re going to go through and why they matter so that we can catch things early, not just to avoid chronic disease later down the road, but to also feel good today.

Dr. Casey Means (00:09:18):

That’s exactly right. What’s so interesting about the energy story is that right now we’re dealing with so many people just don’t feel good. They have FLC syndrome, as Mark Hyman says, feel like crap syndrome. We feel tired. We feel anxious. We don’t have the pep in our step that we want. We know something’s wrong. And we’re often going to the doctor and hearing, “Oh, your labs are normal, nothing to worry about.” We know, in our gut, that that’s not good enough, that there’s got to be something more that we can figure out about how to optimize our health. What’s interesting is that this way we’re feeling today, even when we’re young, maybe just not enough pep in our step, not enough energy, that’s the same process that’s going on that will ultimately lead to chronic disease.

Dr. Casey Means (00:10:00):

These symptoms, in a sense, are a gift, because they’re showing us that something is off right now, something is not optimal. And that is a gift, because we can do something about it. But unfortunately, as you alluded to, right now in our system, we don’t take action or intervene until things are really flagrantly wrong on our lab testing. And usually when the green check mark in the electronic health record that says everything’s fine moves to a red X, and the doctor says, “Oh, there’s a problem,” usually that means that there’s probably actually been underlying dysfunction for a long time, but it hasn’t quite met that diagnostic threshold. So, there’s this window of many, many, years when we’re otherwise healthy, maybe don’t have a diagnosed disease, but don’t feel our best when we can actually dig in much deeper to these lab tests and start to pick up clues of what might be going on.

Dr. Casey Means (00:10:54):

And so, I think that’s what this conversation is really about is to help people figure out, what are the clues in these tests that the doctor’s ordering for us that we actually can look at and start to understand if there might be some early dysfunction that we can actually do something about? And the beautiful thing is, is that with slight tweaks in our diet and our lifestyle, we can really turn these lab tests round. We can move them into a much more optimal range. We can improve our energy now, and we can set ourselves up for much better outcomes in terms of chronic disease.

Dhru Purohit (00:11:26):

One more other thing I want to touch on, as a medical doctor and having all the training, now on our last podcast episode, you talked about how your family was into wellness, you’ve been into wellness for pretty much growing up, so there was a lot of education that you had that typical doctors don’t have, but tell us a little bit about what education you received when it comes to some of these areas that are highly impacted by lifestyle factors, especially diet. What education did you get in medical school, and how does that impact interpretation when it comes to what’s normal? Most of the population is normal, but most of the population is sick, versus what’s optimal.

Dr. Casey Means (00:12:09):

Yeah. You just brought up such an important point, which is what we’re being told is normal has to do with what’s going on in the population. And usually a few standard deviations away from the mean is what we categorize as normal. But the average American adult right now is sick. So, we don’t want to be just orienting around what’s the average and two standard deviations from that mean. An example of this is that what’s normal for, for instance, liver function tests have actually creeped up over the past 30 or 40 years, because the average American now has liver disease. I mean, 45% of American adults now have fatty liver disease. And that’s going to show up on your liver function test. And so, do you want to be two standard deviations from the mean of that? No. You want to be in a much, much, better range.

Dr. Casey Means (00:12:59):

Unfortunately, with training, we’re really taught to see black and white. You’re either normal or you are in the diagnostic disease state. But that’s not the way biology works. Biology is a spectrum. And we’re always moving back and forth on this spectrum based on what’s happening in our lives, how we’re living, how we’re eating, and what our lifestyles are. And so, just putting yourself in a bucket of normal/abnormal, that’s the first thing we should move away from. We should stop thinking that we’re fine if we’re just in the “normal bucket.” And that there’s a problem if we’re in the abnormal bucket. We should start to really begin to look at things as spectrums and where we are on the spectrum of health. And that’s something that I don’t think is emphasized in conventional medical training. Because a lot of it’s about triaging. And you need to focus on who’s the person I really need to focus the most energy on. And that’s the person who’s in the diagnosable disease state. But we need to do more than that.

Dr. Casey Means (00:14:02):

Now knowing that most of the symptoms that are facing people today and diseases are actually diseases that develop over decades. That whole window of predisease is where we need to focus energy, and where we don’t in our conventional medical practice right now. And so, because of that reality, and because of the way the system is set up, the onus is actually on us to stop outsourcing our judgment to other people who are focused more on the black and white, no disease or disease state, and to actually start understanding for ourselves what some of these biomarkers of predisease are so that we can take action and have agency in our own lives. So, that’s where education is really important.

Dhru Purohit (00:14:46):

On the topic of education, I love the Levels blog, we have a link to in the show notes. Because, one of the things you guys highlight there is the incredible amount of research that’s constantly coming out that supports why we want to be paying attention to some of these things. For example, people, we’re not talking about fasting insulin as much, even though we’ve had the ability to run that test for quite a long time. It’s gotten a little bit more popular, but still a lot of people aren’t necessarily looking at that, forget even just optimal or not optimal. So, my guess, and this is just a guess, but a good chunk of the research on what we know when it comes to metabolic health and what these lab numbers really should look like is probably come out in the last 10 to 15 years.

Dhru Purohit (00:15:36):

That means that, if you’re a medical doctor, well intentioned, I have many medical doctors in my family, my brother-in-law’s a cardiologist, and they’re doing the best job that they can, they have so much to keep up with, but if you’re a medical doctor, first of all, they’re not getting that much education on nutrition in the first place. You talked about that on your podcast episode with a guest recently. But the second component is that, if they graduated school quite a bit ago, they may not be aware of the latest research. So, I hope that the doctors are listening, which they are too, because they’re trying to dial in their own health as well.

Dr. Casey Means (00:16:09):

Definitely. And I think another thing about the physicians, I think your point is absolutely right on, everyone here is well intentioned. But the system is set up in a certain way that really drives training. And one of the big systems issues that we face is that it’s a very pharmaceutical centric system. Medications have been life saving in many cases. We think about things like antibiotics. They’ve absolutely extended life for many conditions. But because we are so focused on, “What do we have in our toolbox that we can give to someone that’s simple and easy?”, we lean on medications. And so, that’s actually really driven how we’ve interpreted lab tests actually.

Dr. Casey Means (00:16:49):

So Rob Lustig, Dr. Rob Lustig talks about this quite a bit, which is that, if you actually look at the cholesterol panel, we focus so much on LDL. A lot of people know, oh, LDL is the bad cholesterol. It’s a very nuanced topic. But the odds ratio for LDL and risk of heart disease is about 1.3. And it’s actually 1.8 for triglycerides. But we hear a lot less about triglycerides. People aren’t running around saying, “Oh, triglycerides is the bad part of the cholesterol panel.” You just don’t hear it talked about it much.

Dhru Purohit (00:17:23):

Right. A lot of people know their HDL and their LDL. And I’ll ask them what was your triglycerides? And they’re like, “I don’t know. I have to go back and look.”

Dr. Casey Means (00:17:31):

And you wonder why. And I think there’s good evidence that’s part of the reason why we had so much of a focus on LDL is because we had a medication for LDL early.

Dhru Purohit (00:17:41):

And tell everybody what that medication is.

Dr. Casey Means (00:17:43):

Statins. Right. And so, we did not have a great medication for triglycerides. We now do have medications for triglycerides, but they have quite a bit of side effects, fibrates, and aren’t aren’t used as much. And so, what’s interesting, though, is that triglycerides, they have a higher odds ratio for increased risk of heart disease. But they didn’t have a medication, and so we don’t hear about them as much. And they are such an important indicator for what’s happening in our metabolic health, how our diet’s impacting our health, and are so easy to change with dietary interventions. I’ve had patients who have just gotten off refined sugar and refined carbs, and in a month have dropped their triglycerides by about 100 points. And so, we really need to start orienting around less about which lab tests are important because of how we can intervene with medications, and actually focus on which ones are the best signal for what’s going on in our metabolic health, and which ones do we have evidence-based dietary and lifestyle avenues to get them in a better place.

Dhru Purohit (00:18:43):

I’m one of those people. I definitely have a family history, genetically influenced, that predisposes me towards higher overall markers of cholesterol and triglycerides that are there, partially. And so, when I went to my physician in high school and he saw that my triglycerides were off the charts, and he was like, “This is just something that you’re going to have to watch out for and be there.” And I dropped almost 100 points. I dropped almost 100 points by getting off of… At the time I was vegetarian. That’s not the reason that I was there. I was eating junk food, even though it was vegetarian, and you can eat junk food that’s vegetarian. You can eat keto junk food. You can eat any kind of junk food that’s out there. And by moving towards actually truly what, at the time, I was doing more of a plant based diet, eating more vegetables, cutting out all these processed carbohydrates, cutting out all the processed sugars, my triglycerides completely changed.

Dhru Purohit (00:19:41):

I think that’s a perfect jump off. We’ve been teasing towards these lab tests. You mentioned three of them in the beginning and we have a bunch more that are here that we’re going to walk through. But let’s talk about the first one that you mentioned and why that ratio is so key. Everybody talks about HDL and LDL, but we are not hearing as much about the ratio that’s out there. So, give us a little background on that.

Dr. Casey Means (00:20:03):

I really love looking at triglyceride HDL ratio, because what it does is it tells us two really important things. The first thing it does is it’s a surrogate marker for insulin sensitivity. The average doctor, as we talked about, is not ordering a fasting insulin on their patients, which is definitely one of the best ways to look at your insulin sensitivity. But triglyceride HDL ratio has been shown to really be a signal of what’s going on with our insulins sensitivity.

Dhru Purohit (00:20:33):

Almost like a little smoke detector that’s there, that “Hey, we got to pay attention a little bit more. Something might be up.”

Dr. Casey Means (00:20:37):

That’s exactly right. And the beautiful thing is these are two tests that are in our standard cholesterol panel. So, almost every doctor is ordering that on their adult patients. So, you probably already have this information. And so, even if your doctor’s not willing to order a fasting insulin test for you, you still can get a clue of what’s going on with your insulin sensitivity. That’s one of the first reasons I love this. The second reason I love this test is because it also gives us a signal of what’s happening with our small density LDL. And so, some people, who listen to your podcast, might have heard about this already, but basically, LDL, which we typically think of as our bad cholesterol, actually has several different components that make up that total number. One of them is the high density LDL form. And one is the small density LDL form. And it’s actually the small density LDL fraction of that total LDL number that is dangerous for heart disease.

Dhru Purohit (00:21:32):

Yeah. I’ve heard it compared to those are like golf balls, and then you have beach balls. The beach balls are big and fluffy, they’re not going to damage anything. But the golf balls are going to break a window and cause all sorts of challenges inside of the bloodstream.

Dr. Casey Means (00:21:44):

That’s exactly right. The small density ones you can think of like the little BBs that can lodge themselves into the vessel wall and cause that inflammation, and that plaque, and that buildup. The beach ball versions, the high density LDL, are going to bounce around and float around in the bloodstream and aren’t as much of a problem. And this triglyceride to HDL ratio is a surrogate marker for what’s going on with small density LDL. And because our standard cholesterol panel doesn’t break it down into that fraction of high density or small density LDL, having a surrogate marker is really useful. The way that you can get your exact numbers for those fractions of LDL is to get what’s called advanced lipid testing or NMR lipid testing. But again, that’s not something that’s typically going to be ordered in standard conventional medical practice.

Dhru Purohit (00:22:31):

Right. Especially if you’re under a certain age, they may actually have you pay out-of-pocket to get it, because it’s not seen as something that should be run on everybody.

Dr. Casey Means (00:22:41):

Right. Using this super simple fraction that you can just calculate on your iPhone can tell you about insulin sensitivity, can tell you about where you stand in terms of small density LDL, which is the more dangerous type. So, that’s why I love it. But your doctor is very unlikely going to mention this to you, even though there’s actually a good amount of research addressing that it’s important for understanding our metabolic health [crosstalk 00:23:04] status.

Dhru Purohit (00:23:04):

Maybe even one of the leading predictors, along with just high triglycerides in general, of a cardiac event coming down the road.

Dr. Casey Means (00:23:12):

That’s right. Yeah. I believe that there’s actually, with people who have an elevated triglyceride to HDL ratio, 16 fold higher risk of heart disease. This is just a really important biomarker that we’re not talking about. And again, part of that reason is probably because triglycerides have been largely overlooked, because we haven’t had a good medication for them. So, triglycerides are, of course, the numerator of this test. And what triglycerides really, to me, give a signal of in patients is dietary quality. Are people eating a lot of refined foods, refined sugars, refined grains, liquid fructose? That is going to go into the body, overwhelm the system, and be converted into triglycerides. So, that’s really, if someone has a triglyceride level of over about a hundred, I’m thinking.

PART 1 OF 4 ENDS [00:24:04]

Dr. Casey Means (00:24:03):

If someone has a triglyceride level of over about a hundred, I’m thinking we probably need to clean up the dietary quality and specifically focus on getting rid of the refined grains, the refined sugars, and the fructose.

Dhru Purohit (00:24:12):

And one quick question for you. You may know this, or you may not, but a lot of people are familiar. We’ve talked about it a bunch, the Level CGM, the continuous glucose monitor, and why I’m such a big fan of it. And we know that if you track or use a CGM, we can see that your blood glucose is… There can be a big delta throughout the day that’s there. When it comes to triglycerides, I was meeting a doctor recently because I got lab results done in September, and he’s like, “I saw you were just in Italy and I’m sure you probably ate a lot of different stuff and things like that. Know that your triglycerides might be a little bit higher because that trip was just three weeks ago.” Do we have any sense of how long it takes to adjust or how often that number is changing? If somebody wanted to swing a hundred points in the right direction or the wrong direction, do we know roughly about how long that might be?

Dr. Casey Means (00:25:09):

Yeah, that’s such a great question. It’s a fairly dynamic molecule. I don’t know on a day to day basis, how big this swing can be. But I do know from my own practice that people who have fully cut out refined grains, like flour, wheat flour, et cetera, and refined sugars of which, of course, there’s like 50 names to refined sugars. And so it can be hidden in everything, but fully cutting those out, dropped their triglycerides a hundred points in one month. And so that is just huge in terms of… And I think that was basically dropping it from in half, essentially from about 200 to 100. So these things can move quickly. And of course, in the opposite direction as well. If you’re in Italy and eating a bunch of pasta, it can go up. But what I love about tests like this that can shift quite quickly is it’s so motivating because you make a change, and you can see the results very quickly, and that’s incredible feedback.

Dhru Purohit (00:26:07):

It’s super inspiring for anybody who’s listening or watching, because there’s a lot of times we feel just stuck and it’s scary. It’s scary because you’re thinking, “Well, maybe I had a parent that developed Alzheimer’s or I had a grandfather that had heart disease or had a heart attack or a stroke or whatever.” But there’s so much, and I hope that everybody really gets that the moral of today’s podcast is really, you have so much more control over your health than you ever imagine. And obviously, hats off to companies like Levels that are making a lot easier to take that control that’s there, but there’s a lot that you can do. And the best things that actually move the needle in the right direction are all the things that we’re already doing, sleep, lifestyle, exercise. And of course, dietary interventions.

Dr. Casey Means (00:26:58):

Definitely, definitely. So to get down to brass tacks for people who are like, “What numbers should I shoot for?” I think really for triglycerides, which again is the numerator of the triglyceride HDL ratio, triglycerides, if you’re over a hundred, you should really start to be thinking about how can I cut out some of these refined sugars, grains, fructose in the diet. The standard lab panel will say, if you’re under 150, you’re fine. But actually it looks like lower than that is better. So definitely shoot for lower than a hundred, ideally less than 70 for your triglycerides. In terms of the triglycerides to HDL ratio for that, there is no standard guideline on what this should be. Because again, we haven’t really focused on this ratio, even though there’s good research to suggest it’s very predictive of our metabolic health status and heart disease risk.

Dr. Casey Means (00:27:48):

So this is really more expert consensus, but it looks like it actually it may be somewhat race specific, so less than shooting for less than 2.5 for this ratio in people of Caucasian ethnicity appears to be good and less than 1.5 for people of African American descent. So basically just take those two numbers, throw into your calculator on your phone and see where you land. Less than 2.5 for people who are Caucasian and less than 1.5 African American descent. I would actually say, you can go even tighter, no matter what ethnic background you’re coming from and really shooting for one. A ratio of one is probably optimal.

Dr. Casey Means (00:28:35):

That basically means that your triglyceride level is equal to your HDL ratio. So this bad form of fat in the bloodstream, triglyceride is low. And your HDL, which is the good cholesterol quote unquote good cholesterol, that recycles cholesterol that brings it back to liver for clearance is really high. So for all practical purposes that might look like a triglyceride of 80 and an HDL of 80. That ratio would be one. And that’s basically saying, you’re looking good, metabolically. Your insulin sensitivity is probably really good. If we tested your fasting insulin, it would probably be quite low. And if we tested your small density LDL, it would also probably be quite low. So that’s what you can do with that ratio to give you a snapshot of what’s going on with those different features.

Dhru Purohit (00:29:21):

Well, I’m excited because you have a lot of members and people that are using your app. Now, I’m excited for people to do this test. We’ll chat a little bit about how the audience can actually do it if they want to. And then to gather that data and to start publishing some information on it. What is optimal? We have a lot of people using Levels that are trying to focus on optimal health. And hopefully that can give more guidance out there because like you said, there’s not really the strong guidance that’s there for people who are looking for that right now from the standard medical institutions that are there. Let’s pivot into the next test that you had mentioned, which is fasting insulin. What are we thinking about when it comes to ideal numbers for that? And again, why is it so important?

Dr. Casey Means (00:30:05):

Yeah. So the lab slip, depending on the lab, it’s going to say different things, but a lot of them are going to say that less than 25 for fasting insulin is normal. This is totally wrong. Much lower is better. If you survey the leading metabolic health experts in the country who have really drilled into this research, almost all of them are going to say that less than 10 is where you want to be. And several of them have an even tighter range like 2 to 6 or 2 to 8. So if you’re fasting, insulin’s up in that 20 range for fasting, that probably means that there’s already a significant amount of insulin resistance going on. So what this test is telling us is essentially how hard the body is working and how much insulin it’s having to produce to keep insulin low. Again, insulin is that hormone that helps you take glucose out of the bloodstream into the cells.

Dr. Casey Means (00:31:06):

And when there’s insulin resistance, which is that physiologic process that’s leading us towards metabolic dysfunction towards diabetes and all the associated conditions, the body’s essentially resistant to that insulin. It’s having to pump out a lot more to get that glucose out of the bloodstream into the cells. So just knowing you’re fasting glucose alone without knowing how hard the body’s working with production of insulin to get it at that level is not that useful because for instance, you and I could both have a fasting glucose level of 80, which by all accounts is quite good and healthy and normal. But if my body is more insulin resistant, and therefore is having to produce a fasting insulin of 25 or 30 to keep the glucose at 80, and your body is really insulin sensitive and you have a fasting insulin of 2 to keep your blood sugar at 80, we are completely different metabolically.

Dr. Casey Means (00:32:02):

I’m on the road towards metabolic disease, type 2 diabetes, et cetera. And you’re really doing great. Your pancreas is not having to work as hard to keep that glucose in that level. So that’s why having insulin in conjunction with glucose is just so, so, so much more information. And because the body is incredible and can compensate for so long by producing excess insulin to keep glucose in a more stable range before that whole system of compensation breaks and fasting glucose starts rising, we’re missing that window of that overcompensation period, unfortunately, by not testing fast insulin in standard practice.

Dhru Purohit (00:32:42):

I had a buddy of mine, close friend of mine recently, who had set some intentions for the new year and then got on a CGM with Levels and he was on his best behavior and trying to really lean into optimizing his blood sugar. And he was having a hard time with weight loss. And I was saying, “Hey, listen, don’t be discouraged.” Because he felt like he was doing everything right. We just need some more data that’s over here. Your fasting insulin, which he hadn’t had in… He didn’t have any of that in his recent blood work. And he’s pretty in the know generally speaking.

Dhru Purohit (00:33:16):

So we need to look at a few more markers that are out there because there could be reasons why you can’t get rid of that stubborn belly fat or why you feel like, okay, now you’re in your late thirties, and it’s so much harder for you to maybe get rid of that excess weight compared to when you were in your late twenties. So I think that’s important for people to understand that as more people are paying attention to glucose, which is great and fantastic, there’s other markers that we want to be looking at too that help us round out the story.

Dr. Casey Means (00:33:42):

Yeah, definitely. And I think one of the interesting things to remember is the liver is really the center of where a lot of this is happening metabolically. And what’s interesting is that… So the pancreas delivers insulin directly to the liver, and the liver, unfortunately, because of our huge amount of fructose that we’re eating in our diets… Which is fructose, now high fructose corn syrup is just making its way into so many of the packaged foods we’re eating. Of course, there’s a large fructose load juice because it’s essentially concentrated fructose. And of course it’s filling sodas. Because we’re eating so much of this fructose and it’s overwhelming the liver, the liver is essentially converting this excess sugar into fat. So we’re getting fatty liver disease, which we talked about earlier. 45% of American adult have now, and that fatty liver disease makes the liver insulin resistant.

Dr. Casey Means (00:34:43):

So then the pancreas is sending insulin to the liver, and it’s seeing all this insulin resistance that’s caused by the fat building up because of this excess refined fructose carbs and sugar. And it’s having to do so much more. So just kind of key point here, we got to clear the liver of the fat so that it becomes less insulin resistant so that the pancreas doesn’t have to produce as much insulin to basically get the glucose out of the bloodstream. And the way to do that is get rid of all liquid fructose, the sodas, the juice, the high fructose corn syrup and the packaged foods, and then minimize or eliminate the refined sugars and the refining carbohydrate rates. All of which are going to contribute to that fatty liver disease, which is the root of our insulin resistance, which of course is the root of our pancreas having to produce more insulin, which ties back to what you were talking about with belly fat.

Dr. Casey Means (00:35:37):

Because insulin, aside from being the hormone that takes glucose out of the bloodstream, is also a hormone that blocks us from burning fat. And so the more you’ve got it circulating around the body, the more it’s basically telling your body hold onto that fat. Don’t burn it. We’ve got tons of glucose around for energy. We don’t need to tap into our fat stores. So it’s definitely a helpful test to get if you are dealing with that stubborn fat. Another really interesting thing is that if you’re fasting, insulin is quite high, meaning that you are quite insulin resistant, you may not tolerate carbohydrates as well, even healthy carbohydrates like vegetables or beans or lentils or something like that because your body is just less able to process the glucose that’s in those foods. And I’ve seen this with patients and with members in the Levels community where they’ve started out with a high insulin level, somewhere around 30, 35, and really healthy foods like tomatoes or even too many greens like broccoli or chickpeas or lentils spiking them through the roof because they were quite insulin resistant.

Dr. Casey Means (00:36:45):

But after focusing on foods that keep their glucose down, eliminating their refined sugars, fructose, grains over time, that insulin started coming down. And I’m thinking about a specific Levels member whose insulin came down from 30 to 5 after learning how to reduce blood sugar spikes with the continuous glucose monitor. And when their insulin was down at 5, they could start to incorporate much more of those healthy carbohydrates without the huge glucose spikes because their body was so much more insulin sensitive. So using these lab tests and then these tools to understand our diet together can sometimes really help us progress along this spectrum and actually be able to incorporate these healthy carbohydrates in a way that’s not causing all this sort of erratic glucose. So just so that people are aware, just because something spiking you now does not necessarily mean it will in the future. But a lot of that is dependent on our insulin sensitivity.

Dhru Purohit (00:37:46):

Just another reason why when people want debate about what’s the ideal diet for people, it’s also kind of like, what’s the ideal diet for you right now. And then a little while later, that could change. And so that’s just such an important part of the story in getting out of the polarization. It’s away from polarization and more towards personalization. Because in the personalization, the truth will start to reveal itself, but you need the data to be able to do that. I’ve shared multiple times on this podcast that I went towards more what would be seen as a ketogenic diet. And this was about three years ago, and I did it for about two years. And generally speaking, I’ve had other members of my family that have done this. My brother-in-law, the cardiologist down in San Diego, he did it, and his lipids… And plant rich, we’re talking about clean keto just for everybody who’s listening. We’re not talking about eating a bunch of bacon and that’s it. We’re talking about still a ton of plant food that’s the base of the diet, all the rich polyphenols sources, and phytonutrients and other things, all the low starch, healthy vegetables, and even still some fruit that are part of that too. And then some targeted plant protein and other things, but a big cut on the refined sugars and carbs and other things like that. His lipids all headed in the right direction, including his NMR testing. And mine went completely in the other direction. And it’s just another reminder. And I’ve been digging into this and making some changes and other stuff, and I personally cannot handle larger amounts of saturated fat.

Dhru Purohit (00:39:23):

So even though I love MCT oil, I won’t be adding it to my coffee every single morning and using coconut oil on a regular basis. As some of the fats that I was using in more of my keto approach, I switched more towards avocado oil and olive oil. And just doing that, my lipids are already heading in the right direction. All these tests that we’re talking about here, I just went actually this morning to get them redone, and my lipoprotein A, which was also… Sorry, lipoprotein B was also super high, and it started coming down significantly. So I felt really good.

Dhru Purohit (00:39:58):

I started to have a little bit of a GI disruption, and that’s when one of the doctors in my network said, “You should go back for your physical. Get all these tests done, and see are you having some challenges with this way of eating? It may not work for your right now because of a combination of reasons.” So I felt okay, minus some small things, but if I didn’t intervene now, who knows what would have happened like 20 years from now? So this is why test, don’t guess, and figure out what actually is the right diet for you.

Dr. Casey Means (00:40:28):

Absolutely. And I think it’s another testament to why actually testing maybe on a more frequent basis can be really helpful because if you make a dietary intervention, if you wait until maybe a year until you retest some of these things, you may not actually be able to create that one to one relationship between the intervention and what actually happened. So for many people, like for instance, if you’re adding more saturated fat or adding more plants or cutting out refined sugars and grains, retesting after one to two months on some of these metabolic health tests can be a great indicator of whether you’re moving in the right direction and can be extremely motivating. So the more we can tighten up those feedback loops, I think the better. And of course, the continuous glucose monitor is kind of the ultimate in the biofeedback loop, because it’s just that really instant feedback on each thing you’re eating.

Dr. Casey Means (00:41:26):

But that’s only part of the picture of course. And some of these other lab tests that we’re talking about give you a bit more of that comprehensive picture, but we definitely encourage people to think about using… There’s so many amazing tools now, like direct to consumer lab testing, where you can actually order these yourself, do the test at home, and really get more of that tighter feedback loop between a dietary intervention and what’s actually happening in your body.

Dhru Purohit (00:41:52):

Before we jump into A1C and why that was listed as number three in your top three that we start off at this at the top of the episode. And then we got a bunch more to cover after that, all high quality information you guys are offering this metabolic health panel to folks, in addition to the continuous glucose monitor, people can get that. Maybe just mention how can people sign up for it. And what does that look like, and where do they go to get their blood drawn?

Dr. Casey Means (00:42:19):

Yeah. So in an effort to get this type of information to more people on their terms and their timeline, we’re now offering as part of the Levels membership, not just access to continuous glucose monitors and of course the Levels software that helps you understand what’s going on with your glucose levels, but we’re also offering this metabolic health panel, which is a blood test that gives you a lot of these tests that we’ve been talking about. So it’s your full cholesterol panel, so total cholesterol, HDL LDL, and triglycerides; high sensitivity CRP, which is an inflammatory marker because of course we know that inflammation and metabolic health are very tightly linked; your hemoglobin A1C, which is that three month marker of average glucose; fasting insulin, which honestly I’m most excited about this test because it is very hard to get through just the standard primary care physician. They’re just not used to ordering this, but it gives you so, so, so much information.

Dhru Purohit (00:43:14):

And just one thing on that if I can interrupt you. I was telling a buddy of mine to go get his fasting insulin. And he came back and he was like, “I’m getting pushback from my doctor in terms of a little… I just moved to a new town. I want to get it done. He’s a new doctor.” And it’s kind of like, “Who are you to tell me to do my job and why we should be ordering this?” And not everybody’s like that, but it’s just again, friction inside of the medical system.

Dr. Casey Means (00:43:35):

Exactly. So we’re trying to make this as frictionless as possible. And there’s research that suggests that it takes 17 years between when we understand things in the scientific literature and when it makes it to clinical practice. And unfortunately, we’re in the middle of that window right now where we know fasting insulin so important as a biomarker of pre-disease, of pre-disease of these diseases that are affecting monumental numbers of Americans, but we don’t really have access to that biomarker. So Levels is making that possible. So on top of that, the last one people have access to is fasting glucose. So that’s the metabolic health panel. And essentially you can get this through Levels membership. A phlebotomist will actually come to your house, draw your blood at home, and then the levels will show up in the Levels app. And they’ll actually show you not just what the standard ranges are for those tests, like what’s on the lab slip, but what are the optimal ranges for those.

Dr. Casey Means (00:44:28):

So what is the consensus expert opinion of where we should really be shooting and how to interpret these in a more comprehensive way? So this is just really allowing you to be more of the CEO of your own health. This is allowing you to not have to outsource all the judgment about what’s going on inside your body and let you really start to take some ownership. And the cool thing is you can order these as frequently as you want. You could get them once a year. You could do them every month if you want. You could do this panel three months after starting a dietary intervention. You can start to see how what you’re learning on your continuous glucose monitor is impacting these other metabolic labs. So it’s really up to you. And so that’s a new offering that we have with Levels that I think is going to give people a lot more context on what’s going on with their continuous glucose numbers. And I’m thrilled to see how people respond to it.

Dhru Purohit (00:45:19):

Yeah, I’m super thrilled, and I’ve been very vocal in my newsletter online on social and on the podcast. I’m an investor in Levels. I really believe in you guys. You’re one of my favorite health communicators, and that’s why I have you on the podcast, not just to promote the company, but really just to educate the audience that’s there. And I love the idea of democratizing medicine. And this test is 179. Right?

Dr. Casey Means (00:45:42):

Yeah.

Dhru Purohit (00:45:43):

It’s still, people are going to pay for it, but I’ve run these tests before. It’s been more expensive when I’ve gone sometimes and had to pay them out of pocket and even trying to convince your doctor and other things like that are there. So I would rather deal with the frictionless component. And I think it’s an investment in your health, but it’s a beautiful thing to be able to do and have access to. And we have a link of the show notes if anybody wants to sign up. We’ve got a lot more things to cover here. So we’re going to jump back in. But if you are listening, you can go to levels.link/dhru, D-H-R-U, and you can get access to all these labs. Let’s jump into A1C.

Dr. Casey Means (00:46:23):

Yeah. So A1C is this three month average signal of what’s going on with your glucose. So what it’s measuring… So it’s hemoglobin A1C. So we have hemoglobin as part of our red blood cells circulating in our bloodstream. And those hemoglobin molecules basically get sugar stuck to them, because there’s also sugar circulating in the bloodstream. And depending on what the concentration of sugar is in your bloodstream, more sugar is going to stick to the hemoglobin. So this is actually measuring how much glucose is stuck to the red blood cells. Of course, if there’s a higher amount of glucose, your percentage of hemoglobin that has sugar stuck to them is going to be higher. So that’s glycated hemoglobin, and that’s what hemoglobin A1C is measuring. That’s why it’s measured as a percentage because it’s percentage glycated hemoglobin. So we want this to… If you just go to the doctor and you’re an adult, they’re going to order a hemoglobin A1C.

Dr. Casey Means (00:47:20):

And basically if it’s less than 5.7, they’re going to say you’re totally normal. If it’s between 5.7 and 6.4, that’s considered prediabetes. And if it’s 6.5 or above, that’s considered type 2 diabetes. Probably more likely less than 5.5% or even less than 5 is where we want to shoot for in terms of average glucose. So not just less than 5.7, but actually a tighter range. Depending on who you talk to or what research you look at less than 5.5 or less than 5, but essentially lower is better as it is for almost all these tests except for HDL where higher is better. But that’s, hemoglobin A1C, and I think this is a really important test for everyone to have because it is-

PART 2 OF 4 ENDS [00:48:04]

Dr. Casey Means (00:48:03):

But that’s hemoglobin A1C, and I think this is a really important test for everyone to have, because it is just a big general snapshot of kind of where you are in terms of glucose. It has a lot of limitations for sure. One limitation of it is that it doesn’t show you glycemic variability. It’s not showing you what’s going on the ups and down swings in your glucose, day-to-day, which of course are very important. We know that glycemic variability, whether you’re more flat and stable or more spiky, is an independent risk factor for developing type-2 diabetes, heart disease, and other cardiometabolic problems. So we want to keep that spikiness down. And hemoglobin A1C is not telling us anything about that, but it’s telling us what our average glucose levels are over time. So it’s useful in that sense. And if you’re below 5.5, below 5, you can have a sense that you’re kind of in a good, good category.

Dr. Casey Means (00:48:57):

It’s also got limitations because everyone’s red blood cells actually last different amounts of time. Some people’s red blood cells last 90 days, others last more like 120 days. And so based on how long your red blood cells last, that can kind of impact this reading. Ethnicity and certain genetic variants can actually impact the shape of our hemoglobin and how propensity for glycation. So there’s little factors there, but more as a general shot, it can give you a picture of kind of where you’re at on the spectrum.

Dhru Purohit (00:49:26):

What I love about this is that all these numbers together paint a story. And sure, okay, there might be a variation of this, and there might be ethnicity variation in that and there might be components that play in. But if all your markers are not in the optimal range and you pay attention to your health, and you really feel like you’re making an investment in your health, and you feel like you’re eating a diet or doing a philosophy or an approach on health that you would be hoping that is making you healthier, but your labs are in the wrong category or not in the optimal range. That’s a good indication to have a little bit of like taking a step back and saying, “Hey. Like, this is what the data says. Am I open to changing my approach a little bit?” And that’s where we drop down ideology and we step into just a sense of, “Well, what’s actually going to help me feel better?”

Dhru Purohit (00:50:23):

And last time you were on the podcast, we had a discussion a little bit about this that you can do any diet incorrectly. Now diet gets all the attention. We don’t talk enough about these other categories, sleep and working out, although it’s getting a little bit more attention. But diet typically gets the most amount of attention and it causes a lot of debate because people get very animated about their approach.

Dhru Purohit (00:50:46):

And there’s a lot of layers that go into it. There’s planetary layers. There’s animal welfare. There’s a lot of layers and everybody has a different feeling or a different interpretation of what that means. There’s people who eat meat that only eat meat that they hunt. And they feel like that’s actually the most ethical thing that you could do. And then there’s people who on the other side of the spectrum that feel that, again, everybody has their own idea of what’s right and wrong. But when you get your labs, if you’re not heading in the right direction, especially if you test over time, it’s just more information of, “Let’s step out of what my feelings are about what should be done and actually step into what’s going to help us head in the right direction.”

Dr. Casey Means (00:51:27):

That’s exactly right. I mean, data cuts through so much of this noise about the diet wars because the reality is the body is this incredible complex system with many redundant pathways. Also each body is different, of course, genetically, microbiome, everyone responds to foods differently. You know, you and I could eat the exact same piece of bread and have totally different glucose responses to it. So, everyone’s different. We’re also different day-to-day as our own bodies, like we were talking about with the insulin story. Insulin could be 30 and three months later could be 5. And so you’re going to respond to food differently in those two different states.

Dr. Casey Means (00:52:07):

I really like to think of the body as this incredible dynamic entity that is kind of like a shape shifter. It’s different literally day-to-day, based on how you’re living, what you’re doing and what you’re putting into it, based on the amount of sleep you got the night before, the amount of cognitive stress you’re under, what you ate the day before, whether you moved your body a lot or a little, it’s a different body. Even the thoughts that we have create a whole different hormonal milieu in our body day-to-day.

Dr. Casey Means (00:52:38):

And so it’s just it kind of makes it seem totally nonsensical to say that there is one particular diet or lifestyle for everyone. And because, I think, we can pretty much say that that probably doesn’t make a lot of sense, then it comes down to, well, how do you determine the right choices for you? And certainly subjective feeling has a huge part about this. How do you feel? How does food make you feel? How do different lifestyle choices make you feel? And we should absolutely be tapping into that body awareness and that sense of interoception or what’s going on inside our bodies and can we sense it and perceive it. But the biologic data and the biomarkers can really help create a link between our choices and how we feel and what the actual results are in our bodies.

Dr. Casey Means (00:53:29):

So I love using these tests in part as a way to prove to myself that the choices that I’m making are moving me in the direction of my goals and my priorities, or not, and feel really, really confident with the choices I’m making, even if they are different than what some really loud voices on social media are saying, or that a doctor is saying, or that books are saying. If I have the data and I know how to interpret it, I can feel comfortable with my choices for my body. And I think that more access to this type of data is going to be one of the levers that really pulls the rug out from under the diet wars where we have to actually be held accountable to what the truth is inside our own bodies, as opposed to food marketing, the loudest voices, or the minimal amount of information that our doctors were taught in medical school.

Dhru Purohit (00:54:19):

I have another buddy that called me a few weeks ago, because I’m always talking about this and people are looking for what’s the right information out there. And I try to send them to information sources that I’ve… Or doctors that really can help them on their journey. But he just got told by his doctor that he has fatty liver, going back to us talking about insulin and everything. And he eats a traditional South Asian vegetarian diet, which, by the way, a lot of people think of it as traditional, but it had way more actual plant foods in it and way less refined carbohydrates, which is what a lot of it is made up of now. And that’s kind of the diet that I grew up eating.

Dhru Purohit (00:54:56):

And I remember sharing with him this story that I understood about how do we induce fatty liver in an animal if we wanted to, in the most popular way that we unfortunately is consumed around the world. I think it’s a little bit cruel. And I think a lot more people are realizing that is foie gras. The delicacy that’s there, which is the liver of the duck. And it’s kind of a sad situation, but they force feed ducks basically corn. Corn and in some cases depending on the country and other things, other things that would be like cornmeal and refined carbohydrates to basically pump the animal full of refined carbohydrates, is sugar inside of the diet and that induces fatty liver. And so I said, “Listen, I know you feel very attached to this way of eating and you can still be vegetarian in this case.” That’s very important to him. It’s part of the tradition and everything like that.

Dhru Purohit (00:55:56):

But stepping out of this, what we think of as our traditional diet, which really is not that old. It’s not like our paleolithic ancestors were eating that way of being vegetarian, even if they were, and incorporating more healthy plant foods. And maybe also cutting back on the alcohol a little bit as well too, which was a big part of his diet. So it just was a funny story and a thing for me that until he went and got tested, he didn’t really know that what he was doing wasn’t working for him.

Dr. Casey Means (00:56:29):

I think that’s such an important story because it really highlights a phenomenon that is happening in this country right now is that we are becoming human foie gras in a lot of ways. I mean, 45% of American with fatty liver disease now, that’s what’s happening to us. And it can really be linked to this excess consumption of corn products like what’s happening with the geese, but also, of course, the refined sugars, refined grains, and the fructose. And so it’s really simple to reverse. And the nice thing is that it’s much simpler to reverse early in the process than it is late because when the liver has been fatty for a long period of time, that’s generating a lot of inflammation in the liver and that can ultimately lead to scarring and actually more of an end stage disease state where the liver permanently has structural changes.

Dr. Casey Means (00:57:17):

So being able to clue into a lot of this stuff early is the time to do it. And we’re seeing this in kids now. And so really zeroing in on these metabolic lab tests is important for this reason. And actually one that probably out of the scope of the conversation today, but looking at your liver function test is really important too. Again, this is one where the range is very large. Some of the tests that you might hear about are AST and ALT which are different transaminases, liver enzymes, that basically rise when there’s liver dysfunction. Typically, we’ve heard about them rising in relation to alcoholic liver disease, but now we’re seeing them rise in relation to dietary induced liver disease. So just one take home point for people who are looking at their labs, if you’re looking at your ALT, it’s probably going to say, shoot for below, like normal is below the forties. Sometimes the ranges will go into the fifties. But really shoot for below about 25. You want really optimal liver health. And that can be one slight clue of what’s going on in your liver. But, of course, the whole picture of what’s happening with your insulin, your triglyceride/HDL ratio, these also give us a signal, of course, of what’s happening in the liver as well. So, yeah, it’s a great example with your friend and we just, we all need to be focusing a lot more on what’s happening in the liver.

Dhru Purohit (00:58:37):

Absolutely. Let’s talk a little bit about inflammation and C-reactive protein. Why does this laboratory marker matter and what could be some of the things that could be setting it off as a red flag that there’s some excess inflammation going on in the body?

Dr. Casey Means (00:58:55):

Yeah. So CRP is one of the key markers that we can track in the bloodstream of what’s going on with inflammation. It’s called an acute phase reactant. It’s a protein that’s generated in the liver, and it can go up in response to infection, autoimmune disease, cardiometabolic disease, heart disease. And it’s a great signal of basically what our baseline inflammatory state is.

Dr. Casey Means (00:59:19):

It’s also one that is frequently ordered in the doctor’s office. You may actually have one on a past panel, or you could ask your doctor to get a CRP. And you may actually want to ask for an hsCRP, which is a high sensitivity CRP test. And based on what lab you’re going to, they might say that less than two milligrams per liter, or less than three is normal. We really want to shoot for less than one, and ideally even less than 0.5. We want that inflammation to be low because we know that chronic inflammation can drive metabolic disease. And so this is definitely a test you want to clue into and be getting every once in a while to make sure you’re not creeping up and that there’s not something kind of simmering underneath the surface, like a chronic low grade infection that you may not even be aware of. So definitely one that I include in my metabolic, sort of comprehensive picture to get at least once a year.

Dhru Purohit (01:00:13):

This is one of those confusing ones because I’ve seen different lab reports that are out there. And when they talk about the reference ranges, you’ll see the reference ranges can be like zero to five. And it’s like, “Wow. That’s like a huge range that’s there.” And again, this just goes back to the fact that more research continues to go out there or more research, in the case of CRP, there’s been quite a bit of research that a lot of people that have been talking about, that different studies that are there. But it’s more recognized in terms of its importance because there’s so many physicians like yourself and functional medicine doctors that are out there who are talking about the reason that it’s important in relation.

Dhru Purohit (01:00:53):

My brother-in-law would often say that when it was in that lower range, even as a cardiologist, they often didn’t even talk about it because there was a question of, “Well, what do we tell somebody to do?” Right? “What am I going to tell somebody to do if it’s still elevated, but it’s in that lower end of the range?” And a lot of doctors don’t know. Again, well-intentioned, well-meaning, they’re trying to do their best, but they weren’t educated even what should they look in the direction of? They just felt like, “Okay. This is going on. We don’t know why, but it’s not so, so high that some major issue is going on, but it’s still elevated enough that we’ve got to do something, but we don’t know what to do.”

Dr. Casey Means (01:01:28):

Right. And when fat is essentially in the wrong place, or there’s excess fat, it’s going to generate inflammation. When there’s fat in the liver, you’re going to get inflammation in the liver. Adipose tissue, fat tissue, in its own right can be inflammatory. And different cell types in the inflammatory pathways like macrophages can basically take up residence in this tissue and create these inflammatory programs, secrete their inflammatory chemicals that cause this threat sense in the body that we do not want over time. So clearing out that excess fat from the liver, from the visceral fat, this can actually help our CRP come down. As cardiometabolic disease improves, CRP will improve. So, anything you’re doing to improve metabolic health will actually, usually parallel with CRP declining.

Dr. Casey Means (01:02:20):

And I think, generally speaking, we can also think about general anti-inflammatory dietary and lifestyle strategies. Of course, a lot of the refined processed foods that we’re eating, they generate inflammation in the body, whereas a lot more of the whole foods, especially the omega-3 rich foods, like chia seeds, flax, fatty fish, these things have these anti-inflammatory properties. Of course, there’s other incredible food chemicals that can do this, like turmeric, which has curcumin, which actually reduces the activation of one of our inflammatory pathways, NF-kappa B. So use food as medicine when you’re approaching inflammation. So thinking about really just a comprehensive anti-inflammatory strategy is really important in our diets.

Dr. Casey Means (01:03:06):

Another one to think about is our microbiome, of course, because the microbiome secretes short chain fatty acids which go into our bloodstream and can have also an anti-inflammatory effect. So we want to keep our microbiome on point, which, of course, means feeding it what it needs to thrive in the right populations. These are high fiber foods, the nuts, seeds, beans, legumes that are going to let the microbiome do what it needs to do to produce anti-inflammatory chemicals.

Dr. Casey Means (01:03:36):

And so there’s so much there, but CRP can kind of give you that general sense of what’s going on. And if it’s elevated, you definitely want to take action. You want to take stock of your diet. Is it pro-inflammatory? Are there anti-inflammatory components? Do I have excess fat in the wrong places? Do I have underlying stealth infection that I need to dig into more? Is there some sort of autoimmune process going on, et cetera? So that’s where it can be kind of useful. And certainly if it’s elevated, there’s absolutely dietary and lifestyle things that you can do to move it in the right direction.

Dhru Purohit (01:04:11):

That’s a beautiful thing about all these things is that my business partner, Dr. Hyman, you were just on his podcast. You’ve been on there a couple times now. I love those episodes. He always says like, it’s not like there’s one diet, that’s there for brain health. And then there’s another diet that’s there for cardiovascular health, and there’s another diet that’s good for your microbiome. The beautiful thing is we’re covering all these, individually, as indications, as smoke detectors that we want to be paying attention to, because sometimes one might be elevated and one might be a little bit more normal, but it’s still worth paying attention to. But generally, the same intervention overall is going to be beneficial. And those are a list of all the things that you just shared there. It’s an important reminder because sometimes people obsess about one of these areas. But your overall approach, that’s going to bring you into wellbeing, especially dietary wise, anti-inflammatory diet, a lot of the healthy Mediterranean fats that we’ve talked about, avocados, avocado oils, olives, olive oils, other things like that, cutting out the refined carbohydrates, the refined sugars inside of the diet, especially the liquid sugars, which are getting a lot of attention right now, even things like fruit juices, which people thought.

Dhru Purohit (01:05:17):

Just really quickly, how could something like fruit juice, which a lot of people thought was healthy, how could that be something now that we’re reconsidering and that it might be driving, because even people who think that they’re eating a healthy “diet”, if they still have a large amount of some of these refined carbohydrates in there and they have large amounts of fruit juice in their diet, their panel could come back looking super wonky. So talk about, let’s talk about fruit juice in particular, how is that that could be influencing some of these things?

Dr. Casey Means (01:05:52):

Right. So fruit, obviously, has many wonderful qualities to it. Fruit is filled with antioxidants. Many fruits have a lot of fiber. There’s tens of thousands of phytochemicals in fruit that are wonderful little molecular chemicals that can help ourselves function properly. Fruit can be a great food to have, but juice is not fruit. Juice is an ultra concentrated form of fruit, of which many of the positive things have been removed. So I think we really need to first associate that juice is not fruit. It is a concentrated, essentially liquid form of sugar with some of the benefits of fruit, but you’re much better off eating a whole piece of fruit.

Dr. Casey Means (01:06:38):

Juice, the issue with juice is that we’re getting essentially like pharmacologic doses of this fructose that’s in fruit because, again, it’s concentrated. And the thing about the body is that it has an amazing capacity to process things and get rid of them. Like it can process toxins in the liver. It can process medications. It can process sugar and take it out of the bloodstream into cells. It can process fructose in a totally healthy way. But the cells only have a certain capacity for this amount of processing. And when you overload the cells in a short period of time with huge amounts of almost anything, there will be dysfunction. And that’s what juice is doing because it’s a huge fructose load that’s usually drank really quickly.

Dr. Casey Means (01:07:23):

So you have this set amount of cells with a set amount of capacity and you’re overwhelming it so you’re going to get dysfunction. You’re going to get byproducts that are damaging. And in the case of fruit, what’s happening is actually quite an interesting story. When fructose is broken down in the liver, it’s broken down into a byproduct through a complex pathway, but eventually uric acid is one of the byproducts that is made. And uric acid, normally the body can handle a certain amount of uric acid and dispose of it. But when you have such a big fructose load, your uric acid rises in the cells. And what that does is it actually goes to the mitochondria and it causes oxidative stress. It causes that oxidative damage that overloads the capacity of the body to essentially counteract it.

Dr. Casey Means (01:08:12):

So you get oxidative stress in the mitochondria, our little energy factories. And what that does is it essentially blocks the mitochondria from doing their job, which is converting glucose into ATP and instead shunts glucose into fat because, so fructose creates excess uric acid, uric acid damages the mitochondria, the mitochondria can’t do their job well in producing ATP from glucose. The glucose gets shunted to fat storage and now you’ve got fat in your liver.

Dr. Casey Means (01:08:41):

What’s interesting is that if you eat the amount of fructose that’s in one piece of whole fruit, this doesn’t happen. Your body converts it to uric acid. The body manages the uric acid. It doesn’t overload the mitochondria. Everything’s smooth sailing. You’re not converting the glucose to fat. Things are good. But it’s when you overload it really quickly that we have a problem. There’s actually interesting research that’s been done that shows if you actually drink a Coca-Cola slower, like over the course of several hours, versus just pound it in five minutes, it’s a very different effect on the liver because in the slower version, your body’s kind of constituently able to process and not get overwhelmed. But when you’re slamming it, you’re, of course, going to overwhelm the capacity of these cells. So, that’s really kind of one of the reasons we don’t want to drink liquid sugar. It happens too fast. It overwhelms the systems. It outpaces the cells’ capacity. And then we get dysfunction and storage of excess in ways that we don’t want that create organ damage.

Dhru Purohit (01:09:42):

Yeah. And we’re teasing out fruit juice here for a moment, but we’re really talking about any liquid sugar.

Dr. Casey Means (01:09:46):

Right.

Dhru Purohit (01:09:47):

But fruit juice in particular because a lot of people and especially parents think that they’re doing, again, the best thing that they can for their child. At least they’re not drinking a soda. And everything exists on a spectrum. Everything exists on a spectrum. But as we get updated information, we take a look at things and we say, “Well, is there a better way to go about this?” And reevaluating the total concentration of maybe fruit juice in our diet or any liquid calories.

Dhru Purohit (01:10:13):

I posted something the other day saying that I’ve dialed in and kind of made a homemade latte. I used to enjoy walking to the coffee shop, other stuff, but I’d see, back in the day, I never really drank oat milk a ton, but I’d have it occasionally. I saw that oat milk would send my blood sugar off the charts. But then even most almond milks that are out there are sweetened, but you can make it at home. You can make a little coffee, a little latte at home. There’s plenty of brands that are out there that are unsweetened, have no fillers inside of them, like carrageenan, which has some suspect, potentially suspect impact on the gut microbiome and other things like that. But you can get a clean almond milk. You can make a latte at home and it’s enjoyable. And mine scored a nine out of 10 on my levels, which is a good thing, by the way. It scores your meals and helps you understand its impact on your blood sugar.

Dhru Purohit (01:11:06):

So yeah, as we get more information, we start to reevaluate and then we make adjustments and we do it without freaking out and with data. We don’t want to obsess about any one particular thing or any one particular food or thinking this one thing is going to be the downfall of us or this one area is going to totally throw off our health. When we improve our baseline our ability to have flexibility every so often, if we so choose to, increases. And that’s not just when it comes to diet, although that’s a big part of it, I would say that the biggest takeaway that I had from wearing the Levels CGM is that I could be eating the same diet this week as, let’s say, two weeks from now, but if I don’t get in my three workouts a week, my blood sugar is completely different than when I do workout. When I do workout, my blood sugar response is so much better and I have enough of…

PART 3 OF 4 ENDS [01:12:04]

Dhru Purohit (01:12:03):

Is so much better and I have enough of my metabolic health panels that have been taken at different times that just by including a 30 minute, high intensity workout, for me, that feels good, my overall panels are so much better, even though I’ve been eating basically the same between those two panels that are there.

Dr. Casey Means (01:12:23):

Definitely and it’s so good to figure out those personalized insights for yourself. I mean, the thing about the exercise is it changes everything. Muscle is a huge glucose sink. It pulls glucose out of the bloodstream and uses it and disposes of it. It also clears out the liver of excess fat and stored glucose in the form of glycogen because you’re putting the body under a stress where it needs more energy. It pulls it out of its stores and the liver is one of the big stores. It really can change the game, like you said, week to week and be able to see those impacts. I mean, I imagine that was motivating to you to keep on doing those three workouts a week.

Dhru Purohit (01:13:05):

That has been one of the most motivating things for me for working out. That’s been the most motivating thing because there’s just this confirmation that not only does it matter so much, but it’s being reflected. I think that’s actually more important because there could be a lot of variables if somebody’s motivation was say to lose a little weight. Okay, great. That’s fine. Anybody can have the motivations that they want to have and that’s up to them to have those motivations. Depending because we’re talking about these labs, it’s way bigger than just one marker. You’re fasting, insulin could be really high because you’ve been eating a particular way or living a particular way for so long that we need a little bit more length of time for your body to get that number lower, which then will impact the ability that you put on weight, especially belly fat that’s there.

Dhru Purohit (01:13:54):

But when you see that some of these markers that change on a more regular basis are improving, it’s that confirmation that you’re heading in the right direction. You guys were so kind enough to send level CGM to my friend, Dr. Rangan Chatterjee, who’s been using it over the last month, since January, I think in January. He said, “This is the biggest habit and behavior reminder that I’ve ever had and I eat like really clean. This is just such a reminder of what works and doesn’t work,” and I think they’ve built a really great system. Anyways, a little love that I wanted to throw in your guys’ direction. Let’s get back to the lab test. I think there was one test that we didn’t get a chance to cover-

Dr. Casey Means (01:14:42):

HGL

Dhru Purohit (01:14:42):

… HGL. Yes.

Dr. Casey Means (01:14:44):

Yeah. This is one of the ones you’ll see in sort of a metabolic lab panel. It’s one of the four things that tests in a cholesterol panel and this is typically thought of as the good cholesterol. This is one of the forms of the cholesterol packets that floats around in the blood stream that brings cholesterol back to the liver, helps recycle it, helps get rid of it and so it’s taking it away from the blood vessel walls and moving it away from sites where it can be harmful, so we want HGL to be higher. I think it’s the only test we’re talking about today where higher is better. And typically, you’ll see that on a lab slip that it says anything above about 45 milligrams per deciliter is normal. It’ll sometimes be broken down by gender, like above 40 for women or above 50 for men is where you want to shoot for, but around 45, but the reality is we probably actually want it to be much higher, like above 60, maybe in the 80s or 90s or up close to 100.

Dr. Casey Means (01:15:42):

This is if you’re just on the edge of like 45, 46, your doctor will probably say to you, “Great, that’s normal. Your HGL is normal. Your good cholesterol is in the normal range,” but I think as we learned from today, you need to think about this in the big picture context. Here’s an example. We talked about the importance of triglyceride HGL ratio, surrogate marker of insulin sensitivity, of small density LDL, the harmful LDL. Well, imagine a situation in which the standard lab range says that triglyceride less than 150 is normal and HGL above 45 is normal. You might have a triglyceride of 149 and an HGL of 46 and your doctor says to you, “Great, your cholesterol panel is totally normal.”

Dhru Purohit (01:16:27):

“Keep doing what you’re doing.”

Dr. Casey Means (01:16:28):

“Keep doing what you’re doing.” Well, that’s going to be a triglycerides to HGL ratio of three to one, of three or about that. That’s way too high. That pretty much indicates like full fledged there is a metabolic problem, but each test in its own right is sort of falling into the “normal range,” so that’s why you’ve got to look at these things in context. What we really want is for those numbers to come much closer together. Triglycerides, low end of normal. HGL, high end of normal. The ratio closer to one. That’s going to be a much better signal that you’re in a better place on the metabolic spectrum, but unfortunately it may be missed by your doctor who’s just looking at the electronic health record and looking for those green check marks that you were generally falling into the normal range.

Dhru Purohit (01:17:17):

All this goes back to, we got to be the CEO of our own health. It’s okay to have people… When you’re an actual CEO, you hire people that are smarter than you in different topics, but you’re synthesizing that information and trying to make the right decision for everybody’s best interest that’s inside of the company and the shareholders and other stuff. When you are the CEO of your health, it doesn’t mean that you know every in and out about these lab markers. It doesn’t mean that you think that just because you have data that you went to medical school. It doesn’t mean any of that. What it means is that you are choosing the right people and pulling in the right inputs to help you synthesize information so that you can make a decision of what direction and what actions you want to continue and what actions you maybe want to pull back from.

Dhru Purohit (01:18:08):

You can’t do your job as well as a CEO if you don’t have all the right inputs and the right team that’s there. And so far, that information has been highly protected in terms of right now, most people know you cannot just go and order these tests for yourself. Most testing, actually, I would say there’s been so much controversy about Theranos and as there should have been, but one good thing that came out the whole Theranos situation, as I understand it, was they were instrumental in passing a law in Arizona that allowed people to order their lab results directly, so that’s silver lining ,the tiny little silver lining from the whole Theranos situation. Tiny silver lining from the whole Theranos situation.

Dhru Purohit (01:18:54):

But in the instance for you guys, you guys have figured out the hack, you’ve partnered with another company and there’s supervising doctors that are part of the situation that allow people to have it, but there’s really no reason why people shouldn’t have access to it and then guidance that’s out there to help them interpret it. And they can even order these tests and then go and review them with a doctor.

Dr. Casey Means (01:19:13):

They should, you.

Dhru Purohit (01:19:13):

Maybe you can send your doctor to this podcast if they’re open minded and they want to listen to it. They might learn something and start to begin to optimize their own health that’s there.

Dr. Casey Means (01:19:22):

Absolutely. And I would definitely second that this is information for you to bring to your doctor and start a conversation. This is just giving you access to the information, but one thing that’s really blows my mind is that in only one state in the United States do patients own their health records outright, I believe it’s New Hampshire, but only one. In a lot of states, the hospital or the physician actually own the data. That’s your data from your body. It’s so interesting to me because you think about other parts of our lives where access to information is really critical, like, for instance, our car. Our car now has dozens of sensors all over it; for tire pressure, for the windshield wiper fluid, for the oil. It’s constantly sensing what’s going on in the system and giving you all this information so that you can then have a sense of what’s going on with the car and pull in the mechanic if you need them, obviously, if something is wrong.

Dr. Casey Means (01:20:23):

Similar with our finances. We obviously have access to the information about what’s in our debit account and what our credit score is and then we have a financial advisor who might advise us about these numbers, but the way we’re practicing medicine right now is as if you did not have access to your debit account balance, to your credit score, to when your credit card payment is due, if you didn’t have access to see how much mileage is left until empty on your car, whether your oil needs to be changed. None of it. You don’t get to have it unless you submit a form and have someone give that information to you. Imagine if just to know how much gas was left in your car, you had to submit an official form to the company to give you that information.

Dhru Purohit (01:21:10):

Or the DMV.

Dr. Casey Means (01:21:10):

That’s kind what’s happening with our health. We, in many cases, can’t easily access it, transfer it, give it to other people to look at. That’s insane. We think that health is some sort of different thing and it’s a very, almost paternalistic, I don’t really love that word, but it’s sort of a authoritarian view of things of like this is too serious and it’s too complex and it’s going to be a problem if you are trying to interpret it for yourself, I would like to throw out that system. We all deserve access to our own health information, excellent information to feel comfortable looking at it. Of course, we’re not going to be the financial advisor or the mechanic, we’re not going to be experts in it, of course, unless we had advanced training in this, but we should at least have some baseline understanding of what we’re looking at, what it means, whether this is a problem and when to ask for more assistance and help.

Dhru Purohit (01:22:09):

This is all just a legacy of a system that minimizes lifestyle interventions. Because even if somebody said, “Okay, there’s the medical industrial complex and there’s big pharma, but it came with good intentions.” Let’s say somebody gave the benefit of the doubt and said that. Okay. That a lot of these things you want your doctor to be able to decide what drug or what other component, but we know now there are so many things we can do on a lifestyle level to be able to influence these things. So having that information, many people who are listening to this podcast might be well more aware of the lifestyle interventions that can influence these panels that we talked about than even their doctor themself.

Dhru Purohit (01:22:53):

I was watching a documentary about the history and the evolution of medicine and Freakonomics also did a really good series on this called Bad Medicine. It has part one, part two, part three, we’ll link to it in the show notes, but in the 1950s, because there was very limited things that you could do for a patient that had cancer, the standard of care at that time, I think it was late ’40s, early ’50s, was it was up to the doctor to decide whether or they wanted to tell the patient if they even had cancer. Part of that directive came on, “Well, we don’t want people to be suicidal if they know that they have cancer because there’s not a lot we can do and maybe they’ll have a mental health crisis. Maybe they’ll be so depressed, they won’t want to make progress on other stuff. And again, we can’t really do much anyways, so it’s up to you to decide, do you want to tell the patient?”

Dhru Purohit (01:23:41):

And sometimes, even doctors would tell the family, but say, “Don’t tell the patient because there’s not much we can do.” I mean, we’re a little bit in that place right now where a lot of times a doctor will see that you are very clearly on your way to diabetes, you’re in that prediabetic area. It’s like, “Well, everybody is. Everybody’s a little fat. Everybody’s a little bit prediabetic. Everybody’s blood sugar is fucked up. Everybody’s this is that and whatever-

Dr. Casey Means (01:24:05):

And people aren’t going to eat healthy.

Dhru Purohit (01:24:06):

… and people aren’t going to eat healthy. I mean, that’s crazy. How could you tell somebody to lose weight or eat healthy or other stuff.” Again, that’s their limited knowledge and awareness of what’s possible, so just keep doing your thing and maybe one day we’ll hope for a drug that can fix the situation. We don’t have to live in that world anymore and we can be a big part of changing things around and that starts with you having access to the information that you need to optimize your health, feel good, so that, let’s remember the whole reason why, when you feel good, you can give love and attention to all the things that matter in your life and you can be an incredible citizen who looks out for other people, looks out for your family and makes a difference in only the way that you were designed to make a difference on this planet.

Dhru Purohit (01:24:50):

That’s why we’re doing this all. There’s no goal to be just healthy for healthy sake, we have plans and we have goals. We want to make a difference. We want to be at our grandkid’s wedding. We want to be there to run around. Whatever it might be, everybody has their own version of goals, but that’s the reason why all this stuff matters. That was my little rant.

Dr. Casey Means (01:25:12):

I’m so glad you brought it back to the basics there, like this is not just about getting some A grade on a lab slip, this is about actually be able to embody our core passion, our core truth, what we want to bring into the world and to be able to be a force of light and good in this world and it’s easier to do if you feel good and if your cells are functioning properly. It comes back to that and I really appreciate you bringing it back to that.

Dhru Purohit (01:25:40):

The opposite of that is when you feel bad, you take your hurt out on everybody else. Whether it’s emotionally, physically, other stuff, you’re just driven by poor motivations. And I really think that a lot of what we’re dealing with today in the world, not that it’s an easy fix, it’s not, it’s going to take generations of people like you and other experts that have been on this podcast that are educating people and creating companies and solutions to help them in that direction, but when you feel bad, you’re not a good citizen for the world and you add in more hurt to the world because you’re hurting yourself. My heart goes out to everybody that’s in that category and I appreciate everybody who’s listening today that is trying to step out of that place if they are in that place. Casey, remind us again, maybe take us through a little bit of a recap, if you could. We covered a lot of information, but it’s always nice to get a little bit of a recap and then we’ll close up with some concluding thoughts.

Dr. Casey Means (01:26:37):

Absolutely. I’d say in terms of a recap, the first thing I’d say is, one, like you said, start to think of your involvement with your lab results as you being the CEO of your health, I love that, and make sure that you’re really looking at your lab tests and giving them a critical eye, really looking at them for yourself and not just take everything at face value. I would say in terms of some of the bare bones, basic metabolic tests that we want to be looking at, at least every year, maybe more frequently, we’re talking about fasting glucose, ideally fasting insulin, hemoglobin A1C, a full cholesterol panel, which includes total cholesterol, LDL, HGL, triglycerides, CRP to look at inflammation. Make sure you are looking at your triglycerides to HGL ratio, which you’re going to have to calculate for yourself. And certainly if you can get some liver function tests in there as well, ASTALT, that’s great as well, but make sure you’re looking at these and looking at them as a whole story.

Dr. Casey Means (01:27:37):

To get into totally just the specifics really quickly, I’ll run through them. For CRP, we want to make sure generally it’s less than one, ideally less than 0.5. LDL, which we typically think of as bad cholesterol, this one’s a little bit more complex because on our standard panel we can’t see what the subfractions of LDL are, so the number itself is sort of tough to know what to do with it. We most care about small density LDL. But once you see your LDL number, first of all, if it’s less than about 100, that’s great. That probably means that it’s low enough that the small density LDL probably wouldn’t even be high enough for it to be a huge problem, so less than 100 is a good sign, ideally less than 70. But once you’ve got your LDL number, immediately go to your triglyceride HGL calculation, which can be sort of a surrogate marker for your small density LDL fraction.

Dr. Casey Means (01:28:23):

You want your triglyceride to HGL ratio to be as low as possible, ideally like one or less. But some research suggests that it may be somewhat ethnicity or race specific, so less than 2.5 to one in people of Caucasian descent, less than 1.5 to one in people of African American descent. Aside from the triglyceride to HGL ratio, you want to just, of course, zero in on your triglycerides. Most lab panels are going to say less than 150 is normal, you want to definitely be tighter than that. Less than 100, ideally even lower, maybe even like less than 70. For HGL, higher is better. Ideally shoot for above 60, but getting up into the 70s, 80s, 90s is great.

Dr. Casey Means (01:29:10):

Fasting insulin, ask your doctor for it. Maybe share some of the pearls that you might have learned from this episode with your doctor to kind of encourage them to order this for you. It’s actually a really cheap test. It’s like $15. Somewhere between two and six, two and eight is ideal. Definitely want to be probably less than 10. That’s kind of like the really quick wrap up of kind of what we’ve talked about. But the key point I would also say is that none of this is medical advice, people should definitely talk to their doctors about the interpretation of these results and these are just sort of like general things to kind of create a framework for what you should be thinking about when you look at your lab tests.

Dhru Purohit (01:29:50):

No, that’s beautiful. Levels has made it super easy. Again, I’m such a big fan. It’s why I invest in the company, it’s why myself and Dr. Mark Hyman are advisors. We believe in getting access to all this information that’s there. The test only $179 bucks, which is super affordable. If you’re going to be looking at a few meals out, it can easily end up adding up to that thing and you get access to all that information that’s there and you can sign up. Levels.link/Dhru and the link is in the show notes for anybody who’s watching or wants to come back and pull it up a little bit later on. What is some of your hope now? I mean, this is just recently launched. What are some of your hope of what having access to this information will do for people who already have the CGM or might be using a CGM from levels right now? What are your hope in terms of that and then the larger implications of just everybody having at access to this?

Dr. Casey Means (01:30:51):

My two big hopes are, first, that for people using a Continuous Glucose Monitor, this can really help them figure out whether the changes they’re making based on the CGM data are leading to shifts in these bigger lagging indicators of metabolic health. So for instance, you can imagine if you see on the Continuous Glucose Monitor that Cheerios are spiking your glucose through the roof, which they do for most people, we can pretty clearly know that that’s going to be an excess of glucose in the bloodstream that the body’s going to have to process And that may be feeding into a high triglyceride level. And maybe if you shift your breakfast to something that does not have a huge glucose load, like chia pudding or eggs and avocado, over the course of a few months, you might see your triglycerides drop hugely and so that type of feedback between what you’re learning and implementing based on CGM data and how it’s actually fitting into your bigger metabolic health metrics is really exciting to me.

Dr. Casey Means (01:31:55):

It gives people like another layer of closed loop, bio feedback about some of these markers that we know are associated with long term disease risk. I think more broadly, one of the things I’m excited about is getting back to this idea of like the diet wars and that there’s a one size fits diet for everyone. Having this picture and control over when you order it and when you get these labs done allows you to do dietary interventions in your own life, your own N of one experiment, and actually see how it’s moving the needle on your lab work. One thing someone could do is let’s say they, for instance, they pick up The PEGAN Diet, Mark Hyman’s latest book, which is an incredible, very healthy, Mediterranean type style diet, very low in refining carbohydrates and sugars. Try it for two months, get a baseline of this metabolic health panel and do it after two months and watch the numbers change. That is incredibly motivating to keep up some of these lifestyle habits.

Dr. Casey Means (01:32:58):

But for another person, they might be going on a totally different dietary strategy, like all whole foods plant-based or carnivore. Well, they can actually see for themselves how that intervention shifted their metabolic health panel. If the carnivore diet keeps the numbers in a really great range, good for you, continue it. If a whole food, plants-based diet does it, good for you, continue it. If PEGAN diet does it, that’s great, but at least have the data so we’re not just out are yelling about what we think works, but actually focusing on what does work for our bodies. I’d say those are the two things I’m really excited about.

Dhru Purohit (01:33:35):

Those are a beautiful thing to want to wish for the world. And for anybody who wants to step out of that polarization of even the dietary space, which I’m very much in that category, I don’t even like doing episodes where people are arguing about the best approach because I’ve been on all sides of it and I also know that something has worked perfectly for somebody else and it’s worked terribly for me. Not to mention all the other aspects of our life that sometimes somebody is a new mom or dad and they have a period of their life where eating a different way is easier to keep up. There’s periods of our life where, even though we know that alcohol is generally not a supportive thing that’s there… I was on the phone with a friend of mine just a couple weeks ago with another doctor that I connected them to, and they were like, “Look, just being super honest, right now giving up that evening glass of red wine that I have, like a half a glass, not like those big glasses, is just really tough for me, just really tough for me after having two kids and dealing with a lot of stress that’s there,” and a doctor is going to meet them where they’re at and say, “Okay, well let’s work on all these other things.”

Dhru Purohit (01:34:39):

Or they’re going to order this panel and say, “Well, I know you can’t do it now, but I just want to show you that if you don’t change things, here’s where your panel is headed towards.” So Casey, that was a great recap and I’m excited that we have another podcast in the books with tons of free information. Again, if you want to do these tests, you can sign up with Levels. It’s only $179. The link is in the show notes below. But even if you don’t sign up, I hope you got a ton of value today of tests that you can go and tell your doctor to order for you if they haven’t ordered it and get some indication of some questions you should start asking, especially if your numbers come back wonky. Dr. Casey Means, thank you for being back on the podcast and delivering… As always, I super appreciate who you are in the world.

Dr. Casey Means (01:35:27):

Thank you so much, Dhru.

Dhru Purohit (01:35:29):

Hey YouTube, if you enjoyed what you just saw, keep watching for more great content on how to improve your brain and your life.

Dr. Casey Means (01:35:36):

The research suggests that as you move higher in the normal range towards a prediabetic fasting glucose level, your risk for a whole host of diseases from stroke, to heart disease, to of course.

PART 4 OF 4 ENDS [01:35:48]