“The beauty of glucose is that there are tools, right now, that can measure our glucose levels in real-time... Unlike these other variables, we can actually see how this biomarker is changing based on choices that we made five minutes ago.”

Dr. Casey Means

Dr. Casey Means, MD is the Co-Founder and Chief Medical Officer at Levels, a metabolic health company that provides individuals “real-time continuous glucose biofeedback coupled with machine-learning driven insights to inform personalized diet and lifestyle choices.”

Glucose, unlike other biomarkers, provides us a closed biofeedback loop which if tracked helps us make better diet and lifestyle choices on the fly. Other biomarkers, such as genetics or cholesterol, do not provide that real-time information which means we cannot track changes around them based on our nutritional and lifestyle choices on a day-to-day basis.

“The beauty of glucose,” says Dr. Means, “is that there are tools, right now, that can measure our glucose levels in real-time, at home, with a wearable sensor. Unlike these other variables, we can actually see how this biomarker is changing based on choices that we made five minutes ago.”

For several years, glucose monitors have been available as a treatment tool for diabetes. What Levels has done is take this technology to the mass consumer market to be used as a precision nutrition tool.

Listen in as Dr. Means explains how Levels translates real-time insights around your blood glucose into actionable steps that you can use to improve your metabolic health today.

Follow Dr. Casey @drcaseyskitchen

Follow Levels @levels

Follow Chase @chase_chewning

Key Highlights

  • Why did Dr. Means decide to focus on metabolic health specifically in helping people improve their diet and lifestyle choices?

  • Why should someone who is not diabetic or prediabetic be concerned about monitoring their glucose?

  • What are the “reps” we need to put into improving our metabolic fitness?

  • What are the indicators of potential blood sugar problems?

Powerful Quotes by Dr. Casey Means

Our mission is to empower people with their personal health information to help them make better daily choices around diet and lifestyle so that they can live their best life right now and enhance performance every day, and ideally ward off chronic problems down the road related to diet and lifestyle.

We can use tools like continuous glucose monitors to actually see how different foods are affecting our glucose and make smarter choices about what foods we’re choosing or how we’re even pairing foods.

Cell biology is complex and it’s about more than just food. We also need to think about the other pillars which are how we sleep, how we stress, how we’re moving, the micronutrient composition of the food in our bodies, our microbiome health, and our exposure to pollutants. All of these things feed into how our metabolic processes work.


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Interview transcript:

Chase  

All right, Casey, what's going on? Welcome to Ever Forward Radio. Thank you so much for being here.

Dr. Casey  

Thank you so much for having me, Chase, I'm thrilled to be here.

Chase  

I got to say, I feel like I missed the red memo mark, for the microphone, you're blending your shirt, your microphone, I got to get like some kind of color coordinated cap for my equipment over here.

Dr. Casey  

Yeah, you need my microphone; it matches your shirt

Chase  

I used to have that actually, I still have I'm looking below my monitor, I used to have that Blue Yeti, all the microphones that I've had, I keep as kind of like little memorabilia around my office and even like my OG, little $65 microphone I used four years ago, completely the wrong way, don't work anymore, I have it plugged into my desk down here. It's just, it's cool to see it, you know how far you've come the little tools that you've used along the way to get better at your craft. And which I think is a great segue into, you know, what we're gonna be talking about today, we have so many great tools for our health and our wellness, nowadays, hardware software, to help us become more empowered about what's going on in our bodies in our minds, and to really take charge. And that's really what you and everybody at Levels is all about.

Dr. Casey  

That's exactly what we're doing. Our mission is to empower people with their personal health information so they can make better daily choices around diet and lifestyle so that they can live their best life right now. And you know, really enhance performance every day currently, but then also, ideally ward off, you know, chronic problems down the road related to diet and lifestyle, which the majority of our chronic illnesses these days are related to that. So we're all about empowering people with the information to make those choices.

Chase  

So when it comes to curating information, or putting together a team to go find the information, there are a lot of different avenues I'm sure you all could have done or gone down when it comes to, you know, genetics when it comes to cholesterol, blood sugar, when it comes to cholesterol, sodium all these things? Why was the focus on blood sugar and glucose? And you know, what it can do for or against us?

Dr. Casey  

Yeah, that's a great question. And the key answer this is that it'll glucose provides us a closed loop, biofeedback sort of circle. So with all the other things you mentioned, like genetics, or even cholesterol, these are things that we cannot get information about in real time and we can't see a change in that variable with our behavior on a day to day basis, it's more of, you know, either a lagging indicator for the case of cholesterol or for genetics, it's something that we're not going to see necessarily change over time. The genetic polymorphisms that show up on our 23andme test are not changing. Now, genetics can change in the sense that we can change gene expression over time with our choices. But that's not a readout that we really have a lot of availability. There's no consumer product that really does that right now, the beauty of glucose is that there are tools right now that can measure our glucose levels, in real time at home with a wearable sensor. This is what a continuous glucose monitor can do. And so unlike these other variables, we can actually see how this biomarker is changing based on choices that we made five minutes ago. Whether it's what we chose to have for breakfast, or whether we sort of allowed ourselves to get stressed in response to an email we read, or whether we got a poor night's sleep, or if we did a high intensity workout versus a walk, all of these things are actually going to have an immediate impact on our glucose levels. And there's a technology now that picks that up that creates a closed loop with nutrition and lifestyle choices. And the crazy thing about nutrition is, we have never had a closed loop system on nutrition. We have had closed loop for fitness with fitness trackers and heart rate trackers, we've had closed loop for sleep with sleep trackers. I love it. So you can wake up and see exactly what happened with your sleep. We even have closely for stress now with HRV trackers and heart rate variability. But we've never known there's never been a tool where you put something in your mouth and you know exactly what's happening in your body. And that's what glucose can do for us. And it's right now the only biomarker that can do that for us. So this technology, continuous glucose monitors, it's been available as a treatment tool for diabetes for several years. But what Levels does is bring this to a more mass consumer market to be used as a precision nutrition tool. So that we have a sense of what's going on with this key fundamental metabolic biomarker in our body.

Chase  

No, you mentioned there predominantly this type of hardware this type of information was for people who already excuse me had a concern had an issue, the diabetics and pre diabetics. Why should someone who is not diabetic why should someone who's not pre diabetic be concerned about monitoring their glucose?

Dr. Casey  

Yeah, well, the interesting thing about pre diabetes and diabetes is that the vast majority of these conditions of this, those conditions is preventable. So right now we have 128 million Americans in the United States with pre diabetes or diabetes. That's like a huge chunk of our population.

Chase  

A lot of people,

Dr. Casey  

It’s a lot of people, it's an epidemic

Chase  

It’s probably, you know, one or one or two of the people who are probably staring at right now.

Dr. Casey  

Absolutely. If you walk down the street, it's close to 40% of people have either pre diabetes or diabetes. And with pre diabetes, which is 84 million people in the United States, 90% of those people do not know that they have a blood sugar problem. The CDC data 90% don't know. And what's so interesting about it is like, even if you've reached that pre diabetic threshold by diagnostic criteria, or the diabetic threshold by diagnostic criteria, that doesn't mean that if you're not in the pre diabetic threshold, that, you know, everything's perfect, because this is a spectrum. This is a spectrum illness, where over time, we move towards these conditions and metabolic dysfunction, and insulin resistance over time, until, you know, one day we go into the doctor's office, and we finally sort of met that criteria for diagnostic threshold. But that, you know, it's we’re marching along this spectrum throughout our lives and there's good evidence to support that 13 to 17 years before we actually reach those diagnostic thresholds where we're showing signs of early problems with our metabolism. 

Chase  

Over a decade before we possibly get a diagnosis, we are exhibiting signs of something that we can get ahead of?

Dr. Casey  

That's right. Yeah, that's so it's specifically and we kind of have to get into a little bit of physiology to understand this. But disorders of glucose, like diabetes, or pre diabetes one of the ways that these develop is that over time, as we, you know, eat diets that are predominantly composed of refined carbohydrates, which are Western American diets are predominantly composed of refined carbohydrates, these are digested, they turn to glucose in the bloodstream, so does refined sugar, of course and when that sugar elevates in the bloodstream, our body has a hormonal response, it releases insulin from the pancreas. And that insulin helps you take that, that sugar out of the bloodstream into the cells so that glucose can be converted into energy. And when there's excess, it's either stored as stored chains of glucose called glycogen, or it's turned into fat. And when this happens, sort of too much when we are getting really high glucose elevations in the blood, or we're just doing it many, many times per day, like let's say, we eat three high carb meals, plus three snacks, that's six spikes of glucose in our bloodstream, that's a lot of insulin the body has to produce to sort of manage that insulin in the bloodstream. And over time, the body gets tired, and it's actually become numb to that signal of insulin. And we develop what's called insulin resistance. And what the body does to respond to insulin resistance, it still has to get that glucose out of the bloodstream. And so the body produces more insulin and it overcompensates and a young healthy body can do that you just push out more insulin, and force that glucose into the cells. So what we can actually pick up on lab tests a lot earlier, is that elevated insulin and that insulin resistance that hyperinsulinemia, which is in this sort of compensatory period, where your glucose levels may not actually look problematic, because your body's working hard on the insulin side to compensate for it. So there are studies that suggest that, yeah, 13 years in one study, we're seeing signs of insulin resistance and elevated insulin before the actual diagnostic sort of test shows that there's a glucose problem. And you can imagine, over time, the body kind of just gets more and more tired, the insulin resistance gets worse and worse and then you start to see that glucose variability show up quite a bit more. So long winded way of saying that part of the reason the average person on the street should care about their glucose is because we're all on the metabolic sort of spectrum and we want to stay in that, you know, healthy insulin sensitive part of the spectrum for as long as we possibly can. And part of doing that is making sure that we're keeping our glucose levels stable throughout our lifetime. We're not getting exposure to these, you know, really high peaks and or really frequent peaks and kind of creating more rolling hills and our glucose levels in our blood with our diet. And we can use tools like continuous glucose monitors, to actually see how different foods are affecting our glucose and make smarter choices about what food foods we're choosing, or how we're even pairing foods. You know, when you add protein, fat or fiber to a carbohydrate, it tends to blunt the glucose response. When you walk after a meal it tends to blunt the glucose response. If you add vinegar or cinnamon to a meal, it tends to blunt the glucose response. There's innumerable strategies for minimizing the glycemic impact on our body and over time that can keep our bodies sharp to that signal of insulin. So that's sort of like the long term chronic disease part of things. But then there's also just like the current performance side of things, when our glucose, even if we're young and healthy, and our pancreas is working well, if it's going up, down, up, down, up, down, like peaks and valleys, valleys, that's going to have an experience of our, it's going to have an impact on our subjective experience of the day. When we go way up, like let's say, we have five cookies, and our glucose shoots up through the roof, the body is going to soak up, it's going to produce all this insulin and soak up all that glucose, and we may actually have a crash, a glucose crash, and that's sort of like that post meal slump that many of us have had before. And that can be a

Chase  

Food coma. 

Dr. Casey  

The food coma. And that can be associated with a little bit of jitters, anxiety, you know, some mood instability, maybe a little brain fog. So I like to say that a lot of variability in our glucose, even when we're otherwise healthy leads to variability in our day, whether it's mental sharpness, athletic performance, fatigue, or mood. So it's both; it's really sort of at the at the nexus of our current reality and our current performance. And then, of course, our long term disease risk.

Chase  

Insulin resistance, those, those are two words that I used to hear a lot when I was working in clinic, the doctor would come in, you know, the patient be ready to come see the health coach after they just had their physical labs. And the doctor would always say, oh, exhibiting signs of insulin resistance. And it was always my interpretation was that patient seems the person seems to be doing everything right. Air quote here, right. But they're having just that little bit of, you know, that that that little bit of that tummy, it's like that abdominal fat that just they just can't seem to get going away. And maybe the doctor would see some kind of numbers that look questionable, you know, over the months or years in terms of blood sugar, is insulin resistance is that is that the telltale sign that maybe we have that? Is that what's going on? Is that that that last few pounds that we just can't seem to get rid of that is that we're just likes to live? And could that be an initial sign?

Dr. Casey  

Yeah, it definitely can be associated with that. So the interesting thing about insulin as a hormone is that not only does it help us shuttle the glucose out of the bloodstream into our cells so that's a purpose of insulin it by instance, and receptors helps you move that glucose into the cells. But one of its other roles is that it's a blocker on fat oxidation. So it stops you from being able to burn fat for fuel. And glucose and fat are two main sources of energy in the body and you know, we only have about two to three hours worth of like stored glucose in the body if we're working out, you know more if we're just kind of at rest, and so the body is going to kind of use that first. And only when you run out of that, and insulin is in a low state, do you start flipping the switch to burn fat, and that's obviously going to be important for weight loss to be able to actually tap into fat burning. But for the average American who's eating multiple meals a day, lots of snacks, a high refined carbon sugar diet, it's very possible that we're never getting to a state we're in during the day where our insulin really comes down to baseline really, you know, is low and allows us to take that break off of fat burning. And this is why I think so many people are interested in like ketogenic diets for weight loss, but also fasting for weight loss, because both of those strategies keep the glucose exhausted as glucose from the diet, sort of lower the Keto diet through a low carb diet, fasting through just not eating at all. Those are times essentially or your insulin is low, and you're taking that break off fat burning, you can actually flip that metabolic switch from glucose burning to fat burning. And so yes, so people, who, you know, are dealing with that abdominal fat what's interesting about insulin is it preferentially stores your fat around your middle, it preferentially stores what we call visceral adiposity, which is the fat.

Chase  

Lucky for us, right?

Dr. Casey  

Lucky for us, yeah. But you know, you see a lot of people walking around with like, maybe relatively lean appendages, but like really a huge belly. And that's sort of a telltale sign of insulin resistance where that insulin is elevated; we're on that spectrum moving towards a problem. And that insulin is basically stopping us from being able to burn through that fat, but also telling the body to store any excess glucose as visceral fat around our organs and in our belly.

Chase  

When is the best time, the best place in that spectrum to actually take action? Because I can imagine someone who is maybe going to the doctor and the last two years or last five years, the doctors is your sugar's look a little high, but don't worry about it. It's nothing. You know, you're not pre diabetic, you're not diabetic, like, when is when should we actually step in and take note of, hey, there's something going on internally that I need to get ahead of, and how much time really do we have to get to it later, so to speak?

Dr. Casey  

Well, the beautiful thing about metabolic health and really the body in general is that so often, things are reversible, and we can move in the right direction. It's not a one way street with health. And so in so many ways, and there are certainly exceptions to that rule but with blood sugar and insulin sensitivity there, it's very much a two way street. I like to use the term metabolic fitness because we really need to oriented around this idea of like fitness as if we were going to go lift weights, like we the first time we lift weights, we're not expecting to be jacked, we need to do it day in and day out, in order to build the cellular adaptations, that leads to muscle growth. And the same is true of how we should think about improving our insulin sensitivity, improving our glucose, you have to put in the reps in order to achieve metal in order to achieve in metabolic flexibility, and metabolic health and metabolic fitness. And the reps in this case, our days of not spiking your glucose too high of keeping glucose lower and more stable. Those are the reps keeping your insulin down is a rep, which allows your cells to perk up and say, Oh, I need to be more insulin sensitive, because I'm not seeing a lot of it around, I need to perk up a little bit. These are adaptations we can make. So I think, you know, going back to I did a lot of wilderness leadership in my early 20s and one of my favorite lines is the best way to not get lost is to stay found. And so you know, you always want to know where you are in the middle of the wilderness. And that's kind of how I feel about glucose monitoring and knowing about orienting our diet and lifestyle through glucose, the best time to do it is you know, when we're very, very young, we, we want to look through that lens as we approach our diet and our lifestyle so that we can stay found, so to speak. But the hopeful thing is that even if you're well down the road, even in tight, full blown fulminant, type two diabetes, there is evidence that it is reversible. And there's a wonderful company is doing great research in this Virta health, which is diabetes reversal program that's done through a coaching and low carb diet. And they've put out research showing that in 10 weeks, with a dietary intervention, their participants can go from diabetes to a non-diabetic glucose level. And so not to say that this is the only program or a program that like is the end all be all, I actually think there's other strategies other than just super, super low carb to improve insulin sensitivity. But what it shows us is that there is a door towards reversing these even when you're sort of in a late stage. But with that said, starting early, I mean and just crafting a diet that works for you to keep glucose fairly low and stable that you still love and learning those tips and tricks to sort of modulate diet so that it doesn't have so much of a glycemic impact for your personal body I think that's the time to do it.

Chase  

I agree. Absolutely. And I would love to get there. But before we do before we get into kind of like what do we need to do to regulate or even reverse high blood sugar concerns? Can you walk us through and we touched a little bit on already of the food coma? The itis? Can you walk us through from just initial body scans biofeedback to harder telltale signs? How do we know when we have blood sugar concerns? What can we be looking for, to feel to note, brain fog, physically and then even other bigger manifestations?

Dr. Casey  

Yeah, so one thing that's really interesting about blood sugar problems is that it's sort of can masquerade as almost any symptom. And the reason for that comes down to fundamentally what is metabolism. So metabolism is a core pathway that takes place in every single cell in our body to generate energy for our cells and it's basically the process the set of chemical reactions, the body through which we convert food substrates to a currency of energy our body can use. And we have over 30 trillion cells in our body, every single one needs a well-functioning metabolism for our cells to work. And when cells start not functioning properly, when they don't get the energy they need, then we start getting tissue dysfunction, then we start getting symptoms, and then we start getting, you know, disease. So it, it all comes down to the cellular level of what's going on in the cells. And one of those core pathways is metabolism. So it can look like anything. For instance, if your metabolism is, you know, off kilter in your ovaries, it could look like polycystic ovarian syndrome, the leading cause of infertility in America, which is a metabolic condition. If it's happening in brain cells, it could look like Alzheimers dementia, which is being called type three diabetes now because it's so linked to Insulin resistance, but it could also look like depression, anxiety, chronic fatigue, or fibromyalgia, chronic pain. All of those conditions are associated with blood sugar. If it's happening to liver, it could look like chronic liver disease. If it's happening in the blood vessels it could look like any host of blood vessel endothelial problems, and we know that retinopathy, which is an issue with the blood vessels of the eyes is related to diabetes. We know that big vessel disease, like heart disease is associated is directly related to blood sugar problems. We also know that erectile dysfunction, which is a problem with blood getting to the penis, is very much even considered a heart like a warning sign for having blood sugar problems. Men in their 40s with erectile dysfunction, if that's a symptom that that comes up are at this point, you know, it's sort of you must get checked out for blood sugar problems, but it's a very free. So it's really this great masquerader based on where this core pathway is showing its signs in the skin, it can be acne, and we know that blood sugar is related to too much oil production in the skin. So I could just go on and on. But it's amazing, because it could kind of look like anything, it could also just kind of look like feeling crappy, like not like having a little you're in your 30s and you have like some brain flog or fog, you're often tired after a meal 

Chase  

You can’t put your finger on it and you're just like, something's off like, yeah,

Dr. Casey  

Yeah. And I mean, I kind of skipped over the biggest one, which is issues with losing weight, you know, 72% of our country right now is overweight or obese, what is being overweight or obese? It is excess fat storage. How does fat get stored? Through elevated insulin and by not ever having that break of insulin off so that you can actually burn through those energy stores being overweight is really just having too much energy stored as fat that we're not using. So, so there's not a specific sort of symptom that I would say is directly related to like, a one to one relationship. But any of these things that I just mentioned, you know, should be red flags to dig into this deeper, what often will happen is that you go to the doctor's office, and they'll check your finger stick glucose first thing in the morning, and they'll say, Oh, it's less than 100 milligrams per deciliter. So you're totally fine. I'm sure a lot of people would have that experience, someone out there might say, Oh, my gosh, I have polycystic ovarian syndrome, I'm gonna go to the doctor and ask for a finger stick glucose, and they're gonna go in, and maybe it's gonna be 95. And the doctors gonna say you have no problem, there's no, there's no issue here. I think a lot of doctors are starting to realize that we actually have to think deeper than that for a couple of reasons; One, because these diagnostic tests are just single time point measurements that don't tell us about what's happening actually, with the insulin. What if that person with sort of this high normal fasting glucose like 95, you know, maybe there's a person out there who's keeping that glucose at that level with a very low insulin, they're very insulin sensitive, and they're just putting out a little bit of insulin to keep the blood levels that way? Then there's another person out there whose insulin levels are 10 times higher to keep the blood sugar at that same range, they are going to be much farther on that spectrum than the person with the low insulin levels. So a lot of doctors are starting to order fasting insulin tests now, which is not standard of care. But there's many doctors who are sort of starting to incorporate that into their practice. There are other ratios that we can actually tell from our cholesterol tests, like our triglyceride to HDL ratio, total cholesterol to HDL ratio. So these are just from your standard cholesterol level tests and based on what those ratios look like, can actually be predictive of whether you are insulin resistant. And then there's another test you can do with a fasting glucose, and a fasting insulin test, that gives you what's called a Homa-IR score, which is a score of insulin resistance. So these are things that you can, you know, ask your doctor for potentially, to kind of get a sense of where you are in terms of insulin resistance. And then continuous glucose monitoring gives you know, while a fasting glucose test, the standard of care tells you just a snapshot of what's happening with your glucose but nothing about the context the insulin etc. continuous glucose monitoring can give you more of like a movie of what's going on with your glucose levels. 

Chase

And so more of during the events, you know, after the event, you know, it paints a fuller picture a much needed fuller picture. 

Dr. Casey 

Precisely. So an example of this, you know, let's say you have a glucose monitor on and you've eaten a full breakfast, and your glucose, it's going to, you're going to break down those carbohydrates that you ate, the glucose is going to go up in the bloodstream and it's going to come down and that should typically happen for a healthy person in about two hours. And you know, ideally, we don't go above about 140 when we eat that meal. But I would argue we want to not, not go that high, you know ever but just in terms of standard guidelines don't really want to go above 140 after a meal and want to come back down within about two hours. Well, let's say you put it on you, you're sitting there next to your friend, you both eat the same breakfast and one person, you know, goes up and comes down in two hours, the other person goes up and stays elevated for like three and a half hours and then comes down. Well, that's a lot of information that might be a sign, that person is actually more insulin resistant, their body is not responding that insulin well enough to get the glucose and it takes longer for them to clear it from their bloodstream, you're never gonna pick that up from a standard single time point measurement. But on a continuous glucose monitoring, you can. So that's kind of the lay of the land of some of the objective things you could potentially look at, and also some of the sort of more subjective symptomatic things you might see.

Chase  

So then, what can someone do with that information? What can someone do with seeing, oh, wow, this meal that, uh, you know, my whole family is eating or I've been used to eating my whole life, I'm actually learning it causes a longer insulin response, a longer blood sugar spike. Maybe I don't have any other signs or symptoms or concerns yet. But this is something that I'm aware of and I want to get ahead of what can I actually do about it?

Dr. Casey  

Yeah. So there are a couple lenses we can look through. One is food, which, which we should dive into. But then there's another of other a number of other factors that we know can improve our insulin sensitivity that I'll just touch on briefly. So with food, the key point is, is to regain our insulin sensitivity. And we can do that by stopping the constant stimulation of insulin in the body. And we do that by keeping our glucose more stable, essentially. And we can learn how to do that, by, you know, you can, there's lots of books out there about sort of like low carb, low glycemic Keto type diets, you can kind of read about what foods are the major offenders and what aren't. But you can also use biofeedback, like a continuous glucose monitor to actually test for yourself. And that's, that's what I personally recommend. Obviously, I'm biased; I started a company about this, because I'm so passionate about it. 

Chase

Shout out Levels. 

Dr. Casey

The interesting thing is that you and I could both eat a banana and we might have totally different glucose responses to that banana, I might go up from baseline of 70 milligrams per deciliter to 170 and go up 100 points, and you might go up 10 points. And that's what we've seen now in the research is that people respond very differently to the same carbohydrate source. And there was this amazing paper out of Israel five years ago is published in the journal cell that was called personalized nutrition by prediction of glycemic responses. And they gave people 800 healthy people standardized meals, things like bananas, or full meals or cookies, and saw this vast array of responses to those identical foods. And then they looked at what were the predictive factors of that. One of the big predictive factors was actually microbiome composition. So what's in our gut actually changes the way we respond to a carbohydrate, which is fascinating. So the idea of just following like a very restrictive blanket, low carb diet, to me seems less favorable than actually testing, like what works for your body and choosing the things that have less impact and then also using that tool to modulate foods to have least glycemic impact. So doing things like I talked about earlier, like food pairing, making sure that we're not eating carbohydrates alone and pairing them appropriately with fat protein fiber to minimize their impact to, you know, sequence meals appropriately. If we eat protein and fat and roughage before we eat our carbohydrates in a meal, we tend to have less of a glycemic response. If we eat earlier in the day, we tend to have a better response. So just like learning this metabolic toolbox of how to eat to minimize that glycemic impact, therefore minimize that insulin impact, and over time, perk up our, our insulin sensitivity. So that's kind of like big picture for food. It's really just keeping those keeping it more stable. But there's just to quickly touch on there's many other aspects I mean, cell biology is complex, and it's more than just food and there's no one like we've already talked about, there's no one food plan for everyone. It's, it's, it's your personal low glycemic food plan. But we also need to think about the other pillars, which are sleep, how we're sleeping, how we're stressing, how we're moving, the micro nutrient composition of our food in our bodies, our microbiome health, and then exposure to pollutants. So these are kind of like they're really the big factors with

Chase  

I am glad you bring this up. It's gonna be actually my next question was okay, besides taking care of our blood sugar if we have a, you know, concern around that why else should we care about monitoring our blood sugar, what are the other spillover effects, basically? 

Dr. Casey  

Yeah. So, you know, I mentioned those things because all of those things feed into how our cells process how our metabolic processes work. So stress is a really interesting one. When we stress we release stress hormones like catecholamines and cortisol. And these have a really big impact on our ability to metabolize things appropriately. Makes sense; a time of threat, you know, that has to put our body on a different pathway. It's not focused on, you know, optimal, nuanced pathways were in survival mode. 

Dr. Casey  

Yeah and what stress hormones do to our, our body is they actually go to our liver, and they tell the liver to dump out our stored glucose into the bloodstream because traditionally, our threats were going to be physical in nature, we were going to have to run from a lion or something like that, we need an easily accessible energy to run. Now, most of our stressors in our modern world, which is very physically safe, is they're psychological in nature, it's the text message. It's the email, it's the conversation with a coworker, it's the honking, it's these chronic all day, low grade stressors, and our body is still dumping sugar into the bloodstream and yet, we don't need it. So it's just it's sitting there causing, you know, problems. So, there has been research to show that if you can manage your stress response, and you can, you know, using diaphragmatic breathing and parasympathetic nervous system activation,

Chase  

Actually in James Nasser's book, I'm wrapping up now Breath, 

Dr. Casey

Best book ever 

Chase

Mind blowing. In the section now kind of, he's talking about like, the, like the metabolic spillover effect that getting better at breathing can have and talking about blood sugar management and disease management, it's unreal.

Dr. Casey  

It’s incredible. And when he was forced to do mouth breathing by plugging his nose in the Stanford experiment, like his blood, biomarkers, just like went totally out of whack. And it's, it's incredible, you know, our bodies are so finely tuned to help us self-manage our stress, but we've lost a lot of that traditional wisdom, which is so prevalent in so many other cultures, but we just we don't think about I don't think vagal nerve stimulation is something that children are taught in the US and yet it is it is our, our,

Chase  

I'm going to teach my kids dammit, I'm going to teach my kids about vagal nerve stimulation,

Dr. Casey  

I'm with you. I mean, this is about coping, this is about self-soothing, and, and that makes you know, your own life better, but also makes everyone around you their life better when you know how to manage your emotions. And we literally have built in hacks, like there are places we can touch on our body, you know, to actually activate some of the stuff that puts us that changes our stress hormones, and it's kind of amazing.

Chase  

With the listener right now, speaking of breath, to kind of couple what you're talking about here, the cycles that he talks about our nostrils going in in terms of left or night, left or right breathing. The left side is more directly tied to your sympathetic and right, tied to your parasympathetic. I'm pretty sure I got that right. I'll put that down. But just paying attention. Like this is a great biofeedback hack for someone right now is pay attention biofeedback, where which natural side are you predominantly breathing through? And that can be an indicator of, I'm actually stressed out. What am I on edge about? What am I nervous about? What am I worried about? What am I thinking? What am I doing? Who are the people I'm with just a small little thing of paying attention to which nostril you are breathing through can be like the precursor to managing your blood sugar.

Dr. Casey  

Yeah, totally. Totally. It's so yeah, major shout out for that book. It's amazing. I originally trained as an ear, nose and throat surgeon and I was so blown away by how much I did not know about the nose. I'm like, here I spent, you know, nine years between medical school and residency, obsessed with the nose operating on the nose. And in that book, I learned so much about like I'm sending this to every one of my family. So it's, it's a great, it's a great sort of just like, you know, just broad brushstrokes about some other ways we can be thinking about our lives. So, but stress is, yeah, it's huge for metabolic health. And it makes sense from that sort of evolutionary protective mechanism that sort of gone awry. And sleep really fits hand in hand with that we basically know I mean, it's this simple it's like if you sleep, not enough, you are at significantly higher risk for developing metabolic conditions ranging from being overweight, to having diabetes, to having heart disease, to the extent that these are now becoming like sleep is being asked as like standard questions when we're thinking about heart disease risk for people because it's, it's so strongly linked. So one really interesting experiment that was done was they looked at a group, large group of people and they categorize them by people who are short sleepers or long sleepers. Short sleepers were people who are getting 6.5 hours of sleep per night which is not even that does it for us doesn't seem that crazy and long sleepers for 7.5 to 8.5. And they gave each of these different groups or a glucose tolerance test, which is where you take a bunch of glucose, liquid glucose in, and then your you, we track your blood sugar for two to three hours after the test and see what happens and they each group had similar glucose responses. So it's like, oh, so they're the same, it doesn't actually matter. But when you looked at insulin, the short sleepers had to produce 50% more insulin to have the same glucose levels than the people who are long sleepers. So we know that even one night of sleep can make us acutely insulin resistant. There was another crazy study; this one's impacted me a lot where they had a group of healthy, very healthy young men and they subjected them to five nights of four hours of sleep per night, which is extreme, obviously, like that would that would throw us off

Chase  

Sounds like a lot of my time in the military, to be honest. Especially in boot camp.

Dr. Casey  

it sounds pretty crazy for like day to day, but I think back to my surgical residency when I was on call two to three nights a week and all-nighters and so it's not four hours of sleep at night, but on average, some weeks, it was four hours of night asleep. They basically took these healthy young men and in that intervention, converted them from normal to pre diabetic based on their lab studies. And then they gave them basically unlimited like 12 hours sleep a night for the next five nights and people it was reversible. But it's just you think about kids during college kids during like, finals week, how many of those kids are like I say, kids, like it's so long ago, but it was only like 15 years ago, but you know, they're probably flipping in and out of pre diabetes in college like not infrequently. And so best thing we can do, I think for our mental health is just like get a quality sleep and also for a metabolic health. Exercise, just I'll keep it short. Anytime we're moving our body, we're improving our metabolic health. And the reason for this is twofold. One is that muscles are one of our biggest glucose sinks in the body; they are this gigantic, full body place to that's using glucose. And so if you're moving a muscle, even if it means walking across your room, that's just every single one of those muscle fibers is having to take up glucose out of the bloodstream and keep it in more stable range. And the cool thing about muscle is that it's actually able to function in an insulin independent way muscle contraction in its own right allows glucose to be taken up, you don't need the insulin is a lock and key. So it's like a way to dispose of glucose without triggering the whole insulin physiology.

Chase  

So it's that dark knight working, working in the background for us. Amazing.

Dr. Casey  

It is it is and there's been some really interesting studies where basically you take people put them in different groups, one that walks for like 20 minutes, three times a day, before meals, one that walks for 20 minutes day after each of the three meals and then another end. So that's 60 minutes total for each group, or a group that walks two minutes every 30 minutes throughout the day. So each group totals 60 minutes of movement, but at different times, and the people who walk every 30 minutes actually have the best glucose control more than eating before after meals or in chunks. And I think the reason for that is because by moving every 30 minutes, even for just a couple minutes, you're activating the whole body of muscles, and you're keeping those pathways, you know, constituency activated, you're becoming a body that moves as opposed to a sedentary body that has little chunks of movement.

Chase  

So body in motion stays in motion. That's what they say, right?

Dr. Casey  

Yes. I love that.

Chase  

Well, your expertise is very apparent. It's been so great hearing some of these things are a reminder for me personally, but so many other nuances and new studies and new technologies that are coming out of the work that you're doing and the whole team at Levels is well, first of all, I'm thankful thank you so much for what you're doing. And for the education and empowerment you're passing on to the world. And you know, through the audience here on the podcast. And getting towards the end, I know that you all have now been able to not only educate, empower, but now pass off a tool to help somebody track it, become more in tune with their body, learn by feedback and just make a decision or make better decisions for their general wellness to get ahead of diabetes. Someone like myself who has it directly in his family I'm very mindful of carbohydrates and sugar and getting my an once every year but with Levels it has given me daily immediate continuous access to what is going on to some of my food choices to my physical activity choices. And in a lot of ways, it's been a great little just nudge of, hey Chase, you think you're doing the right thing well, maybe for you due to your bio individuality, you need to be doing something a little bit differently. And it's just been that great little nudge for me in maintenance and my wellness and so for that as a thank you but can you please give us the high level view of what is Levels and what is it doing for the person?

Dr. Casey  

Yeah, well, thank you for those kind words that I'm glad it was a positive experience. So Levels is doing exactly sort of what we've been talking about it's giving people this window into their metabolic health through providing access to continuous glucose monitoring technology and then pairing that with software that helps you understand what that data stream means and how to optimize it and improve your diet and lifestyle to keep glucose levels in ideally, a stable and healthy range. Because it is so personalized, each person is going to respond differently to carbohydrates, it allows people to really have that personalized closed loop lens on how these choices are actually specifically affecting your own body and to move towards what you know, more of an optimal state. So our program is a one month program, we call it a one month metabolic awareness journey. And during that one month, people get these wearable sensors that continuous glucose monitors which just stick on the back of your arm, and are super easy, super painless, they last on there for two weeks. So during the month, which is 28 days, you get two of these two weeks sensors. And it's just that it's like a little lab on your arm, it's like a little doing a little lab test on your arm 24 hours a day, it's crazy, like it's, it's like a like a Fitbit or an Apple Watch but it's actually testing something inside your body through this tiny little painless filament that goes under the skin and then it's transmitting that data to your smartphone, and our software interprets that data for you. So that's, that's what Levels does and ultimately, it's all about empowerment, helping people understand their bodies better and helping us make the consistent dietary and lifestyle choices that keep us healthy, both now and in the future.

Chase  

And that's what Ever Forward Radio is all about. That's the meaning behind the message is, you know, what are these things that we can continue to do? What can we learn more about to keep us moving forward? And so the last question, I'll ask you here, Casey, the question I ask everybody is, you know, what does that mean to you? How does your work? How does your mission? How can Levels and what you're doing in the world what does that mean to you to live a life ever forward? How can this help us at the same time?

Dr. Casey  

Hmm. To me, part of moving ever forward just has a lot to do with mindset. It means waking up every morning with a growth mindset and with optimism, and really knowing that the brain and the body are something that are modifiable and modulatable based on habit. And we you know, when we put in the consistent, you know, effort each day, whether it means focusing on a positive gratitude based mindset, or putting, you know, beautiful food into our body or moving our bodies that there is an amazing payoff there is plasticity in the body and we will move in the right direction. So it's just really about keeping that growth mindset and keeping an optimistic outlook on the mind and body because, you know, life comes I think in in waves and you know, there's generally a brighter side down the road, but we can help we can help, you know, make things brighter by the way we approach each day with our habits.

Chase  

I agree. Well, Dr. Casey Means, thank you so much. I don't think we've formally said that. So anybody curious as to what is this lady who what is she talking about? Who is she? Background for sure. I mean, again, your work at Levels is incredible. I've had a great experience so far. And it's great for my continued daily wellness, but also someone like myself who just, I'm unique. Like you're unique. We're all unique. We all have things that we want to achieve in life, in our body composition and our wellness, but also things that we should I think be mindful of because we didn't just pop out of nowhere, right. You know, we've got parents, we've got uncles, we've got family history. So do your due diligence, for sure. Casey, thank you so much. I'll have all your information down in the show notes for everybody. And we'll wrap it there.

Dr. Casey  

Thanks so much Chase.

EFR 458: Improving Metabolic Health and Potential Indicators Your Blood Sugar Levels Are a Problem with Dr. Casey Means, MD

Dr. Casey Means, MD is the Co-Founder and Chief Medical Officer at Levels, a metabolic health company that provides individuals “real-time continuous glucose biofeedback coupled with machine-learning driven insights to inform personalized diet and lifestyle choices.”

Glucose, unlike other biomarkers, provides us a closed biofeedback loop which if tracked helps us make better diet and lifestyle choices on the fly. Other biomarkers, such as genetics or cholesterol, do not provide that real-time information which means we cannot track changes around them based on our nutritional and lifestyle choices on a day-to-day basis.

“The beauty of glucose,” says Dr. Means, “is that there are tools, right now, that can measure our glucose levels in real-time, at home, with a wearable sensor. Unlike these other variables, we can actually see how this biomarker is changing based on choices that we made five minutes ago.”

For several years, glucose monitors have been available as a treatment tool for diabetes. What Levels has done is take this technology to the mass consumer market to be used as a precision nutrition tool.

Listen in as Dr. Means explains how Levels translates real-time insights around your blood glucose into actionable steps that you can use to improve your metabolic health today.

Follow Dr. Casey @drcaseyskitchen

Follow Levels @levels

Follow Chase @chase_chewning

Key Highlights

  • Why did Dr. Means decide to focus on metabolic health specifically in helping people improve their diet and lifestyle choices?

  • Why should someone who is not diabetic or prediabetic be concerned about monitoring their glucose?

  • What are the “reps” we need to put into improving our metabolic fitness?

  • What are the indicators of potential blood sugar problems?

Powerful Quotes by Dr. Casey Means

Our mission is to empower people with their personal health information to help them make better daily choices around diet and lifestyle so that they can live their best life right now and enhance performance every day, and ideally ward off chronic problems down the road related to diet and lifestyle.

We can use tools like continuous glucose monitors to actually see how different foods are affecting our glucose and make smarter choices about what foods we’re choosing or how we’re even pairing foods.

Cell biology is complex and it’s about more than just food. We also need to think about the other pillars which are how we sleep, how we stress, how we’re moving, the micronutrient composition of the food in our bodies, our microbiome health, and our exposure to pollutants. All of these things feed into how our metabolic processes work.


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Interview transcript:

Chase  

All right, Casey, what's going on? Welcome to Ever Forward Radio. Thank you so much for being here.

Dr. Casey  

Thank you so much for having me, Chase, I'm thrilled to be here.

Chase  

I got to say, I feel like I missed the red memo mark, for the microphone, you're blending your shirt, your microphone, I got to get like some kind of color coordinated cap for my equipment over here.

Dr. Casey  

Yeah, you need my microphone; it matches your shirt

Chase  

I used to have that actually, I still have I'm looking below my monitor, I used to have that Blue Yeti, all the microphones that I've had, I keep as kind of like little memorabilia around my office and even like my OG, little $65 microphone I used four years ago, completely the wrong way, don't work anymore, I have it plugged into my desk down here. It's just, it's cool to see it, you know how far you've come the little tools that you've used along the way to get better at your craft. And which I think is a great segue into, you know, what we're gonna be talking about today, we have so many great tools for our health and our wellness, nowadays, hardware software, to help us become more empowered about what's going on in our bodies in our minds, and to really take charge. And that's really what you and everybody at Levels is all about.

Dr. Casey  

That's exactly what we're doing. Our mission is to empower people with their personal health information so they can make better daily choices around diet and lifestyle so that they can live their best life right now. And you know, really enhance performance every day currently, but then also, ideally ward off, you know, chronic problems down the road related to diet and lifestyle, which the majority of our chronic illnesses these days are related to that. So we're all about empowering people with the information to make those choices.

Chase  

So when it comes to curating information, or putting together a team to go find the information, there are a lot of different avenues I'm sure you all could have done or gone down when it comes to, you know, genetics when it comes to cholesterol, blood sugar, when it comes to cholesterol, sodium all these things? Why was the focus on blood sugar and glucose? And you know, what it can do for or against us?

Dr. Casey  

Yeah, that's a great question. And the key answer this is that it'll glucose provides us a closed loop, biofeedback sort of circle. So with all the other things you mentioned, like genetics, or even cholesterol, these are things that we cannot get information about in real time and we can't see a change in that variable with our behavior on a day to day basis, it's more of, you know, either a lagging indicator for the case of cholesterol or for genetics, it's something that we're not going to see necessarily change over time. The genetic polymorphisms that show up on our 23andme test are not changing. Now, genetics can change in the sense that we can change gene expression over time with our choices. But that's not a readout that we really have a lot of availability. There's no consumer product that really does that right now, the beauty of glucose is that there are tools right now that can measure our glucose levels, in real time at home with a wearable sensor. This is what a continuous glucose monitor can do. And so unlike these other variables, we can actually see how this biomarker is changing based on choices that we made five minutes ago. Whether it's what we chose to have for breakfast, or whether we sort of allowed ourselves to get stressed in response to an email we read, or whether we got a poor night's sleep, or if we did a high intensity workout versus a walk, all of these things are actually going to have an immediate impact on our glucose levels. And there's a technology now that picks that up that creates a closed loop with nutrition and lifestyle choices. And the crazy thing about nutrition is, we have never had a closed loop system on nutrition. We have had closed loop for fitness with fitness trackers and heart rate trackers, we've had closed loop for sleep with sleep trackers. I love it. So you can wake up and see exactly what happened with your sleep. We even have closely for stress now with HRV trackers and heart rate variability. But we've never known there's never been a tool where you put something in your mouth and you know exactly what's happening in your body. And that's what glucose can do for us. And it's right now the only biomarker that can do that for us. So this technology, continuous glucose monitors, it's been available as a treatment tool for diabetes for several years. But what Levels does is bring this to a more mass consumer market to be used as a precision nutrition tool. So that we have a sense of what's going on with this key fundamental metabolic biomarker in our body.

Chase  

No, you mentioned there predominantly this type of hardware this type of information was for people who already excuse me had a concern had an issue, the diabetics and pre diabetics. Why should someone who is not diabetic why should someone who's not pre diabetic be concerned about monitoring their glucose?

Dr. Casey  

Yeah, well, the interesting thing about pre diabetes and diabetes is that the vast majority of these conditions of this, those conditions is preventable. So right now we have 128 million Americans in the United States with pre diabetes or diabetes. That's like a huge chunk of our population.

Chase  

A lot of people,

Dr. Casey  

It’s a lot of people, it's an epidemic

Chase  

It’s probably, you know, one or one or two of the people who are probably staring at right now.

Dr. Casey  

Absolutely. If you walk down the street, it's close to 40% of people have either pre diabetes or diabetes. And with pre diabetes, which is 84 million people in the United States, 90% of those people do not know that they have a blood sugar problem. The CDC data 90% don't know. And what's so interesting about it is like, even if you've reached that pre diabetic threshold by diagnostic criteria, or the diabetic threshold by diagnostic criteria, that doesn't mean that if you're not in the pre diabetic threshold, that, you know, everything's perfect, because this is a spectrum. This is a spectrum illness, where over time, we move towards these conditions and metabolic dysfunction, and insulin resistance over time, until, you know, one day we go into the doctor's office, and we finally sort of met that criteria for diagnostic threshold. But that, you know, it's we’re marching along this spectrum throughout our lives and there's good evidence to support that 13 to 17 years before we actually reach those diagnostic thresholds where we're showing signs of early problems with our metabolism. 

Chase  

Over a decade before we possibly get a diagnosis, we are exhibiting signs of something that we can get ahead of?

Dr. Casey  

That's right. Yeah, that's so it's specifically and we kind of have to get into a little bit of physiology to understand this. But disorders of glucose, like diabetes, or pre diabetes one of the ways that these develop is that over time, as we, you know, eat diets that are predominantly composed of refined carbohydrates, which are Western American diets are predominantly composed of refined carbohydrates, these are digested, they turn to glucose in the bloodstream, so does refined sugar, of course and when that sugar elevates in the bloodstream, our body has a hormonal response, it releases insulin from the pancreas. And that insulin helps you take that, that sugar out of the bloodstream into the cells so that glucose can be converted into energy. And when there's excess, it's either stored as stored chains of glucose called glycogen, or it's turned into fat. And when this happens, sort of too much when we are getting really high glucose elevations in the blood, or we're just doing it many, many times per day, like let's say, we eat three high carb meals, plus three snacks, that's six spikes of glucose in our bloodstream, that's a lot of insulin the body has to produce to sort of manage that insulin in the bloodstream. And over time, the body gets tired, and it's actually become numb to that signal of insulin. And we develop what's called insulin resistance. And what the body does to respond to insulin resistance, it still has to get that glucose out of the bloodstream. And so the body produces more insulin and it overcompensates and a young healthy body can do that you just push out more insulin, and force that glucose into the cells. So what we can actually pick up on lab tests a lot earlier, is that elevated insulin and that insulin resistance that hyperinsulinemia, which is in this sort of compensatory period, where your glucose levels may not actually look problematic, because your body's working hard on the insulin side to compensate for it. So there are studies that suggest that, yeah, 13 years in one study, we're seeing signs of insulin resistance and elevated insulin before the actual diagnostic sort of test shows that there's a glucose problem. And you can imagine, over time, the body kind of just gets more and more tired, the insulin resistance gets worse and worse and then you start to see that glucose variability show up quite a bit more. So long winded way of saying that part of the reason the average person on the street should care about their glucose is because we're all on the metabolic sort of spectrum and we want to stay in that, you know, healthy insulin sensitive part of the spectrum for as long as we possibly can. And part of doing that is making sure that we're keeping our glucose levels stable throughout our lifetime. We're not getting exposure to these, you know, really high peaks and or really frequent peaks and kind of creating more rolling hills and our glucose levels in our blood with our diet. And we can use tools like continuous glucose monitors, to actually see how different foods are affecting our glucose and make smarter choices about what food foods we're choosing, or how we're even pairing foods. You know, when you add protein, fat or fiber to a carbohydrate, it tends to blunt the glucose response. When you walk after a meal it tends to blunt the glucose response. If you add vinegar or cinnamon to a meal, it tends to blunt the glucose response. There's innumerable strategies for minimizing the glycemic impact on our body and over time that can keep our bodies sharp to that signal of insulin. So that's sort of like the long term chronic disease part of things. But then there's also just like the current performance side of things, when our glucose, even if we're young and healthy, and our pancreas is working well, if it's going up, down, up, down, up, down, like peaks and valleys, valleys, that's going to have an experience of our, it's going to have an impact on our subjective experience of the day. When we go way up, like let's say, we have five cookies, and our glucose shoots up through the roof, the body is going to soak up, it's going to produce all this insulin and soak up all that glucose, and we may actually have a crash, a glucose crash, and that's sort of like that post meal slump that many of us have had before. And that can be a

Chase  

Food coma. 

Dr. Casey  

The food coma. And that can be associated with a little bit of jitters, anxiety, you know, some mood instability, maybe a little brain fog. So I like to say that a lot of variability in our glucose, even when we're otherwise healthy leads to variability in our day, whether it's mental sharpness, athletic performance, fatigue, or mood. So it's both; it's really sort of at the at the nexus of our current reality and our current performance. And then, of course, our long term disease risk.

Chase  

Insulin resistance, those, those are two words that I used to hear a lot when I was working in clinic, the doctor would come in, you know, the patient be ready to come see the health coach after they just had their physical labs. And the doctor would always say, oh, exhibiting signs of insulin resistance. And it was always my interpretation was that patient seems the person seems to be doing everything right. Air quote here, right. But they're having just that little bit of, you know, that that that little bit of that tummy, it's like that abdominal fat that just they just can't seem to get going away. And maybe the doctor would see some kind of numbers that look questionable, you know, over the months or years in terms of blood sugar, is insulin resistance is that is that the telltale sign that maybe we have that? Is that what's going on? Is that that that last few pounds that we just can't seem to get rid of that is that we're just likes to live? And could that be an initial sign?

Dr. Casey  

Yeah, it definitely can be associated with that. So the interesting thing about insulin as a hormone is that not only does it help us shuttle the glucose out of the bloodstream into our cells so that's a purpose of insulin it by instance, and receptors helps you move that glucose into the cells. But one of its other roles is that it's a blocker on fat oxidation. So it stops you from being able to burn fat for fuel. And glucose and fat are two main sources of energy in the body and you know, we only have about two to three hours worth of like stored glucose in the body if we're working out, you know more if we're just kind of at rest, and so the body is going to kind of use that first. And only when you run out of that, and insulin is in a low state, do you start flipping the switch to burn fat, and that's obviously going to be important for weight loss to be able to actually tap into fat burning. But for the average American who's eating multiple meals a day, lots of snacks, a high refined carbon sugar diet, it's very possible that we're never getting to a state we're in during the day where our insulin really comes down to baseline really, you know, is low and allows us to take that break off of fat burning. And this is why I think so many people are interested in like ketogenic diets for weight loss, but also fasting for weight loss, because both of those strategies keep the glucose exhausted as glucose from the diet, sort of lower the Keto diet through a low carb diet, fasting through just not eating at all. Those are times essentially or your insulin is low, and you're taking that break off fat burning, you can actually flip that metabolic switch from glucose burning to fat burning. And so yes, so people, who, you know, are dealing with that abdominal fat what's interesting about insulin is it preferentially stores your fat around your middle, it preferentially stores what we call visceral adiposity, which is the fat.

Chase  

Lucky for us, right?

Dr. Casey  

Lucky for us, yeah. But you know, you see a lot of people walking around with like, maybe relatively lean appendages, but like really a huge belly. And that's sort of a telltale sign of insulin resistance where that insulin is elevated; we're on that spectrum moving towards a problem. And that insulin is basically stopping us from being able to burn through that fat, but also telling the body to store any excess glucose as visceral fat around our organs and in our belly.

Chase  

When is the best time, the best place in that spectrum to actually take action? Because I can imagine someone who is maybe going to the doctor and the last two years or last five years, the doctors is your sugar's look a little high, but don't worry about it. It's nothing. You know, you're not pre diabetic, you're not diabetic, like, when is when should we actually step in and take note of, hey, there's something going on internally that I need to get ahead of, and how much time really do we have to get to it later, so to speak?

Dr. Casey  

Well, the beautiful thing about metabolic health and really the body in general is that so often, things are reversible, and we can move in the right direction. It's not a one way street with health. And so in so many ways, and there are certainly exceptions to that rule but with blood sugar and insulin sensitivity there, it's very much a two way street. I like to use the term metabolic fitness because we really need to oriented around this idea of like fitness as if we were going to go lift weights, like we the first time we lift weights, we're not expecting to be jacked, we need to do it day in and day out, in order to build the cellular adaptations, that leads to muscle growth. And the same is true of how we should think about improving our insulin sensitivity, improving our glucose, you have to put in the reps in order to achieve metal in order to achieve in metabolic flexibility, and metabolic health and metabolic fitness. And the reps in this case, our days of not spiking your glucose too high of keeping glucose lower and more stable. Those are the reps keeping your insulin down is a rep, which allows your cells to perk up and say, Oh, I need to be more insulin sensitive, because I'm not seeing a lot of it around, I need to perk up a little bit. These are adaptations we can make. So I think, you know, going back to I did a lot of wilderness leadership in my early 20s and one of my favorite lines is the best way to not get lost is to stay found. And so you know, you always want to know where you are in the middle of the wilderness. And that's kind of how I feel about glucose monitoring and knowing about orienting our diet and lifestyle through glucose, the best time to do it is you know, when we're very, very young, we, we want to look through that lens as we approach our diet and our lifestyle so that we can stay found, so to speak. But the hopeful thing is that even if you're well down the road, even in tight, full blown fulminant, type two diabetes, there is evidence that it is reversible. And there's a wonderful company is doing great research in this Virta health, which is diabetes reversal program that's done through a coaching and low carb diet. And they've put out research showing that in 10 weeks, with a dietary intervention, their participants can go from diabetes to a non-diabetic glucose level. And so not to say that this is the only program or a program that like is the end all be all, I actually think there's other strategies other than just super, super low carb to improve insulin sensitivity. But what it shows us is that there is a door towards reversing these even when you're sort of in a late stage. But with that said, starting early, I mean and just crafting a diet that works for you to keep glucose fairly low and stable that you still love and learning those tips and tricks to sort of modulate diet so that it doesn't have so much of a glycemic impact for your personal body I think that's the time to do it.

Chase  

I agree. Absolutely. And I would love to get there. But before we do before we get into kind of like what do we need to do to regulate or even reverse high blood sugar concerns? Can you walk us through and we touched a little bit on already of the food coma? The itis? Can you walk us through from just initial body scans biofeedback to harder telltale signs? How do we know when we have blood sugar concerns? What can we be looking for, to feel to note, brain fog, physically and then even other bigger manifestations?

Dr. Casey  

Yeah, so one thing that's really interesting about blood sugar problems is that it's sort of can masquerade as almost any symptom. And the reason for that comes down to fundamentally what is metabolism. So metabolism is a core pathway that takes place in every single cell in our body to generate energy for our cells and it's basically the process the set of chemical reactions, the body through which we convert food substrates to a currency of energy our body can use. And we have over 30 trillion cells in our body, every single one needs a well-functioning metabolism for our cells to work. And when cells start not functioning properly, when they don't get the energy they need, then we start getting tissue dysfunction, then we start getting symptoms, and then we start getting, you know, disease. So it, it all comes down to the cellular level of what's going on in the cells. And one of those core pathways is metabolism. So it can look like anything. For instance, if your metabolism is, you know, off kilter in your ovaries, it could look like polycystic ovarian syndrome, the leading cause of infertility in America, which is a metabolic condition. If it's happening in brain cells, it could look like Alzheimers dementia, which is being called type three diabetes now because it's so linked to Insulin resistance, but it could also look like depression, anxiety, chronic fatigue, or fibromyalgia, chronic pain. All of those conditions are associated with blood sugar. If it's happening to liver, it could look like chronic liver disease. If it's happening in the blood vessels it could look like any host of blood vessel endothelial problems, and we know that retinopathy, which is an issue with the blood vessels of the eyes is related to diabetes. We know that big vessel disease, like heart disease is associated is directly related to blood sugar problems. We also know that erectile dysfunction, which is a problem with blood getting to the penis, is very much even considered a heart like a warning sign for having blood sugar problems. Men in their 40s with erectile dysfunction, if that's a symptom that that comes up are at this point, you know, it's sort of you must get checked out for blood sugar problems, but it's a very free. So it's really this great masquerader based on where this core pathway is showing its signs in the skin, it can be acne, and we know that blood sugar is related to too much oil production in the skin. So I could just go on and on. But it's amazing, because it could kind of look like anything, it could also just kind of look like feeling crappy, like not like having a little you're in your 30s and you have like some brain flog or fog, you're often tired after a meal 

Chase  

You can’t put your finger on it and you're just like, something's off like, yeah,

Dr. Casey  

Yeah. And I mean, I kind of skipped over the biggest one, which is issues with losing weight, you know, 72% of our country right now is overweight or obese, what is being overweight or obese? It is excess fat storage. How does fat get stored? Through elevated insulin and by not ever having that break of insulin off so that you can actually burn through those energy stores being overweight is really just having too much energy stored as fat that we're not using. So, so there's not a specific sort of symptom that I would say is directly related to like, a one to one relationship. But any of these things that I just mentioned, you know, should be red flags to dig into this deeper, what often will happen is that you go to the doctor's office, and they'll check your finger stick glucose first thing in the morning, and they'll say, Oh, it's less than 100 milligrams per deciliter. So you're totally fine. I'm sure a lot of people would have that experience, someone out there might say, Oh, my gosh, I have polycystic ovarian syndrome, I'm gonna go to the doctor and ask for a finger stick glucose, and they're gonna go in, and maybe it's gonna be 95. And the doctors gonna say you have no problem, there's no, there's no issue here. I think a lot of doctors are starting to realize that we actually have to think deeper than that for a couple of reasons; One, because these diagnostic tests are just single time point measurements that don't tell us about what's happening actually, with the insulin. What if that person with sort of this high normal fasting glucose like 95, you know, maybe there's a person out there who's keeping that glucose at that level with a very low insulin, they're very insulin sensitive, and they're just putting out a little bit of insulin to keep the blood levels that way? Then there's another person out there whose insulin levels are 10 times higher to keep the blood sugar at that same range, they are going to be much farther on that spectrum than the person with the low insulin levels. So a lot of doctors are starting to order fasting insulin tests now, which is not standard of care. But there's many doctors who are sort of starting to incorporate that into their practice. There are other ratios that we can actually tell from our cholesterol tests, like our triglyceride to HDL ratio, total cholesterol to HDL ratio. So these are just from your standard cholesterol level tests and based on what those ratios look like, can actually be predictive of whether you are insulin resistant. And then there's another test you can do with a fasting glucose, and a fasting insulin test, that gives you what's called a Homa-IR score, which is a score of insulin resistance. So these are things that you can, you know, ask your doctor for potentially, to kind of get a sense of where you are in terms of insulin resistance. And then continuous glucose monitoring gives you know, while a fasting glucose test, the standard of care tells you just a snapshot of what's happening with your glucose but nothing about the context the insulin etc. continuous glucose monitoring can give you more of like a movie of what's going on with your glucose levels. 

Chase

And so more of during the events, you know, after the event, you know, it paints a fuller picture a much needed fuller picture. 

Dr. Casey 

Precisely. So an example of this, you know, let's say you have a glucose monitor on and you've eaten a full breakfast, and your glucose, it's going to, you're going to break down those carbohydrates that you ate, the glucose is going to go up in the bloodstream and it's going to come down and that should typically happen for a healthy person in about two hours. And you know, ideally, we don't go above about 140 when we eat that meal. But I would argue we want to not, not go that high, you know ever but just in terms of standard guidelines don't really want to go above 140 after a meal and want to come back down within about two hours. Well, let's say you put it on you, you're sitting there next to your friend, you both eat the same breakfast and one person, you know, goes up and comes down in two hours, the other person goes up and stays elevated for like three and a half hours and then comes down. Well, that's a lot of information that might be a sign, that person is actually more insulin resistant, their body is not responding that insulin well enough to get the glucose and it takes longer for them to clear it from their bloodstream, you're never gonna pick that up from a standard single time point measurement. But on a continuous glucose monitoring, you can. So that's kind of the lay of the land of some of the objective things you could potentially look at, and also some of the sort of more subjective symptomatic things you might see.

Chase  

So then, what can someone do with that information? What can someone do with seeing, oh, wow, this meal that, uh, you know, my whole family is eating or I've been used to eating my whole life, I'm actually learning it causes a longer insulin response, a longer blood sugar spike. Maybe I don't have any other signs or symptoms or concerns yet. But this is something that I'm aware of and I want to get ahead of what can I actually do about it?

Dr. Casey  

Yeah. So there are a couple lenses we can look through. One is food, which, which we should dive into. But then there's another of other a number of other factors that we know can improve our insulin sensitivity that I'll just touch on briefly. So with food, the key point is, is to regain our insulin sensitivity. And we can do that by stopping the constant stimulation of insulin in the body. And we do that by keeping our glucose more stable, essentially. And we can learn how to do that, by, you know, you can, there's lots of books out there about sort of like low carb, low glycemic Keto type diets, you can kind of read about what foods are the major offenders and what aren't. But you can also use biofeedback, like a continuous glucose monitor to actually test for yourself. And that's, that's what I personally recommend. Obviously, I'm biased; I started a company about this, because I'm so passionate about it. 

Chase

Shout out Levels. 

Dr. Casey

The interesting thing is that you and I could both eat a banana and we might have totally different glucose responses to that banana, I might go up from baseline of 70 milligrams per deciliter to 170 and go up 100 points, and you might go up 10 points. And that's what we've seen now in the research is that people respond very differently to the same carbohydrate source. And there was this amazing paper out of Israel five years ago is published in the journal cell that was called personalized nutrition by prediction of glycemic responses. And they gave people 800 healthy people standardized meals, things like bananas, or full meals or cookies, and saw this vast array of responses to those identical foods. And then they looked at what were the predictive factors of that. One of the big predictive factors was actually microbiome composition. So what's in our gut actually changes the way we respond to a carbohydrate, which is fascinating. So the idea of just following like a very restrictive blanket, low carb diet, to me seems less favorable than actually testing, like what works for your body and choosing the things that have less impact and then also using that tool to modulate foods to have least glycemic impact. So doing things like I talked about earlier, like food pairing, making sure that we're not eating carbohydrates alone and pairing them appropriately with fat protein fiber to minimize their impact to, you know, sequence meals appropriately. If we eat protein and fat and roughage before we eat our carbohydrates in a meal, we tend to have less of a glycemic response. If we eat earlier in the day, we tend to have a better response. So just like learning this metabolic toolbox of how to eat to minimize that glycemic impact, therefore minimize that insulin impact, and over time, perk up our, our insulin sensitivity. So that's kind of like big picture for food. It's really just keeping those keeping it more stable. But there's just to quickly touch on there's many other aspects I mean, cell biology is complex, and it's more than just food and there's no one like we've already talked about, there's no one food plan for everyone. It's, it's, it's your personal low glycemic food plan. But we also need to think about the other pillars, which are sleep, how we're sleeping, how we're stressing, how we're moving, the micro nutrient composition of our food in our bodies, our microbiome health, and then exposure to pollutants. So these are kind of like they're really the big factors with

Chase  

I am glad you bring this up. It's gonna be actually my next question was okay, besides taking care of our blood sugar if we have a, you know, concern around that why else should we care about monitoring our blood sugar, what are the other spillover effects, basically? 

Dr. Casey  

Yeah. So, you know, I mentioned those things because all of those things feed into how our cells process how our metabolic processes work. So stress is a really interesting one. When we stress we release stress hormones like catecholamines and cortisol. And these have a really big impact on our ability to metabolize things appropriately. Makes sense; a time of threat, you know, that has to put our body on a different pathway. It's not focused on, you know, optimal, nuanced pathways were in survival mode. 

Dr. Casey  

Yeah and what stress hormones do to our, our body is they actually go to our liver, and they tell the liver to dump out our stored glucose into the bloodstream because traditionally, our threats were going to be physical in nature, we were going to have to run from a lion or something like that, we need an easily accessible energy to run. Now, most of our stressors in our modern world, which is very physically safe, is they're psychological in nature, it's the text message. It's the email, it's the conversation with a coworker, it's the honking, it's these chronic all day, low grade stressors, and our body is still dumping sugar into the bloodstream and yet, we don't need it. So it's just it's sitting there causing, you know, problems. So, there has been research to show that if you can manage your stress response, and you can, you know, using diaphragmatic breathing and parasympathetic nervous system activation,

Chase  

Actually in James Nasser's book, I'm wrapping up now Breath, 

Dr. Casey

Best book ever 

Chase

Mind blowing. In the section now kind of, he's talking about like, the, like the metabolic spillover effect that getting better at breathing can have and talking about blood sugar management and disease management, it's unreal.

Dr. Casey  

It’s incredible. And when he was forced to do mouth breathing by plugging his nose in the Stanford experiment, like his blood, biomarkers, just like went totally out of whack. And it's, it's incredible, you know, our bodies are so finely tuned to help us self-manage our stress, but we've lost a lot of that traditional wisdom, which is so prevalent in so many other cultures, but we just we don't think about I don't think vagal nerve stimulation is something that children are taught in the US and yet it is it is our, our,

Chase  

I'm going to teach my kids dammit, I'm going to teach my kids about vagal nerve stimulation,

Dr. Casey  

I'm with you. I mean, this is about coping, this is about self-soothing, and, and that makes you know, your own life better, but also makes everyone around you their life better when you know how to manage your emotions. And we literally have built in hacks, like there are places we can touch on our body, you know, to actually activate some of the stuff that puts us that changes our stress hormones, and it's kind of amazing.

Chase  

With the listener right now, speaking of breath, to kind of couple what you're talking about here, the cycles that he talks about our nostrils going in in terms of left or night, left or right breathing. The left side is more directly tied to your sympathetic and right, tied to your parasympathetic. I'm pretty sure I got that right. I'll put that down. But just paying attention. Like this is a great biofeedback hack for someone right now is pay attention biofeedback, where which natural side are you predominantly breathing through? And that can be an indicator of, I'm actually stressed out. What am I on edge about? What am I nervous about? What am I worried about? What am I thinking? What am I doing? Who are the people I'm with just a small little thing of paying attention to which nostril you are breathing through can be like the precursor to managing your blood sugar.

Dr. Casey  

Yeah, totally. Totally. It's so yeah, major shout out for that book. It's amazing. I originally trained as an ear, nose and throat surgeon and I was so blown away by how much I did not know about the nose. I'm like, here I spent, you know, nine years between medical school and residency, obsessed with the nose operating on the nose. And in that book, I learned so much about like I'm sending this to every one of my family. So it's, it's a great, it's a great sort of just like, you know, just broad brushstrokes about some other ways we can be thinking about our lives. So, but stress is, yeah, it's huge for metabolic health. And it makes sense from that sort of evolutionary protective mechanism that sort of gone awry. And sleep really fits hand in hand with that we basically know I mean, it's this simple it's like if you sleep, not enough, you are at significantly higher risk for developing metabolic conditions ranging from being overweight, to having diabetes, to having heart disease, to the extent that these are now becoming like sleep is being asked as like standard questions when we're thinking about heart disease risk for people because it's, it's so strongly linked. So one really interesting experiment that was done was they looked at a group, large group of people and they categorize them by people who are short sleepers or long sleepers. Short sleepers were people who are getting 6.5 hours of sleep per night which is not even that does it for us doesn't seem that crazy and long sleepers for 7.5 to 8.5. And they gave each of these different groups or a glucose tolerance test, which is where you take a bunch of glucose, liquid glucose in, and then your you, we track your blood sugar for two to three hours after the test and see what happens and they each group had similar glucose responses. So it's like, oh, so they're the same, it doesn't actually matter. But when you looked at insulin, the short sleepers had to produce 50% more insulin to have the same glucose levels than the people who are long sleepers. So we know that even one night of sleep can make us acutely insulin resistant. There was another crazy study; this one's impacted me a lot where they had a group of healthy, very healthy young men and they subjected them to five nights of four hours of sleep per night, which is extreme, obviously, like that would that would throw us off

Chase  

Sounds like a lot of my time in the military, to be honest. Especially in boot camp.

Dr. Casey  

it sounds pretty crazy for like day to day, but I think back to my surgical residency when I was on call two to three nights a week and all-nighters and so it's not four hours of sleep at night, but on average, some weeks, it was four hours of night asleep. They basically took these healthy young men and in that intervention, converted them from normal to pre diabetic based on their lab studies. And then they gave them basically unlimited like 12 hours sleep a night for the next five nights and people it was reversible. But it's just you think about kids during college kids during like, finals week, how many of those kids are like I say, kids, like it's so long ago, but it was only like 15 years ago, but you know, they're probably flipping in and out of pre diabetes in college like not infrequently. And so best thing we can do, I think for our mental health is just like get a quality sleep and also for a metabolic health. Exercise, just I'll keep it short. Anytime we're moving our body, we're improving our metabolic health. And the reason for this is twofold. One is that muscles are one of our biggest glucose sinks in the body; they are this gigantic, full body place to that's using glucose. And so if you're moving a muscle, even if it means walking across your room, that's just every single one of those muscle fibers is having to take up glucose out of the bloodstream and keep it in more stable range. And the cool thing about muscle is that it's actually able to function in an insulin independent way muscle contraction in its own right allows glucose to be taken up, you don't need the insulin is a lock and key. So it's like a way to dispose of glucose without triggering the whole insulin physiology.

Chase  

So it's that dark knight working, working in the background for us. Amazing.

Dr. Casey  

It is it is and there's been some really interesting studies where basically you take people put them in different groups, one that walks for like 20 minutes, three times a day, before meals, one that walks for 20 minutes day after each of the three meals and then another end. So that's 60 minutes total for each group, or a group that walks two minutes every 30 minutes throughout the day. So each group totals 60 minutes of movement, but at different times, and the people who walk every 30 minutes actually have the best glucose control more than eating before after meals or in chunks. And I think the reason for that is because by moving every 30 minutes, even for just a couple minutes, you're activating the whole body of muscles, and you're keeping those pathways, you know, constituency activated, you're becoming a body that moves as opposed to a sedentary body that has little chunks of movement.

Chase  

So body in motion stays in motion. That's what they say, right?

Dr. Casey  

Yes. I love that.

Chase  

Well, your expertise is very apparent. It's been so great hearing some of these things are a reminder for me personally, but so many other nuances and new studies and new technologies that are coming out of the work that you're doing and the whole team at Levels is well, first of all, I'm thankful thank you so much for what you're doing. And for the education and empowerment you're passing on to the world. And you know, through the audience here on the podcast. And getting towards the end, I know that you all have now been able to not only educate, empower, but now pass off a tool to help somebody track it, become more in tune with their body, learn by feedback and just make a decision or make better decisions for their general wellness to get ahead of diabetes. Someone like myself who has it directly in his family I'm very mindful of carbohydrates and sugar and getting my an once every year but with Levels it has given me daily immediate continuous access to what is going on to some of my food choices to my physical activity choices. And in a lot of ways, it's been a great little just nudge of, hey Chase, you think you're doing the right thing well, maybe for you due to your bio individuality, you need to be doing something a little bit differently. And it's just been that great little nudge for me in maintenance and my wellness and so for that as a thank you but can you please give us the high level view of what is Levels and what is it doing for the person?

Dr. Casey  

Yeah, well, thank you for those kind words that I'm glad it was a positive experience. So Levels is doing exactly sort of what we've been talking about it's giving people this window into their metabolic health through providing access to continuous glucose monitoring technology and then pairing that with software that helps you understand what that data stream means and how to optimize it and improve your diet and lifestyle to keep glucose levels in ideally, a stable and healthy range. Because it is so personalized, each person is going to respond differently to carbohydrates, it allows people to really have that personalized closed loop lens on how these choices are actually specifically affecting your own body and to move towards what you know, more of an optimal state. So our program is a one month program, we call it a one month metabolic awareness journey. And during that one month, people get these wearable sensors that continuous glucose monitors which just stick on the back of your arm, and are super easy, super painless, they last on there for two weeks. So during the month, which is 28 days, you get two of these two weeks sensors. And it's just that it's like a little lab on your arm, it's like a little doing a little lab test on your arm 24 hours a day, it's crazy, like it's, it's like a like a Fitbit or an Apple Watch but it's actually testing something inside your body through this tiny little painless filament that goes under the skin and then it's transmitting that data to your smartphone, and our software interprets that data for you. So that's, that's what Levels does and ultimately, it's all about empowerment, helping people understand their bodies better and helping us make the consistent dietary and lifestyle choices that keep us healthy, both now and in the future.

Chase  

And that's what Ever Forward Radio is all about. That's the meaning behind the message is, you know, what are these things that we can continue to do? What can we learn more about to keep us moving forward? And so the last question, I'll ask you here, Casey, the question I ask everybody is, you know, what does that mean to you? How does your work? How does your mission? How can Levels and what you're doing in the world what does that mean to you to live a life ever forward? How can this help us at the same time?

Dr. Casey  

Hmm. To me, part of moving ever forward just has a lot to do with mindset. It means waking up every morning with a growth mindset and with optimism, and really knowing that the brain and the body are something that are modifiable and modulatable based on habit. And we you know, when we put in the consistent, you know, effort each day, whether it means focusing on a positive gratitude based mindset, or putting, you know, beautiful food into our body or moving our bodies that there is an amazing payoff there is plasticity in the body and we will move in the right direction. So it's just really about keeping that growth mindset and keeping an optimistic outlook on the mind and body because, you know, life comes I think in in waves and you know, there's generally a brighter side down the road, but we can help we can help, you know, make things brighter by the way we approach each day with our habits.

Chase  

I agree. Well, Dr. Casey Means, thank you so much. I don't think we've formally said that. So anybody curious as to what is this lady who what is she talking about? Who is she? Background for sure. I mean, again, your work at Levels is incredible. I've had a great experience so far. And it's great for my continued daily wellness, but also someone like myself who just, I'm unique. Like you're unique. We're all unique. We all have things that we want to achieve in life, in our body composition and our wellness, but also things that we should I think be mindful of because we didn't just pop out of nowhere, right. You know, we've got parents, we've got uncles, we've got family history. So do your due diligence, for sure. Casey, thank you so much. I'll have all your information down in the show notes for everybody. And we'll wrap it there.

Dr. Casey  

Thanks so much Chase.