Unlocking Levels with Dr. Casey Means: Part 2

Don’t you wish you could have an invisible coach sitting on your shoulder, telling you exactly what and when to eat in order to keep your metabolism running in tip-top shape? Unfortunately, that’s not possible – but a continuous glucose monitor, or CGM, could be the next best thing. Dr. Casey Means of Levels realized that most data is overwhelming when it comes to healthy decision making. Something simpler was needed to identify positive routines. In this episode of The Lab Report, Dr. Means shared new insights from recent studies, including the benefits of fasting and the science behind glucose spikes.

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3:15 – Fundamental behavior change is the key to lasting health

When Dr. Means started working with clients on a deeper level, understanding their holistic lifestyle as a part of their wellness, her recommendations started giving patients incredible outcomes. That’s why she believes fundamental change in behavior is the key to long-term health.

“I was spending two hours with each patient for the initial visits and doing tons of advanced lab testing, really getting to know people’s lives, history, lifestyles, and the full picture of their health blueprint. And I created these plans for them that were very comprehensive. And many people just had incredible outcomes in just a few months, and progress I’d never seen in my conventional practice. And it was because we were really understanding each other and there was so much communication and buy-in. I think when you are able to cross that chasm and the patient understands the doctor and the doctor understands a patient, so much transformational activity can happen. That was very exciting. But what I realized was that for people to improve, fundamentally, they were having to change their behavior. They were having to change the daily activities in their life that they do, all the thousands of micro-decisions we make every day to ultimately create conditions in their bodies that would generate health.”

4:43 – Coaching in medicine

A big part of wellness is making the right choices in managing four fundamental areas – sleep, stress, exercise, and food. That’s why coaching is now an integral part of medicine.

“I think the four main things are sleep, stress, exercise, and food. And between those four things, we make so many decisions every day. And the patients who did well were the patients who took my thoughts and my advice to heart and made meaningful changes in those aspects of their lives. And you just saw that their health just transformed. And so it became clear to me that fundamentally, behavior change is required for people to have meaningful, sustainable improvements in their health. Because behaviors translate to molecular conditions in the body, through hormones, through our nervous systems, through micronutrients. I found this interesting because I am having a lot of patients who are really successful, but some patients who are having more trouble making these changes, and I can’t be with my patients 24 hours a day. I cannot be a little birdie on their shoulders saying, yes, do this, don’t do that. Oh, that’s a great decision. Oh, pair this with that food, it’ll be better for your blood sugar. You can’t do that. I don’t think anyone can do that. I ended up realizing that certainly coaching is becoming a big part of medicine now, which I think is wonderful.”

5:55 – Using technology to stop bad decisions

It’s hard for human brains to keep track of all the data regarding our health in order to make good decisions. That’s where technology can step in to help combat the growing health epidemic.

“So there are two issues. One it’s hard for a human brain to process all those inputs. How is a human really supposed to? First of all, you’re not there with your patient 24 hours a day. But if someone’s blood sugar is a little bit high one day, it’s hard for a human brain to say like, Oh, well that’s 10% because they got less sleep last night, 20% because of what they ate, 15% because they didn’t work out, or they only worked out for 20 minutes yesterday. It’s hard to parse out and weight the different drivers of the outcome. And this is where digital tools can actually step in and be really, really, really helpful. So one is that it’s hard cognitively and two is that humans are fundamentally unscalable. We have a massive chronic health epidemic in our country. It is estimated that 88% of Americans are metabolically unhealthy. This is from a UNC study that came out two years ago that looked at lipids, blood sugar, and waist circumference. And basically said, if people meet any of these criteria for what we call metabolically unhealthy, they get that label. And it was 88% of the people they studied. So these are monumental rates. 74% of Americans are overweight or obese. We have 128 million Americans who are diabetic or pre-diabetic, it’s just astronomical and coaches and humans don’t scale. So I started thinking, how can we create digital tools?”

14:18 – It’s about the daily routine

Metabolic health isn’t just about what you eat. It’s about managing other levers such as sleep, stress, and physical activity in conjunction with food. The goal of Levels is to bring awareness to how these things intersect.

“A lot of people might fear hearing about this thinking, oh, it’s just going to tell me that I can’t eat all of my favorite foods, this is to just tell me that I can’t have a cookie and I can have a banana. And that sucks, I don’t want that, but it’s so different than that. It’s actually very liberating in the sense that it helps you build metabolic awareness and a metabolic toolbox of basically how you can utilize all these levers to create a context in the body that processes carbs really effectively. So you might be someone who is able to take a 20 to 30-minute walk after your meals, and that totally blunts your glucose response. Or you might see that sleeping seven and a half hours versus six and a half hours of sleep lets your glucose levels be much more stable the next day, or that doing 10 diaphragmatic deep breaths before a stressful phone call or before a meal might actually blunt your glucose response. All of those things have very real molecular underpinnings. You can build this context for what you’re eating so that your body processes it better.”

17:01 – Compress calories into a shorter eating window

Interesting research shows that fasting for part of the day and eating all of your daily food within a smaller time window may help to lower glucose levels and prevent insulin resistance.

“Compressing the same amount of calories into a shorter period of time seems to have metabolic benefits. So the idea of just calorie in, calorie out. There’s a lot more to it. And that really comes down to hormones and insulin. We know that when you eat carbohydrates or when you get a glucose spike in the blood, the body releases this hormone insulin from the pancreas, which helps your cells actually take up the glucose for processing and use. When that insulin gets stimulated over and over and over again, like in a person eating a high refined carbohydrate, high refined sugar diet, the cells get a little bit numb to this insulin signal. And they’re like, Oh my gosh, there’s so much insulin around, there’s just too much, we’re going to become numb to it. And that’s called insulin resistance. And so the pancreas has to produce more insulin just to get the same amount of glucose into the cells. And then you start getting all this insulin floating around. And that can have a lot of problems with the body.”

18:34 – How fasting makes you metabolically flexible

When you are fasting, there is no glucose in your bloodstream. Your body stops producing insulin and starts burning stored fat. The more your body gets used to doing this every day, the more metabolically fit you become.

“By fasting or by restricting food to a shorter period of time, you can imagine how many hours of the day you’re able to let your body just take a break from producing that insulin and start working through your stored glucose and actually getting into some of that fat oxidation pathway later in the night and as you go on, you know, 12, 13, 14, 15 hours without eating. And what’s nice about that is that as you start working those fat oxidation pathways, you get better at it. And you become what’s called metabolically flexible, where you can balance between glucose burning for energy and fat burning for energy based on what substrates are available. And it’s not like your body’s just used to burning glucose. And so metabolically flexible is a place we want to be. And fasting by reducing the amount of carb exposure or glucose exposure and then insulin exposure allows you to kind of get into that state. And that in turn also increases insulin sensitivity, because if you’re not spiking your insulin so much, your cells all of a sudden they’re like, Oh, there hasn’t been much insulin around. We’re going to become a little bit more receptive to it next time it comes around. And you build that insulin sensitivity and all of that together is essentially you could package with the term more metabolically healthy. So, that’s one of the reasons why even low grade, time-restricted feeding, eating in a six to eight-hour window throughout the day and fasting, you know, for 16 hours or so can be hugely beneficial to health.”

21:38 – The science behind glucose spikes

Healthy individuals are what’s called insulin-sensitive, and have short, narrow spikes from glucose as the body quickly soaks it up. This is called AUC: area under the curve.

“This is an important sort of nuanced point, which is, you can imagine as you eat something and glucose gets released into your bloodstream, your curve is going to go up, you’re going to get a spike, and then it’s going to come down. The time it takes to come down is a big function of your insulin sensitivity. So if you’re very sensitive to insulin, your body’s going to quickly soak up that glucose and it’s going to look like a sharp, narrow peak. If you’re not insulin sensitive, it’s likely that that peak is going to be sustained because you’re having more trouble soaking that glucose up into yourself. So you can imagine like a wide plateau mountain versus like a super tight stalagmite peak. And so that could be quite, quite different as you become more insulin sensitive. You’re going to have that more narrow peak. And there’s a term for this in the medical literature, which is called the area under the curve: AUC, a smaller area under the curve, because it’s an up and down pretty quick. It’s better at a big area under the curve cause you’re going up and you’re staying up and you’re coming down slowly and staying elevated for longer is bad. So getting that AUC tightened up is super important and that you’re definitely going to see as you become more insulin sensitive.”

26:27 – Impact of micro-nutrients in metabolic health

The enzymes we need to break down glucose need micronutrients. They are just as important as sleep, diet, and exercise. How they affect metabolic health is the next frontier.

“That process of converting glucose to energy we can actually use takes so many different enzymes and has so many different byproducts in it. And each of those enzymes requires these micronutrients. Some of the ones I’ve mentioned before, like iron and B vitamins, manganese, and magnesium. And so I use the test basically to really zero in on the micronutrient aspect of metabolic health. And this is one that I think is not talked about enough. We think a lot about food in relation to metabolic health. Some people think about sleep, exercise, and stress. We certainly think about genetics and epigenetics. We think about how medications and infections can affect metabolic health. We know that certain medications hurt metabolic health, and we know that infections can raise blood sugar, but very few people are talking about how micronutrients impact our overall metabolic health. And I think it’s the next frontier, but it’s so nuanced and it’s so personal that it’s hard to talk about. It’s hard to build health programs around it. It’s hard to build digital products around it.”

34:46 – Plant-based diets also need monitoring

Modern plants have often been genetically modified to be calorie-dense, less nutritious, and laden with chemicals. This means even individuals on a plant-based diet can’t eat whatever they want without consequences.

“I’m not just out there saying all plants are perfect to eat in any quantity. I don’t believe that. I believe that some plant-based diets can have really undue collateral damage if you’re not thinking about glucose and metabolic health. So even in a whole foods plant-based diet, with no refined sugar and no refined grains, you can still get yourself into trouble if you’re eating all starchy vegetables and fruits that super spike your glucose. And unfortunately, there’s a lot of landmines in nutrition right now, because of the way that food has been raised and developed throughout time. We’re now seeing these giant pieces of fruit that probably have three to four times more fructose than they did 100 years ago. We’re also seeing foods that are less nutrient-dense because of the way we’ve eroded a lot of our soil and utilize pesticides for decades. Foods aren’t the same as they used to be. So we need a little bit more power and information to actually assess foods properly. And that’s where things like continuous glucose monitoring and things like checking your levels with Nutrobal can be really, really helpful so that you actually have some power to know whether the plant-based diet you’re eating is doing what you want it to be doing.”

Host: [00:00:00] The contents of the lab report are meant for educational purposes only, and are not meant to be misconstrued as a medical diagnosis or treatment advice. Today on the Lab Report, the second half of our Casey Means interview.

Dr. Casey Means: [00:00:13] Oh yeah, we’re getting into wearable devices and continuous glucose monitoring.

Host: [00:00:16] It’s like bio-feedback for your sugars.

The world of medicine can be challenging. Clinicians and patients are always looking for more options, more effective treatments, and in the end, more answers. Functional and integrative medicine focuses on addressing root causes of disease. Here at Genova Diagnostics, we’ve watched this field evolve and grow for over 35 years. We’ve not only adapted, we’ve led. Join us as we talk about functional medicine, laboratory testing, and optimizing health. Welcome to The Lab Report.

Bio-feedback for your sugars.

That’s right. That’s right.

That’s a good one Michael.

Thanks, I’m like a slogan generator.

You’re really good at it.

Thank you. Hello!

Hey Michael Chapman.

Hello  Patty deVores. How are you?

I’m doing great today. Thank you. I hope you all are too. And welcome to the Lab Report

Welcome everyone to this podcast, sincerely. Where are we talking about things like functional medicine, specialty lab testing, integrative therapeutics, and it’s brought to you by Genova Diagnostic.

All of those things. And  if you’d like to, you can subscribe to our podcasts, iTunes, Spotify. You leave us some feedback, some stars, leave a review.

If you’d like to. Or, because we’re telling you to.

Wow! Bossy pants.

I’m giving an option, I’m saying, or they’d like to.

That’s nice of you.

Just saying. And if you have feedback, like maybe on what I just said, then you can write that feedback, you can type it to [email protected] and we’ll look through it, we’ll examine it, maybe get back to, no, we’ll probably always get back.

We’ll always get back to you.

Yeah, we do that. Yeah.

Well, I’m excited because today is part 2 of our interview with Dr. Casey Means.

Truth.

Right. And if you remember from last episode, she’s kind of, like…

Amazing?

Really smart. Like she was a surgeon, a functional medicine doc, a biomedical researcher, and now she’s chief medical officer of Levels.

Yes. She’s definitely what you would consider a professionalist smarty pants.

That’s right.

And we love having these types of individuals on the program because you’re going to get so much insight, so much knowledge, and yeah, we just love it. And this is a great second half of the interview. You’re not going to want to miss it. So I think without further ado, without any more of us blathering on and on,

Let’s just get to it.

Let’s just finish the interview.

Go for it.

Switching gears a little bit and kind of getting into what you were just talking about with the continuous glucose monitoring. I mean, wearable devices are rapidly evolving and emerging as kind of their own place in optimizing health. And so, you’re the co-founder of the company Levels. How did you get involved with the tech side of healthcare?

Dr. Casey Means: [00:02:56] Yeah. Yeah. So that was actually, this is kind of the continuation of the story of my move from surgery to functional medicine. So I had left surgery, I’d started my longevity metabolic health focused, functional medicine practice. And what I realized kind of early on in my practice was, well first of all, it was so exciting! Cause I was spending 2 hours with each patient for the initial visits and doing tons of advanced lab testing, really getting to know people’s lives, history, lifestyles, full picture of their sort of, health blueprint. And create these plans for them that were very comprehensive. And many people just had incredible outcomes in just a few months and things I’d never, progress I’d never seen in my conventional practice. And it was because we really were understanding each other and there was so much communication and buy-in. And there was just, I think when you are able to cross that chasm and really understand the patient, to understand the doctor, and the doctor to understand a patient, you know, so much transformational activity can happen.

And so that was very exciting, but what I realized was that for people to improve, fundamentally they were having to change their behavior. They were having to change the daily activities in their life that they do, you know, all the thousands of micro decisions we make every day to ultimately create conditions in their bodies that would generate health. And so, what I mean by that is that, as we’re walking around every day, we’re making decisions about how we move, how active to be, how we’re going to respond to stressful events in our life. When we’re going to sleep and how we’re going to sleep, and then what we’re going to eat. Not only what we’re going to eat, but when we’re going to eat it, what we’re going to pair it with, what we’re going to do before and after meals. So, I think the 4 main things are sleep, stress, exercise, and food. And between those 4 things, we make so many decisions every day. And the patients who did well were the patients who took my thoughts and my advice to heart and made meaningful changes in those aspects of their lives. And you just saw that their health just transform.

And so it became clear to me that fundamentally, behavior change is required for people to have meaningful, sustainable improvements in their health. Because behaviors translate to molecular conditions in the body, through hormones, through our nervous systems, through micronutrients. And so, I was like, “Okay, well, this is interesting.”, because I am having a lot of patients who are really successful, but some patients who are having more trouble making these changes. And I can’t be with my patients 24 hours a day, I cannot be a little birdie on their shoulders saying, “Yes, do this. Don’t do that. Oh, that’s a great decision. Oh, pair this with that food.”, you know, it’ll be better for your blood sugar. You can’t do that. I don’t think anyone can do that, there’s certainly a coaching is becoming a big part of medicine now, which I think is wonderful, but fundamentally a human – there’s two issues. One, it’s hard for a human brain to process all those inputs. How is a human really supposed to, first of all, you’re not there with your patient 24 hours a day, but if someone’s blood sugar is a little bit high one day it’s hard for a human brain to say like – Oh, well that’s 10% cause they got less sleep last night. 20% because of what they ate, you know, 15% cause they didn’t work out, they only worked out for 20 minutes yesterday. It’s hard to parse out and weigh the different drivers of the outcome. And this is where digital tools can actually step in and be really, really, really helpful. So one is that it’s hard cognitively and two is that humans are fundamentally unscalable.

We have a massive chronic health disease, health epidemic in our country. It is estimated that 88% of Americans are metabolically unhealthy. This is from a UNC study that came out 2 years ago that looked at lipids, blood sugar, and waist circumference. And basically said, if people meet any of these criteria for what we call metabolically unhealthy, they you know, get that label. And it was 88% of the people they studied. So these are monumental rates. 74% of Americans are overweight or obese. We have 128 million Americans who are diabetic or pre-diabetic, it’s just, it’s astronomical and coaches and humans don’t scale. So I started thinking – how can we create digital tools? I mean, our phones are with us all the time. And so how can we use and leverage this technology to help with the sustainable personalized behavior change that will ultimately create conditions in the body that are functional and that generate health? And that is how I started moving a little bit from functional medicine into supporting health tech companies who were thinking about this and trying to create really smart, intelligent software to support patients in that journey.

And that’s how I got started with Levels and really devoting a lot of time to digital health.

Host: [00:07:51] I love it. Well, let’s talk about this Levels, this company that you co-founded Levels. It’s being touted by some pretty big names in healthcare and in the ketogenic research industry. People like Dr. Dom D’Agostino and Drew Manning, just to name a few. So talk to us about the company Levels and how this is different. And in general, just the benefits of continuous glucose monitoring.

Dr. Casey Means: [00:08:12] Yes, absolutely. So Levels is the metabolic fitness company. So, we are laser focused on improving metabolic fitness and metabolic health at scale. Knowing that metabolic dysfunction and insulin resistance and glucose irregularity is at the root of so many of the symptoms and the chronic conditions that we are seeing today. And really, at its core, this is the first product that is available that closes the loop in real time on how what your nutrition and dietary choices, how they’re affecting your health. We have really never had something that has been able to say to you, “Oh, hey, Casey, that food was not good for you, that food caused a problem for you.”. And so, ultimately, this kind of answers the question, like what should I have for lunch? The way we do this is we take a piece of technology called a continuous glucose monitor, which is a wearable device. It’s like the size of a quarter and you stick it on the back of your arm. And it is tracking your glucose levels 24 hours a day, taking a reading every 15 minutes and sending that to your phone. And so this is a internal biomarker that is constantly going up and down the body. And it’s foundational to metabolic health and to overall health that we can actually track.

And the reason this hasn’t really become mainstream before is because this is a tool that’s been traditionally used for the management of  type one and type 2 diabetes only. So they’re FDA approved and they have been for over a decade, to help diabetic individuals have much more granularity into their blood sugar levels. But what we know is that these conditions have metabolic dysfunction. Like type 2 diabetes, these are conditions, basically, that have, you know, we don’t really think about glucose until we get a diagnosis like that. But really the train has been going down that road for likely years, if not decades.

Host: [00:10:13] Right.

Dr. Casey Means: [00:10:13] And most cases of type 2 diabetes and most cases of obesity too, you know, overt signs of metabolic dysfunction, are preventable. And so how can we leverage this technology and use it as a bio-feedback tool, much, much earlier? To let people just get their glucose levels flat and stable, learn how to rapidly personalize a diet so they know exactly how different foods are affecting their glucose. And essentially, allow people to know what foods are right for their body from a metabolic perspective. And in doing so, you know, liberate them from ever having to walk into the doctor’s office and get a surprise about their metabolic health. You know, you don’t want to walk in one year and they say, “Oh, you’re diabetic.”. How neat would it be if everyone just really knew exactly where they stood on the spectrum of metabolic function or dysfunction? And was constantly able to modulate and just really have ownership over that data and know how to craft a lifestyle and a set of dietary choices that kept things really in the green zone. And in doing so just made their current daily life so much better, but also, you know, potentially prevent a lot of these chronic metabolic diseases. So that’s what we’re solving for. We’re pairing continuous glucose monitors, making them mainstream for the health seeking population. And pairing it with really intelligent software to help people make, understand the data stream and make these personalized decisions for their metabolic health.

Host: [00:11:41] Yeah. And it makes a lot of sense, you know, you’re talking about not just using this in diabetic patients, but using it and in almost all of your patients, given the statistics that you just rattled out about how frequent metabolic dysfunction is. So let’s just get into it just a little bit more too like, how does a continuous glucose monitor change with respect to things like exercise? Or with respect to, maybe somebody’s hormonal fluctuations or menstrual cycle, things like that? Like, what are some of the details that people need to be aware of?

Dr. Casey Means: [00:12:13] Yeah, absolutely. Well, I think the core thing that people need to be aware of is that everyone is going to respond to food and lifestyle choices differently in terms of their glucose levels. So, something I like to say is that – a carbohydrate in the mouth is not glucose in the blood. There is a lot that goes on between those 2 things that is highly, highly personal. So, you know, the 3 of us could all eat a banana and have vastly different glucose responses. And what that means is that for 1 of us, with the low glucose response, it’s probably a fine choice for us. Our body can handle it, it can process it in a way that it’s not causing a glucose spike. But for the person in the group who has a very, very high glucose spike to a banana, it’s probably something they want to avoid because those glucose spikes are harmful to health. I think that’s the first thing to know, is that this concept of a glycaemic index that we’ve kind of been told about for years. Which is that saying like, okay, if everyone eats a piece of white bread, it’s going to have this glucose response. That’s probably not accurate. And it’s been more recent research that was out of the Weissman Institute in Israel, 5 years ago, there was a paper that was published called Personalized Nutrition by Prediction of Glycaemic Responses. That did just that experiment I sort of described, of everyone eating the same food and then seeing what the glucose responses were. And they saw that it was just all over the board. So we really need a more nuanced, personalized approach to keeping our glucose levels stable. And then, the other factor you mentioned, you know, hormones and exercise. There are so many other factors that change what our glucose reading is going to be. And the really big ones are physical activity and exercise, our stress level and how we respond to stress, and then the quality and quantity of our sleep. Those are some of the biggest behavioral factors and hormones certainly come into that as well for women. We know that glucose fluctuates differently in the follicular versus the luteal phase. So those are also things to keep in mind. But I think a lot of people might fear hearing about a product that like, “Oh, it’s just going to tell me that I can’t eat all of my favorite foods.” .You know, like, all this is just going to tell me that I can’t have a cookie and I can’t have a banana, and that sucks. I don’t want that. But it’s actually, I would say, it’s so different than that. It’s actually very liberating in the sense that it helps you build metabolic awareness and a metabolic toolbox of basically how you can utilize all these levers to create a context in the body that processes carbs really effectively.

So you might be someone who is able to take a 20 to 30 minute walk after your meals and that totally blunts your glucose response. Or you might see that sleeping 7 1/2 hours versus 6 1/2of sleep lets your glucose levels be much more stable the next day. Or that doing 10 diaphragmatic deep breaths before a stressful phone call or before a meal might actually blunt your glucose response. All of those things have very real molecular underpinnings and so you  can kind of build this context for what you’re eating so that your body processes it better. So I’ll pause there, but…

Host: [00:15:29] Yeah, that’s super interesting as well. You know 1 other thing that I think about and the answer is probably going back to everyone’s’ a little bit different, but fasting is really, really common these days, intermittent fasting is gaining more and more traction. Have you noticed anything either in the literature or in your experience, how the CGM reacts to people who are in intermittent fasting?

Dr. Casey Means: [00:15:51] Yeah, absolutely. There is pretty amazing data showing that all types of fasting can be really beneficial for metabolic health. And it’s really across the board. It’s from time restricted feeding, where people are just eating in a more narrow window throughout the day and then having a little bit more time at night where they’re not eating, to more extended fast. Like 3 and 5 day fast. So, on the less extreme version, which is just eat in a shorter window during the day, and then don’t eat for, you know, a longer period during the day, there’s really cool research there. There was one study that took a bunch of people and they had them eat between, all their calories, between 8:00 AM and 2:00 PM. And then they took a different group and they had them eat the exact same amount of calories, the same food, between 8:00 AM and 8:00 PM. So one was eating between 8:00 AM and 2:00 PM, and one was 8:00 AM to 8:00 PM. So it was just spreading out the calories over a longer period of time. And what they found was that the group that eight between 8:00 AM and 2:00 PM had lower 24 hour glucose levels, lower insulin levels, they just were metabolically healthier. So compressing the same amount of calories into a shorter period of time seems to have metabolic benefits. So the idea of just calorie in calorie out, there’s a lot more to it, and that really comes down to hormones and insulin. And we know that when you eat carbohydrates or when you get a glucose spike in the blood, the body releases this hormone insulin from the pancreas which helps your cells actually take up the glucose for processing and use. And when that insulin gets stimulated over and over and over again, like in a person eating a, maybe a high refined carbohydrate, high refined sugar diet, the cells get a little bit numb to this insulin signal. And they’re like, “Oh my gosh, there’s so much insulin around.”, we need to like, there’s just too much, we’re going to become numb to it, and that’s called insulin resistance. And so the pancreas has to produce more insulin just to get the same amount of glucose into the cells. And then you start getting all this insulin floating around and that can have a lot of problems to the body. The first being, that it tells the body not to burn fat, it’s essentially a signal to the body “There’s tons of glucose around so we don’t need energy from other sources like fat.”. So it’s a big break on fat burning and fat oxidation. So insulin blocks fat burning and I think this is a big reason why we’re seeing such an overweight and obesity crisis in our country. Because we are a culture that is constantly spiking our glucose to the foods we eat, we’re constantly spiking our insulin. And we’re not giving our bodies the chance to just have a low insulin state where we have to tap into our fat stores. It’s just not happening! And so by fasting or by restricting food to a shorter period of time, you can imagine how many hours of the day you’re able to let your body just take a break from producing that insulin and start working through your stored glucose and actually getting into some of that fat oxidation pathway later in the night. And as you go on, you know, 12, 13, 14, 15 hours without eating. And what’s nice about that is that as you start working those fat oxidation pathways, you get better at it. And you become what’s called metabolically flexible, where you can balance between glucose burning for energy and fat burning for energy based on what substrates are available and it’s not like your body’s just used to burning glucose. And so metabolically flexible is a place we want to be and fasting by reducing the amount of glucose exposure, and then insulin exposure, allows you to get into that state. And in turn also increases insulin sensitivity. Because if you’re not spiking your insulin so much, your cells all of a sudden they’re like, oh, there hasn’t been much insulin around, we’re going to become a little bit more receptive to it next time it comes around. And you build that insulin sensitivity and all of that together is essentially, you could package with the term “more metabolically healthy. “. So, that’s kind of 1 of the reasons why even low grade time-restricted feeding, eating in a 6 to 8 hour window throughout the day and fasting for 16 hours or so can be hugely beneficial to health.

Host: [00:20:07] And have you seen that there’s a blended glucose response with the CGMs during that time? Or maybe after a period of time of did the behavior change incorporating fasting?

Dr. Casey Means: [00:20:18] Yeah. You know, over time, what I would expect to see from most people, is that, if you’re doing this for months in a row and really building that metabolic flexibility and that insulin sensitivity, that over time, yeah, you’re probably going to see your fasting glucose and your average glucose start to come down. As you become more insulin sensitive and more metabolically healthy, by keeping these glucose and insulin spikes down by doing a fasting regimen, your body is naturally going to be able to manage its glucose at baseline a little bit better. So that’s 1 thing. And then, in terms of the actual glucose spikes, that’s a great question. I don’t have a clear answer on that, if you’re intermittent fasting and you eat the exact same amount of carbs. Let’s say you, after 2 months of fasting, you eat the same meal that you had in the beginning of the fasting experiment, would you have a lower spike? I’m not a 100% sure about the answer to that. I think the overall 24 hour glucose levels are certainly going to be lower, but whether the actual spike is going to be lower is hard to know. I would say, I think that the spike will be shorter in duration. So this is an important sort of nuanced point, which is, you can imagine as you eat something and glucose gets released into your bloodstream your curve is going to go up, you’re going to get a spike and then it’s going to come down. And the time it takes to come down is a big function of your insulin sensitivity. So if you’re very sensitive to insulin your body’s going to quickly soak up that glucose and it’s going to look like a sharp, narrow peak. If you’re not insulin sensitive it’s likely that that peak is going to be sustained, because you’re having more trouble soaking that glucose up into your cells. So you can imagine a wide, more plateau mountain versus a super tight, stalagmite peak. And so that, I imagine, could be quite different. As you become more insulin sensitive you’re going to have that more narrow peak. And there’s a term for this in the medical literature, which is called the “area under the curve”, AUC. A smaller area under the curve, cause it’s an up and down, pretty quick is better, and a big area under the curve, cause you’re going up and you’re staying up and you’re coming down slowly and staying elevated for longer, is bad. So getting that AUC tightened up is super important and that you’re definitely going to see as you become more insulin sensitive. So just, kind of getting into the weeds there, but it’s kind of interesting.

Host: [00:22:59] Yeah, that’s great.

And It’s good to know that terminology because I think we’re going to see it show up more and more as the biomarker to be looking at with CGM. So I appreciate that.

I agree with that. And even just this variability of these levels of glucose, to watch it in real time and to have some empowerment around what you’re doing metabolically is important, because a lot of this gets missed in something like a hemoglobin A1C, which averages over 90 days. So this is important information. And I also want to turn this a little bit to how you use continuous glucose monitoring as it relates to testing. And we know that you use a lot of Genova’s tests. We’re so thankful for that and we love that, but how do you pair these things together?

Dr. Casey Means: [00:23:39] Yes, absolutely. So, I think for people who maybe aren’t familiar with NutrEval listening to the podcast, I will give a brief overview. And you guys will probably be able to give a better overview, but –  it’s a urine and blood test that really gives an incredible overview of nutritional needs and micronutrient needs. And it is not something, so ultimately, the readout is going to say you probably need more antioxidants, like vitamins, A, C, and E. And alpha-lipoic acid, coenzyme Q10, or you may need more or less B vitamins. And then looking at B1, B2, B3, B6, B7, B9, B12 it’s going to say you may need more or less on the minerals. Tell you about essential fatty acids like Omega3s and Omega6s, tell you about your amino acid protein levels. So it’s this very, very comprehensive readout of nutritional status. But what’s interesting about it is it’s not actually looking at the levels of those things in the blood or the urine. It’s looking at different byproducts of metabolism and cellular processes in the body. And knowing that for everything to happen in the body, basically things are being converted to other things all the time. And those conversions are happening through chemical reactions that are based on enzymes. And those enzymes require these micronutrients, like the ones I just listed, to function. So if A turns to B because of enzyme X, and enzyme X is using all these co-factors, and A is really high, it means it’s not converting to B well. Then we can assume that maybe we’re missing those co-factors for enzyme X and we need more of them so that A can be converted to B. So it’s a functional test, basically saying, “These enzymes are probably not working optimally.” and we probably need more micronutrient support to get these pathways working. And then looking at that for things all over the body and gives us really an incredible read out. So that’s sort of the way I look at the test, if you guys want to chime in at any point.

Host: [00:25:49] You’re hired Dr. Means. We’re going to hire you in medical affairs. That was a very good explanation.

Perfect.

Dr. Casey Means: [00:25:56] But one of the things I love about this test in particular, is that it looks super specifically at the citric acid cycle. Which is a processes happening inside the cell, inside the mitochondria, and basically how glucose is converted to cellular energy in our body. So glucose is this foundational unit of energy in the body, we get glucose in our bloodstream. But we actually need to convert it to something else to be able to use it as a currency that our cells can use to do the functions they need to do. And so, that process of converting glucose to energy we can actually use, takes so many different enzymes and has so many different byproducts in it. And each of those enzymes require these micronutrients. Some of the ones I’ve mentioned before, like iron, and B vitamins, manganese, magnesium. And so I use the test, basically to really zero in on the micronutrient aspect of metabolic health.

And this is one that I think is not talked about enough. We think a lot about food in relation to metabolic health. We think about, some people think about sleep, exercise, and stress. We certainly think about genetics and epigenetics, we think about how medications and infections can affect metabolic health. We know that certain medications hurt metabolic health, and we know that infections can raise blood sugar. But very few people are talking about how micronutrients impact our overall metabolic health. And I think it’s kind of the next frontier, but it’s so nuanced and it’s so personal that it’s hard to talk about. It’s hard to build health programs around it, it’s hard to build digital products around it. But what I love about the NutrEval is that it really zeroes in on that aspect. Because someone could be eating a great diet, low carb, exercising, but if they’re vastly deficient in magnesium or their B vitamins, it’s just not going to work well, and so we’ve got to zero in on that. So, my dream, one day is to see a NutrEval that can be done iteratively, every few weeks, to be used more as a dietary bio-feedback tool. So anyways, that’s my plug for that. But something I think a lot about is how lab tests can be used for actual behavior change. The thing I like about CGM is it’s sort of this lab test that you’re doing every 15 minutes. And therefore it’s closing the loop on your behaviors and the outcomes, and therefore it can become a behavior change tool.

So that’s where I want to see things moving more with testing, is how can we really see the direct actions of what we’re doing and how it’s affecting these things. But it’s been profound for many of my patients, in terms of helping them select the right foods to maximize their micronutrients or metabolic health. So that’s one I use quite a bit.

Host: [00:28:48] That’s awesome. Yeah, it really makes the point too. We talk a lot on,  in our consults, and on this podcast as well, about the importance of these micronutrient co-factors, and as you mentioned, you’re talking specifically about the mitochondria, which are your energy factories of your cells. And so if you are not, if those enzymes, if those pathways aren’t operating very well, then it’s very common for there to be some issues around ATP production and energy production overall.

Dr. Casey Means: [00:29:15] Exactly. Yeah, it’s like each of these things are necessary, but not sufficient for overall metabolic function. And so you have to be thinking about it, I think, holistically, to get the maximum positive outcomes. And for each patient I’m thinking about, you know, the diet, the sleep, the stress, the exercise, and the micronutrients. And that’s where NurtEval really shines.

Host: [00:29:42] Do you do any stool testing? Do you use any stool tests?

Dr. Casey Means: [00:29:46] I do. I was going to say, I do do stool testing, which would have been an unintentional pun, but I use the GI Effects 3-day stool testing. And that is also a Genova product. And I find that valuable, mostly to give a landscape of whether people are doing really well with metabolic health or not doing, I’m sorry, with their microbiome health or not doing super well. Like, how much we really need to focus on this. So for those listening,  microbiome is an incredibly important factor of our metabolic health. And one interesting factoid on that study that I mentioned out of Israel, out of the Weizmann Institute, Personalized Nutrition by Prediction of Glycaemic Responses, when they looked at all those individuals who are wearing CGMs and eating standardized meals and people were having vastly different glucose responses to the same carbohydrate load. They actually found out what were some of the deterministic factors of how people would respond to food. And one of the key statistically significant factors was their microbiome composition. Which is fascinating! They’re basically eating our food first and determining what we get. And there’s been other research showing that the bacteroides and firmicutes ratio is very important in terms of whether people are likely to be metabolically healthy or obese or lean. We want more bacteroidetes to firmicutes in that ratio. We know that byproducts of microbiome activity, like short chain fatty acids, they’ll eat the fiber that we eat and then produce short chain fatty acids, that these are molecules that go into our bloodstream and have metabolic impact. And you can actually transfer microbiome from a metabolically unhealthy mouse to a normal mouse and turn that mouse metabolically unhealthy just by transferring the microbiome. And so it’s just, there is a lot there. And so I do stool testing because it kind of gives me a big overview gestalt of whether this is an area that we really need to work on for maximizing metabolic outcomes. So, I’m often looking at the short chain fatty acid levels and seeing if we’re in the red on those. I’m looking to see if there’s significant dysbiosis, if the microbiome composition is sort of skewed in one direction or the other. I’m also just looking to see if there’s gut inflammation and whether it seems like there may be leaky gut or some sort of overgrowth. Because you gotta get those things cleaned up if you want things to be working properly. And so it’s been helpful I would say, for sure.

Host: [00:32:45] Yeah. I mean, that’s a ton of information on those tests for sure. And a ton of information that you have provided for us today. I wanted to talk a little bit about your social media. You built a community around plant-based eating. Tell us about Dr. Casey’s Kitchen.

Dr. Casey Means: [00:33:01] So yeah, Dr. Casey’s Kitchen really arose out of my totally nerdy, dorky love for the science of food. And getting back to that concept of food as molecular information, I really wanted to reframe eating and food for people in a way that made it this really fun, sort of bio-hacky, empowering experience, and thinking about how we have so much more agency over our health than we think. And we just kind of have to know the science and know the details and make it fun. And so, I wanted it to be a mix of really innovative plant-based cooking that was all through the lens of what the science has to say. So I’ll talk a little bit about, like, I did a post on a, I think it was like a blueberry pie that I made. That of course was like, sugar-free, grain-free, really healthy “pie”.

Host: [00:33:54] I saw it, I saw it.

Dr. Casey Means: [00:33:57] Yeah, so I was like, “Okay, let’s do a lesson on anthocyanin,”,which is like avery specific antioxidant that is associated with the purple color of foods like blueberries. And let’s go through some of the literature of what the molecular biology of anthocyanin is, and what are the studies that show that it has an impact on health outcomes. And kind of educate people on that. And the other fun thing I love to do is just show people how much you can do with plants. I would say the bulk of what I eat is fruits, vegetables, nuts, seeds, legumes and beans, and spices. So I’m really not eating much, I would say I’m a molecularly  focused, plant-based person who’s obsessed with metabolic health. So what that means is that I’m not just eating, like I’m not just out there saying all plants are perfect to eat in any quantity. I don’t believe that. I believe that some plant-based diets can have really undo, have collateral damage if you’re not thinking about glucose and metabolic health. And so even in a whole foods plant-based diet, so no refined sugar and no refined grains, you can still, I think, get yourself into trouble. If you’re eating kind of all starchy vegetables and fruits that super spike your glucose. And unfortunately, there’s a lot of landmines in nutrition right now, because the way that food has been raised and developed throughout time, we’re now seeing these giant pieces of fruit that probably have, you know, 3 to 4 times more fructose than they did a 100 years ago.

We’re also seeing foods that are less nutrient dense because of the way we’ve eroded a lot of our soil and utilized pesticides for decades. And so foods aren’t the same as they used to be so we need a little bit more power and information to actually assess foods properly. And that’s where I think things like continuous glucose monitoring and things like checking your levels with NutrEval can be really, really helpful so that you actually have some power to know whether the plant-based diet you’re eating is doing what you want it to be doing. And so it’s very much an Instagram account that’s focused on a nuanced biochemistry based approach to plant-based eating. And making sure that there’s not collateral damage associated with that eating pattern. And also how much opportunity there is to eat just beautiful, incredible meals that are so diverse and amazing with a pretty simple array of building blocks that you’re working off of. So one of my favorite things to do and that people like a lot is like how I use nuts and seeds in a variety of different ways. I can make, certainly nut milks, and out of nuts and seeds, I’ll use really strange combinations of nuts and seeds. Like I’ll make flax, pumpkin seed milk, which I’m doing that because pumpkin seeds have tons of magnesium and flax of course has Omega3. And so if I want to make, if I really want to optimize my magnesium and my Omega3s, I’ll make a unique milk like that. If I want to more optimize my selenium or get some selenium compounds, I’ll do Sesame seeds and Brazil nuts to make my milk. And I’ll show that process and why I think about it that way. And then I make all sorts of like creamy salad dressings, mayo like substances, I’ll do cheeses. All these things that can just be made by taking nuts and seeds and mixing them with other interesting things like lemon juice or lime or tamari or spices. And it’s just, there’s so much you can do with a Vitamix and herbs and nuts and seeds. So the sky’s the limit.

Host: [00:37:34] That’s awesome.

We love it. So we follow you there and we’re going to encourage everyone to follow you at Dr. Casey’s Kitchen or your website Caseymeansmd.com. But before we end this. We have one last question.

Yeah, I have one question and this is a question that’s a little bit of a tangent, but it’s sometimes good play this game a little bit. But it’s called the Fireball. And the fireball question that I have is, do you have a favorite vegetable? And if so, why?

Which is your favorite child, in essence?

I know, I’m catching you off guard here.

Dr. Casey Means: [00:38:04] Oh my gosh. This is such a hard question.

Host: [00:38:06] I know.

It’s the Fireball.

Dr. Casey Means: [00:38:10] This is going to be the stumper question of the day – favorite vegetable. I would have to go with, I think I’d have to go with broccoli.

Host: [00:38:23] A classic.

Dr. Casey Means: [00:38:24] And the reason is, obviously cruciferous vegetable, nutronomic powerhouse. It’s one of the only vegetables that have been studied in clinical trials to reverse cancer progression. So really interesting to look up, prostate cancer and cruciferous vegetables, you’ll see a lot of papers showing that late stage prostate cancer has been slowed down and moved in the right direction with a food intervention. There have not been a lot of studies actually showing that food based interventions can halt or reverse cancer. So that’s really interesting. Dean Ornish talks about this quite a bit in his book “Undo It”. It’s also, I mean, you can do so much with broccoli, but one thing I love showing people is that you can make rice out of broccoli stems. So you just take broccoli stems and throw them in the food processor and pulse it a little bit and you end up getting this totally rice like consistency. And I’ll throw some curry powder and some chopped apricots in there and make like, a really nice curried rice and I’ve actually fooled people, not knowing that it was broccoli. And so I feel very proud about that. So it’s just a powerhouse from the health perspective and really versatile in terms of substituting grains.

Host: [00:39:41] That’s excellent.

I love it.

And most people just throw away the steps. Now you know what to do with the stems.

I know, I didn’t know you could do that. It’s great. But Dr. Means this has been a ridiculous amount of great information and we can’t thank you enough for coming on the show with us today.

It has been a tremendous honor and pleasure, so thank you.

Dr. Casey Means: [00:40:00] Thank you so much for having me and I really appreciate what you guys are doing at the podcast and at Genova and yeah, I’m a big supporter.

Host: [00:40:08] Awesome. Thank you. Have a great rest of the day.

Dr. Casey Means: [00:40:11] Thank you.

Host: [00:40:15] So after this interview I kind of want one of these continuous glucose monitors.

I do too. And it sounds like Levels is the place to get it. All the cool kids are wearing them.

For sure. And a few things if you’re out there listening and you’re interested in getting a CGM yourself, you can get one through Levels and, we’re actually providing a link in the show notes. Because there’s currently a waitlist, but the link in the show notes is going to allow you to bypass the waitlist.

Special link for the Lab Report listeners.

Yeah. So that’s really cool. You’ll go through a little bit of a screening process in order to get it, to get the prescription, and then you’ll be able to have the CGM delivered to your house. So, pretty exciting.

Check out that link.

Yeah, for sure. The other thing, broccoli. It seems to be running away with it.

Yeah, right! Are we keeping a tally here?

A lot of people, a lot of broccoli fans out there from a vegetable standpoint, but understandable. It’s a popular vegetable.

Understandable. It’s got a lot of research to that broccoli.

When you’re speaking to someone who’s plant-based in their diet and they say broccoli, it gives a little bit more gravitas I think.

I agree. Yeah. It’s sort of like they are familiar with all the ins and outs, all the nooks and crannies of the vegetable world, and they pick broccoli.

There it is.

Time and time again, really. It seems to be the case. Next time on the Lab Report I share my CGM results.

That will be fascinating.

No, I’m not going to do that. I’m never going to do that.

That actually might be fun.

You’ve been listening to the Lab Report. If you like what you hear, please subscribe to our podcast, rate us, and leave us a review. To learn more about Genova Diagnostics visit our website at gdx.net. There you’ll find information on specific testing, educational resources, and how to connect with our show.

Call us at +1 800-522-4762. Or email us at [email protected].

You know what’s really great?

What?

Water. It’s really great. I’m just saying.

Thanks for the endorsement.

We don’t talk about it hardly at all. Maybe we should do a whole episode on water because water is pretty important.

Okay.

It’s like breathing. We don’t, you know, we’ve actually probably talked more about breathing than we’ve talked about water.

It’s an interesting point, but I’m a little bit worried about you. You all right?

No.

Maybe you need some water.

Perhaps.