June 3, 2022

Friday Forum is an All Hands meeting for the Levels team, where they discuss their progress and traction each week.


Josh (00:00):

Welcome to Friday Forum, June 3rd, 2022. Oops. All right, big news here is we are cleared to get started on IRB enrollment. So the big IRB studies, which we’ve been building for well over a year now, are finally approved to go active. Website’s live, our first batch of inventory is in hand, so the pieces are coming together. There’s still certainly some background work being done to get to this final liftoff moment, but there’s just a tremendous amount of area under the curve that’s been accomplished, so huge, huge moment.


Related to that, engineering, like I said, is continuing to make progress on the various Liftoff flows, primarily the transfer portal to get people into the IRB enrollment process and through that new flow. So we will definitely need everybody on the team to try these things out, kind of work on them with us, be some of the Guinea pigs before we really go live with this stuff. So anyway, very excited for this. Cannot contain my excitement, actually, with all the pieces that this enables for us.


On the Now side, so Now 2.0, new interaction patterns. You can kind of see in the screenshot over on the side, some of these cards that are sticking up on the bottom here, some really cool design work being done to improve based on the user research we’ve been doing. This is moving into spec work and then engineering resourcing. We’re also developing a new scoring approach. This markup here is quite instructive, I don’t know if you can read the red text. But a lot of work going on, on the Now page, including this new score, which is focused on improving variability and spikes. So kind of just breaking down one of the elements of glycemic control, which is super important, and making it more approachable.


The beauty of the Day score is that it is multifactorial. It’s a little bit of a black box for people, so they can’t quite tell how do I improve this? So we’re trying something that is very straightforward. If you improve spikes, you’ll see this visually and we can help modulate one of the big elements of metabolic function.


On the UK side. So UK Alpha, we’ve got about 100 kits ready to go over here. This is really exciting. We’re also at 70% GDPR compliance, which is huge. Tracing this number, it felt felt like a huge project to get started in the very beginning, but now being well past the midpoint is quite exciting. The website internationalization and UK podcast tour planning process is underway and we’re pushing the beta for UK to August 15th. So a lot of stuff going on behind the scenes there, really exciting.


Persona project, so this is part of the new product initiatives. So as many of us know, we’ve been working on honing focus on the product goals, key initiatives, as part of the larger company objectives process. This Persona initiatives or Persona development project, Lauren’s taking lead on this, it’s going to revisit all the Persona work we’ve done and for the target member that we’re building for now help us better understand pain points, expectations, goals, who this person is, where they are in their life so that we can meet them there. So this is going to be really informative process, kind of going back to many of the very earliest lead call days that we were doing in 2019, 2020, and also looking to the new information that we’ve learned over the past year.


The Active Member Survey results are in. I think we talked about this last week, but we sent a survey to 2,000 people, active members, and we learned a huge amount about wearables, interests. This definitely goes into the Persona project, but overall, highly recommend checking out that link. There’s a lot of great detail in there about who people who are in the product today and also where the opportunities are to build for them. Other great stuff, so happiness, we’re now at five weeks with happiness over 90, which is amazing. That’s the target. The monthly happiness score is 95 and subscriptions for the month were 2X new orders, so some exciting standouts there. Excuse me.


We tried an onboarding party, so we talked about this last week. Five new members were starting their Levels journey, all started together. This was an opportunity, it’s almost the development of the white glove onboarding experience that we were experimenting with previously, and this was super informative. We’re going to do two more sessions in June and kind of continue to experiment with these community initiatives where people can be part of a cohort. There’s a lot of newness associated with trying Levels. This is a very new technology, it’s a new experience, and we can answer questions right in the moment that they crop up and that really helps people feel more comfortable.


Then lastly, paid partnership strategies. We’ve got an updated budget. Lifespan season two. So for those of you who we’re not here for the Lifespan version one or season one, it’s David Sinclair’s podcast, which was a pretty tremendous success for us as sponsors. We’ve locked that in for season two, I think that’s going to be early next year. “Not locked yet,” Tom says, so working on locking in season two. We don’t have dates yet, but that is slated for part of our initiatives and then more partner seeking experiments as part of that updated strategy for later this year. So we’ve had some real grand slams with those partnerships so far and looking forward to the next round.


Let’s see, tons of great stuff on Whole New Level, the How to be a Digital Nomad episode came out. Rob talked about more bigness, more of the sort of big initiatives or incentives that are out there that kind of end up with incentives that don’t necessarily work for the mainstream. We had Dr. Steven Gundry on, who wrote The Keto Code. We were in Outside Magazine, both their buyers guide and their best wearables of 2022 features, which was really awesome to see The Patch right there next to the Apple Watch and other cool stuff. Spoke with the former US Surgeon General, who’s very excited about what we’re working on. It’s amazing to have support from people with the stature and this view of public health, who have been kind of in the industry forever.


Let’s see, had some good coverage of Sustainable Dish, Hal published a Medium article on his history with health issues and how Levels would’ve helped him, so really want to shout out Hal for taking part in that Everyone on Content Initiative. Dr. Terry Walls, our new medical advisor, published newsletter this week about how she uses Levels in her journey against MS, which I found really fascinating. If you haven’t yet listened, I highly recommend the episode with Casey and Dr. Terry Walls, it’s an amazing glimpse into where she started, where it all started for her.


This one over here, Uric Acid with Dr. Perlmutter. This is just something I wanted to shout out. We’re at over half a million views on this YouTube video that we posted three weeks ago. Tons of amazing comments, well over a thousand comments. It was really awesome to see the deep dive from Matt on this. Let’s see, some great content posted, new affiliate Mike Hanna, and Amazon Creator Lab. I think that kind of covers it.


All right, I want to jump ahead and welcome Lara to this morning’s Friday Forum. Lara’s a partner and affiliate for Levels, PhD in Nutritional Biochemistry, and runs the Nourishable YouTube channel. Lara, I would love to hear some words. I really appreciate you setting some time aside this morning to come and chat with the team. It’s always awesome to have really amazing partners who are well-aligned and can see the future of metabolic health and would love to just hear some thoughts.

Lara Hyde (07:27):

Great. Well, thank you so much. Are you guys able to hear me? It looks like I’ve unmuted myself. Yeah, okay, perfect. Yeah, no, it’s really great to come speak with you all today. So as you see in my introduction, I really come from a background in academia. Back when I was doing my PhD, I was within the nutritional epigenomics space, and so my first kind of lens into all of this personalized nutrition field was through that lens of genomics. Then since I finished up my PhD, there has been so much advancement in other areas where there’s evidence that we’re so different from each other in how we respond to foods, particularly within how we respond metabolically and the really major role of the microbiome. So I have been following all of that data really closely and through my YouTube channel have certainly made many, many videos kind of exploring that area.


I find where my interests fall now is what are the most important biomarkers for us to be measuring to personalize our diet and lifestyle based on. Again, through my YouTube channel I’ve had this opportunity to try out so many different products within this direct to consumer space that it’s just really interesting to me to try and figure out what is the most effective for actually improving health, which biomarkers should we be measuring? I think that’s where Levels is in really such a powerful place with using continuous glucose monitors to measure our glycemic responses, because there is so much data about just how variable it is.


I think then the other thing that I’m really interested in academically is what are the best ways to motivate behavior change, and specifically motivate sustainable behavior change? That’s another place where the Levels product, in the way that it can offer dynamic real-time data to individuals based on their actual lifestyle and their actual diet, I think is really powerful. So I feel very excited about the growing field of using continuous glucose monitors and a healthy population to help sustain good metabolic health.


I’ve tried out several different direct to consumer CGM products and there’s so many things about the Levels product in particular that really stand out to me. The first thing is really just how transparent I found Levels to be in describing how they came up with their glucose scoring methods. I think, again, this is going to be me looking at this as a scientist, but at first I was like, where did these numbers come from? That was a question that I had with each different CGM that I tried, is where do these numbers come from? How do I know that this 85 or 76 that I got, what does that actually mean in terms of health? I really liked how transparent Levels was in describing, “These are the studies that we used, this is what we know, this is what we don’t know yet, but this is kind of where our scoring is coming from.” So it’s been also exciting to hear about some additional developments in the scoring system that you talked about earlier today, Josh.


Then the other thing that really stands out to me about Levels is the challenges feature, because so often it can be really confusing to try and figure out how do you run an experiment on yourself. So I love the challenges feature for, first of all, really walking a user through how do you create an experiment that has some decent controls in it so that you can actually get some good data out of it, but then also really inspiring users with here are some different factors that we know impact glycemic responses. Here’s some different factors that you could try out yourself and really be able to identify some tweaks that could be impactful in your glycemic responses. I think those are some of the things that really stood out to me about Levels compared to the other competitors that I really like. I’m not quite sure where we are with time right now, I don’t want to speak over my time limit.

Josh (11:56):

No, no, that’s super helpful and awesome to hear the insight, especially the focus on what are the big levers of driving metabolic health. Glucose is super powerful, super interesting, but in many ways we’re trying to approximate other biochemical interactions that are happening using the glucose molecule. We are all very excited about the future of biological observability where multi-molecule detection is possible in these same closed feedback loop approaches.


You touched on the second piece, which marries that really nicely, which is the transparency piece. If you add more complexity and more molecules and more overhead, without transparency, without detailed but approachable explanations of what this means and how you do or do not improve a score, it goes hand-in-hand and it starts in the DNA. Although love that feedback that we did as good a job as we could of explaining our scoring methodologies, there’s always room to grow and improve, and I would love to hear from your experience so far what one thing that you would change maybe or one or two things you would change or improve about the Levels product, if anything comes to mind.

Lara Hyde (13:11):

Well, I think the first thing, and this isn’t really specific to Levels, this is more specific to the Freestyle Libra, is just having to scan all the time. I’m sure that that’s something that you’re all very well aware of, but that certainly is a challenge. I know sometimes I did it up missing out on data because I didn’t scan and all of a sudden missed out on some interesting experiments.


I think the other thing that really stood out to me, because the first time that I tried Levels was actually over Christmas vacation when I would say that my eating habits were different than typical and certainly involved more alcohol than I usually drink, but what I seemed to notice was that for me, on the days that I consumed alcohol, it really blunted my glucose scores or my glucose spike, and so I ended up getting these better scores. I know that there is some data to show alcohol can have this effect, but also that may not be the best method for users to take away from this, is like, oh, great, I should just drink alcohol all the time. I think that there could be some room for suggesting, “Oh, you may have gotten great scores here, but watch out for this particular behavior that we noticed that you tracked.”

Josh (14:27):

Love that, yeah, that’s such a good example and one that really over time has become more and more apparent because there’s so little research on the topic, especially among people who are not living with diabetes. There’s very little information about continuous responses to these really high leverage molecules like ethanol. We started to see it and were like, what’s going on here? I certainly experience it, it’s a pretty dramatic shift almost immediately. Initially I think the response is, oh, cool, this is kind of a hack. My glass of wine is helping with dinner. But then you see the disruption of sleep and you see what sleep can do to insulin resistance over time, and so it starts to be a realization that there are other things happening behind the scenes that if we can’t expose directly, we have to expose just their education and information.


So I absolutely love that example. We have a lot of conversation going on behind the scenes about how to elevate this stuff. We call alcohol the invisibility cloak here at Levels because of the effect that it has. So with great power comes great responsibility. If you can see that and we can expose what’s going on, at least educationally, it’ll be a big improvement. Anyway, I love that one. Thank you, Lara, so much for joining us today. We’ve got kind of a full meeting and would love to have you stick around. We have another share towards the end, but totally understand you’re busy and if you need to take off, just want to say thank you from the whole team for taking some time on this Friday morning.

Lara Hyde (15:46):

Well, it was great to speak with you and I’m so excited to see where Levels goes next.

Josh (15:50):

Awesome, thank you. Okay, quick culture aside, just want to elevate the content team, Casey and Haney and everyone that works together to get the data from our systems into an approachable written form, our guest writers. We get so many examples from people out there who are saying that the content is changing their life, and this is a newsletter, someone who wrote in and said she looks forward to reading these emails from Levels. It’s such a rare thing for a business to email you and for you to look forward to it. I just want to generate some appreciation there. This is not to be taken for granted and it’s making a huge impact. Cool, Miz?

Miz (16:35):

All right, so goal of this slide, I think we do these leadership reading groups and book clubs and there’s a lot of really valuable information in there that helps align the team for the people that participate in those. Again, open invite for anyone to jump in on the next one. But what I want to do here is kind of pull out some of those lessons learned and some of the conversations that are had and bring the vocabulary to the broader team so that we’re working from a shared foundation. We speak a lot about decision-making, DRIs, consulted, accountable, but let’s kind of take a double click into decision making and look at one specific framework. This one from Brave New Work we haven’t entirely adopted, but there’s some good principles in here to share that I wanted to run us through.


So there’s six steps to decision making in the Brave New Work approach, which there’s sociocracy, holacracy, tons of different decision making frameworks, but in this one particularly six steps. The first is to propose. So if you identify attention, you propose a solution. That can look like a memo, it can look like a document, can look like a few paragraphs with suggestions, and you pose that to a group. In our world, in our memo database, we have the consulted field. What that means, that’s a specific invitation for people to provide advice, and you are seeking out their advice by consulting them, but it’s not veto power. It’s just inviting input.


The next two steps are clarify and react, and these are distinct steps, and I think that’s an interesting kind of difference in this process. On the clarify step, you’re inviting questions and understanding, and people can ask questions and probe on the proposal as you’ve written it, but they’re not yet providing suggestions. So this is really a chance for back and forth to make sure the wording is correct, to understand what you are trying to say. As someone participating in the process by giving input, this is where you ask questions and try to better understand what they’re getting after.


From there, there’s inviting suggestions for improvement. So after you understand what’s going on, you can as a participant give input on what might make it better or improve it. The owner then takes all of that, adjusts, edits, clarifies, changes language based on people’s understanding, based on the suggestions, and chooses, has the decision making responsibility and power to choose what to adjust and not. That’s an important piece.


The next part here is consent, and this is where some definition is really important. Consent is an opportunity to voice objections. Objections are reasons that this would be unsafe to try or cause irreparable damage. So the important detail here is that you can only object if this is not safe to try, if this will cause damage. This graphic on the right has your personal preference, that’s kind of what you wish to happen. There’s a range of tolerance, which things you’re okay with, you don’t prefer them, but it’s okay. Finally, objection, this wouldn’t be safe to try. It’s getting comfortable with that definition, that decisions are going to be made where not everyone’s in full agreement, there’s not consensus, but it’s good enough, and that’s the part that’s important here to make clear. If you’re objecting on grounds, it can’t just be a simple veto, you have to make it safe enough to try. That’s where it gets into the integration piece and has enough integration where it’s safe enough to try and you can achieve consent and move forward, and the decision maker makes that clear and publishes it and moves on.


So there’s a very clear framework for decision making and very clear steps to run it through that. We don’t necessarily follow all of these, but I think some of the definitions around range of tolerance are really helpful and that that’s really what I wanted to highlight. This goes for anyone making any decision, identifying any tension. So obviously DRIs have their area of responsibility that makes the most sense, but if you identify a tension and want to propose a solution, it’s fair game within our culture to do that and here’s a good framework to use.

Josh (20:25):

Awesome, thank you, Miz. A lot of the stuff we’re driving from the leadership book club and what we’re learning from other organizations, so I highly recommend checking out those recordings and joining the book club to get a really detailed breakdown. This is an awesome summary of how decision making can work in one framework, but I highly recommend the deeper dive that these books provide. Thanks, Miz. Okay, main thing, Levels shows you how food affects your health. No changes here, continuing to drive towards it. With that, we have Maz.

Maz (21:04):

Hi everyone, quick update on company objectives. Again, as a reminder, the three objectives are member retention, improving members’ health, and member acquisition. Update on the key initiatives, US Liftoff, very excited for this and thanks to JM, Chris, Scott, and the team to really working through the last things and dealing and working through a number of curveballs. So big thanks to them, I’m really excited for this and they’ve really been knocking the ball out of the park, so thanks to the team.


On the Core Metabolic Health product, we’ve made a lot of progress and have been working with design, product science, data science, and content to really pull a product together that can help improve people’s health. So really good collaboration and putting a system together and really building muscle to actually use all these functions to deliver a product that can improve people’s health. There’s also a lot of work going on into Now 2.0 and the new scoring, which I will provide an update in the async part of this Friday Forum.


On UK Liftoff, we are scrubbing what it actually takes to deliver and enable UK and also what it will take to actually have a good experience in the UK. We’re going to scrub that and figure out resourcing on what it actually takes to get this to be a successful product.


In addition to the key initiatives, which have been going well and I’m really excited for, following the setting of company objectives I’ve been working with a few folks, including JM and Ben, to really set the functional OKRs. These are really the problems, the big problems that the teams are thinking about to solve. These are not in digital tasks, these are not responsibilities, but these are really the big things that we need to solve as each function to make the company successful and go to default live.


So this is a list that I’ll be working with each of the functional heads. Ben was kind to be the first, and so we’re going to work through this. So expect to hear from me in the next couple of weeks to really work on each of the functional objectives and what are the big problems that we’re thinking about, so in the end we’re all pulling in the same direction and solving the biggest problem that will get us to where we need to go. That is all for this week, thanks very much. See you guys next week. Bye.

Josh (23:32):

Thank you Maz. All right, Experimentation and Learning, which I believe this week is Brett.

Brett (23:45):

Sorry, I couldn’t find the mute button. That was a panic. Hi, everybody. Yeah, so learnings, I spend a good number of weeks both prototyping and we’ve reviewed this, but feel free to check it out, it’s in the Map, which is a giant file that shows kind of everything, but logging and scoring were two things that, with a ton of help from Mike D, who is insanely talented at wrangling people, far more than myself who had to do it for myself for a long time, so shout out to Mike D for being really a champ and getting really key people, almost too good. I’m curious as to how he did it.


Anyhow, I got to talk to… I think this will be easier if I share my screen, give me a second. I got to talk to a lot of really interesting people. Demographic-wise, it did skew towards… Am I sharing? I’m not sharing yet. It skewed toward women, I’d say 30 to as far as I think we talked to somebody who was like 71. It was awesome. It was really fun, it’s a really fun task. I like talking to people, especially the members. Sans two people, they were all really positive about Levels and their Levels experience. I got quotes like, “This is changing my life, this is improving my health stuff,” that I was really trying to get logging answers, but I ended up finding… Of course, when you go looking for one thing, you find a bunch of another. So if you want to follow along, the mocks aren’t up-to-date in this, but awesome logging is the objective and the notion doc that just generally talks about what the goals of the project are and what we’re trying to abstract here.


I’m just going to kind of read through this at a high level really quick for the key things, and I’ll talk a little bit more about them in depth after. But basically, people really described Bite integration, they basically described it without saying Bite. They’re like, “It’d be great if you could give me nutritional, it’d be great if I could do this, it’d be great”… Then a few people would say, “I think that the computer knows that I need to do this.” They basically alluded to ML and alluded to some of the ideas that were there without saying it.


It was clear that logging, for a bunch of habit-forming reasons, needed to be really light and easy if you wanted it to be, but then people also wanted depth. Some people wanted to describe very specifically what they were doing, but they were also asking for features that came inside of Bite automatically. It’s great, with full bite integration we’re getting that depth of use case without making people do more work to get to it, so that was pretty awesome. Some people log dancing and drinking each dance session and each drink, which I was like, that’s not how I think of logging, but it was fun to hear that we had somebody doing that.


It was interesting that almost ubiquitously people saw themselves as being good users or being good Levels or bad Levels. So they were like, “Oh, I was being really good because I had my sensor on.” So there’s this concept that kind of arose without people talking about it of this feeling of being watched and this feeling of being observed by the monitor and then also this feeling of wanting to hide from it occasionally. So that was really interesting, people wanted to turn off the data while they did something bad, which I don’t know how to support or correct for, but it was funny to them in the meetings, but it also kind of seemed like it alluded to some kind of anxiety. So wondering if there’s something we do in settings where we just say, “Don’t look right now.”


People wanted to keep their numbers in a certain place, so they just wanted to not be seen, and we don’t really have that option without taking it off. So I don’t know, I didn’t really come to any great solutions for it yet, but it was an interesting emergent property that kept coming up. Sam’s cousin described it specifically. She’s like, “I want a button that says don’t look, and let me go eat something wild and then let me come back.” So we either need to let people know to celebrate trying new things or trying these things because they will gain more information and it’s okay to not do great for a day or change the scoring mechanism or turnoff score for this time. There’s a lot to be thought out there. It was a interesting emergent point.


The sliders everybody really liked. So if you look, before Casey says anything, we took carbiness out of the sliders in later experiments, but we made this slider for size and carbiness, which was just this kind of funny way of just saying, “What did you do here?” Everybody seemed to get it when there’s a hover state and they kind of all made assumptions that were pretty accurate about how we would do that, so that was really interesting. I also just got lots of… We got giggles. It got people to giggle. So when the animation goes off at the end and it’s like, “Woo,” and there’s a little guy that dances or there’s a particle explosion, there’s highlights in the video interviews where it happens, so you can either hear a giggle or see a giggle, which getting people to laugh is my ultimate goal. Getting a smile out of somebody is I think one of the most powerful things you can do as a designer in bringing people back, so I was really happy about that.


We had some people who, because the photos didn’t give them information, kind of lost trust. They were like, “Oh, I stopped taking the photos because it didn’t give me anything.” So that was, again, more evidence around Bite integration being powerful. Everybody that I talked to it for scoring and for logging loves the score. Now, they don’t always score well, I thought that they were all going to be people who scored 70s and 90s, but they weren’t. They were people who kind of just seemed to it. My intuition that would be if somebody got a 50 or a 60 and it was the orange and stuff, but they were just kind of like, yeah, they knew why they did it. They knew why it happened. They’re like, “Yeah, I ate a pizza and then I went for donuts and I got a 50.” They kind of had made peace with it.


One big flag case, which I want to point out here while I have a lot of attention, I don’t get to talk to everybody often, is that Sam’s cousin especially switched sensors and the new sensor she was behaving, or let’s call it adherence for fun, she was adherent to our protocols like Sam’s family sister level. So she was on it, she’s like an athlete, you can watch the interviews and scoring. She’s a very healthy, fit person and she was pissed and she stopped using it because tied a sense of identity to the score and she worked harder and then the scoring didn’t feel fair.


As soon as you play a game, if you guys ever want to dork out on Game theory, just drop me a one-on-one and we can go to the moon, but it’s not a game if you don’t agree to the rules and it’s not a game if it’s not fair. So we’re playing a game with when we put in a score. When we abstract the score, if we don’t play the game fairly, then that’s an obvious reason to leave a game. So just wanted to point that out.


We talked a little bit with different people that where I can pull strings to talk about how we can maybe calibrate between two sensors. Finding a way to bridge those two things I think would be greatly beneficial, because if we have people going censor to censor and they feel like they’re doing better, and they’re playing a game and they’re not playing fair, that’s on us. We can’t really put that back on them in any way.


So what else? There’s lots of “loves us” in here, that felt great. It’s really awesome to talk to users who are just really happy and really enjoying their experience. We had two bad ones, just to balance out this feedback, and they were people who one didn’t feel like they got any kind of guidance. So the Now project was obviously not released into any of their things, so they were regular users. We refunded both these people. They were really happy and they offered to come back and give more feedback. The other one was just like, “I know sugar, I know when I eat carbs it’s going to go up and sugar’s going to go up. What else do you have for me?” Which is similar to not saying what’s not the Now but didn’t abstract a lot of individual value. So it was learning points for all of them.


Scoring is in here as well, do just to go across scoring… I don’t think this is me. Is that my doc? This is not my doc. I can pull up scoring, but yeah, same high level stuff. Tons of learning around, again, back how people tie their identity to the score. Tons of learning around how people want to be scored, I can go into that another time. But yeah, just high level on experiments and research. It went really well, learned a ton, made tons of changes from both feedback from the team, which was really awesome, Casey and Maz dug in with me, and then also these individual users. So I think scoring is in a pretty rad place and that’s all for me.

Josh (33:56):

Awesome, let me jump back in with my share screen here. Cool, very insightful. Appreciate that, Brett, and I can’t help but think that this focus on the new score strategy, or at least experimenting with the spike and variability approach as opposed to a number score that people are always trying to optimize, which there are things that are outside of our control, like censor to censor calibration, we’ll learn a lot inevitably about these things. Super cool, thank you Brett.


All right, jumping to hiring updates. So happy to announce that Jason Shu is going to be joining us on June 6th, which is right around the corner. Had a really awesome chat with Jason, very excited to have him joining the team. It’s going to be just another force multiplier, as I like to say, so get ready. Then open roles, we still have the three roles here, software engineer is perennially open, visual designer, and support associate. Continuing to look for great people, so if you are or are aware of someone who would be a great fit for the Levels culture, please send them over to Levels.link/careers or shoot us a cold email. Okay, Casey’s metabolic Pearl of the Week.

Casey (35:12):

Hello team, happy Friday. Here’s your Metabolic Pearl today, which is on recent research on women and cardiometabolic disease and how the risk for cardiometabolic disease differs between men and women. Just to circle back on the intent of these Metabolic Pearls, the purpose of this is to surface really table stakes metabolic health education for the team and also to surface some really interesting new research that’s coming out that may have interesting implications for our members.


So jumping right in, some pretty crazy and sobering stats about heart disease in women. First of all, half of the women in developed countries will die of mostly preventable heart disease or stroke as their cause of death in their lifetime. Half of women in developed countries. One woman dies at cardiovascular disease every 80 seconds in the United States. Women actually experience higher cardiovascular mortality compared with men, even though the common assumption is that men fare worse from cardiovascular disease.


There are also dozens of risk factors that affect women exclusively, like things like hormonal factors and some traditional risk factors that affect women differently than they affect men. I’ll go into those in the next slide. Women also account for two-thirds of all cases of Alzheimer’s disease and it’s thought that maybe some of the gender differences between men and women with Alzheimer’s dementia is in fact due to these underlying poor cardiometabolic factors in women. This statistic is crazy to me, less than half of doctors think that heart disease is a top concern for women, even though it is the top concern, it’s the top killer for women in the United States, and less than half of women know these facts.


So why are there differential risk factors for both men and women in terms of heart disease? So first of all, women have smaller coronary arteries than men on average, and these are the arteries that supply the heart with blood, and so they may be more susceptible to obstruction just by sheer size. Women also have 50% higher risk of insomnia, and we know that sleep deprivation is a big problem for metabolism via its impact on so many hormones. Women also have a higher lifetime prevalence of anxiety and depression, which can lead to psychosocial stress that contributes to poor metabolic health. At menopause, women lose the protective effects of estrogen on their metabolic health. After menopause, that is when women just have this stark increase in rates of obesity, diabetes, heart disease, stroke, Alzheimer’s, dementia, when they lose that estrogenic effect.


Pregnancy is also a risk factor for cardiometabolic disease. Lots of physiology changes in pregnancy and it can be the onset of things like high blood pressure or gestational diabetes, which then increases risk for diabetes down the road. Oral contraceptive use is a risk factor and in some studies has been shown to increase the risk of acute heart attack by approximately fivefold, this is particularly in women who already have cardiovascular risk factors like high blood pressure and smoking.


Women tend to have higher rates of trauma and adverse childhood events that can predispose to metabolic dysfunction. In terms of environmental toxins, this one was quite interesting to me, women can have adverse effects of environmental toxins, things like mercury and others, at lower concentration, so it can affect them at lower doses. These things can affect mitochondrial function, and we talked about this a lot in our obesogens Metabolic Pearl.


Another interesting one, more antibiotic prescriptions go to women than men, which can impact microbiome, which can directly impact metabolic health. Lastly, women have different symptoms of heart disease compared to men, and so they sometimes don’t get picked up as early, and women have more non-specific symptoms. They don’t have as much that crushing chest pain and left arm pain of a heart attack, it’ll present sometimes with just more subtle signs like nausea or shortness of breath or fatigue or fainting or a sense of impending doom, rather than those really overt symptoms.


The paper talked about some interesting facts about blood sugar, which is that women show adverse effects of elevated fasting glucose at lower thresholds than men and coronary artery disease risk increases substantially in women with fasting glucose greater than or equal to 110, whereas that curve goes up at a sharp rate, a little higher in men, in terms of fasting glucose. Dr. Gottfried suggests that this lower cutoff should be considered carefully in female patients.


So what do we do about all this? Well, it’s hard to see this graphic in detail, but this is a matrix that some precision medicine or functional medicine doctors will use to try and really understand the full picture of what’s going on with a patient with cardiometabolic disease, or really any symptom or disease you can use a matrix like this. Really the gist here is understanding that what’s going on for each patient is hugely multidimensional and all aspects of diet, lifestyle, history, and biology and genetics must be taken into account to really be able to treat a specific patient properly. There’s really no one size fits all approach for everyone because there are so many different vectors that go into increasing metabolic risk, and of course then for ameliorating it.


So you can see on this matrix it talks about a lot of things we talk about a lot like sleep, exercise, movement, nutrition, stress, various cardiometabolic biomarkers, other risk factors like smoking and stress. I think we already got stress. But really, it’s just important to remember how multidimensional this is and there’s really not a silver bullet. There are things that have been studied that do potentially have benefit for by and large, and so these are things like the Mediterranean diet. There have been studies on Mediterranean diet in women and metabolic health improvements, and this is focusing on whole, unrefined foods and lots of plant polyphenols. Additionally, microbiome manipulation, so increasing prebiotic fiber-rich foods, and then some research on targeted probiotic strains like Akkermansia that can help with cardiometabolic health, sleep and mental health optimization, optimized physical activity, making sure people are getting enough physical activity, blood sugar and insulin control, avoidance of environmental toxins, and then for women, possibly bioidentical hormone therapy after menopause.


So there’s a lot more to it, but that’s kind of a broad overview of some of the differential risk factors women have for cardiometabolic disease and a framework here for thinking about how to assess it and potentially reverse it.

Josh (40:33):

Amazing. Thank you, Casey, and thank you Dr. Gottfried, our amazing advisor really. I’m sure some stuff that we should share more widely than just this group, but I love these Metabolic Pearls. Oops, let’s not play that again.

Casey (40:50):

Hello team, happy Friday. Here’s your-

Josh (40:53):

Okay, individual contributions, we made it. I’m going to stop the share, pop open the participants list, and this week we’re going from the top. All right, so that means I start. Let’s see, this week, couldn’t be more excited about the IRB Liftoff and some of the background stuff that comes with that, which I’ve been looking forward to for many years. We all know what details I’m referring to, but overall, this is just such a huge project that is just so cool to see it going live. Appreciate all the work that’s going into it and continuing to follow along with amazement. On the personal side, not much to report on. I’m looking forward to kind of a catch-up weekend this week. Memorial Day was a really nice one, got to explore Austin a bit, and just going to hang back this week. Ben?

Ben (41:52):

Professionally, super stoked on the newsletter, Dr. Casey’s Kitchen. It was one of those things where I was reading all the words and just trying to memorize everything, so love that. Always a pleasure getting the opportunity to record with Rob too, so that was very cool this week. Then personally, shout out to Cameron Haynes for his new book, Endure, it’s very good for anyone who likes him. That’s it.

Josh (42:17):

Nice, I think I have that on back order. Alan?

Alan (42:26):

Hey folks. So work-wise, excited to see the spike stuff coming together. We’re kind of all converging towards kind of an interesting place in terms of the behavior change work. I’m feeling pretty optimistic about a bunch of changes on deck. Personal, I’m going to start running again. Took a break after the half-marathon. I’m not looking forward to it because everyone knows running sucks, but I’ll be back at it anyway.

Josh (42:53):

Good luck, man. I’m hoping to do the same at some point. Hopefully you’ll inspire me. Azure?

Azure (43:01):

Hey guys. Alan, you should post on Strava and we’ll get excited for you. I like this Friday Forum a lot. I’m super excited about the IRB, the scoring stuff is kind of crazy and cool, that was my style of Metabolic Pearl. Then personally, I’m going to go fly to Europe this weekend and I’m flying to San Diego tonight, so I’m excited for everything right now.

Josh (43:28):

Sounds amazing. Brett?

Brett (43:33):

So yeah, I’ve been coming out of the scoring framework weeds, jungle, Amazon, whatever, coming out of it and it’s fun. It was a journey. I reread books, white papers, too many white papers. I’m never opening PubMed again. But it was really fun, it was nice to go deep. I really miss just kind of moving pixels a little bit, so I talked with Alan already, I’m kind of going to take maybe an icon project next and just let my brain ramp down. Well, I mean not immediately, but sooner than later. Personally, I’m actually in the Bay for the first time in a long time, doctor’s appointments kind of back to back to back, but for the next four hours I get to kind of go to my old favorite restaurants and see town a little bit and see what’s changed before I head back up to Tahoe. Yeah, it’s fun, life’s great.

Josh (44:35):

Coming down out of the mountains.

Brett (44:37):


Josh (44:38):


Chris (44:40):

On the Levels front, definitely excited about Liftoff as every day is a challenge. Then also the scoring 2.0, some of the visuals that Alan and team are working on I really think are going to make it much more transparent and easy for our members to understand and grasp because it’s a big area of frustration people get. They don’t understand, so the more that we can simplify it, I think it’s really going to resonate with our members, so I really appreciate all the work there. On the personal side, I’ve got the dump trailer charged and plan to move about 20,000 pounds of dirt this weekend. I’ll be out playing in the tractor like a little kid with my Tonka toys, so looking forward to that.

Brett (45:21):

So jealous.

Josh (45:24):


Hui (45:28):

Yeah, work-wise, still onboarding, I guess, getting to know more people, more content, more of our coaching and more engineering stuff. One small thing I was doing yesterday, I always finally able to spin up the emulator and running our apps on my [inaudible 00:45:47] locally. Then I was looking at the code, this thing called Interact Onboarding, and then I couldn’t just find where on the app that is. Then suddenly I realized, oh, it’s on the home tab and it’s one of the cards. Then that moment I was like, wow, I finally connected the code to our app for the first time. Personal-wise, I’m going out next week, summer vacation starts in our family. Me, husband, and our son, we are going to Mexico, excited for that.

Josh (46:20):

That’s so fun, awesome. Love hearing about the onboarding stuff too. Jenn?

Jenn (46:26):

Work-wise, I’m really excited about the new scoring stuff. I can’t wait to see how that comes out and rolls out. Personally, vacation next week is whatever, it’s whatever, but my really big exciting thing is that I finally sat down, got over the fear of making my own mayonnaise. So I am free. I am known as Miss Mayonnaise in my family, so this is a big breakthrough for me, so that’s all

Josh (46:53):

I made mayonnaise once, I had a batch I had to throw away and then a batch that came out perfectly. Haven’t done it since. JM?

JM (47:01):

Maybe unsurprisingly, I’m very excited about Liftoff for all the reasons that have been said. In my world, I turned 40 this week, which was interesting. Last weekend I was away with the family and did some fun things. I can’t believe we’re lifting off, I can’t believe I’m that old, and that’s it. I mean that all in a very optimistic light, of course. Have a good-

Josh (47:28):

Hitting running PRs right before the forties.

JM (47:30):

Hitting running PRs right before the forties, that’s right, and in the forties, [inaudible 00:47:33].

Josh (47:33):

That’s where you want to be.

Taylor (47:33):

Levels going to make 40 the new 30.

Josh (47:37):

That’s right, Levels IS making it the new 30, roll back the aging. Lara, no pressure. If you’re still on the call and you’d like to share something personal, would love to hear from you.

Lara Hyde (47:46):

Yeah, well I think just kind of from the professional side, I’m just really excited to hear about all the developments going on IN Levels. I feel like there’s so many kind of little questions I had from that more science perspective that I see are being very actively addressed, so that is super cool to me. On the personal side, I’m just recovering from COVID rebound from Paxlovid, so feel fine, but I’m forced to stay at home. So yeah, just doing a bunch of projects around the house, I’m going to brew my first kombucha.

Josh (48:14):

Very nice, glad you’re feeling better. Maz?

Maz (48:17):

Hey guys, professionally, it’s been just really fun working with everybody on the scoring and Now page. Really enjoyed working with Alan and also really getting the data science and the science team involved, and Azure and Taylor and everybody, so it’s just been tremendously fun for me. Liftoff, obviously, it’s just a big highlight. On the personal front, I’m just going to spend some family time this weekend, so nothing crazy but should be fun.

Josh (48:47):

Nice. Miz?

Miz (48:50):

Yeah, on the personal side, I’ll throw a Liftoff out there as a generality, but I’m just excited to see what comes of it, excited for the shift change that all happen across functions. Otherwise, just a really calm professional week, which is great. I always enjoyed those. On the personal side, I’m more of a indie documentary fan, but I watched the original Top Gun for the first time and enjoyed all the cheesiness. Then seeing some movies, so Everything Everywhere All at Once, eh, but maybe the new Top Gun will be interesting. We’ll see.

Josh (49:19):

Got both of those on my agenda as well, possibly this weekend. Yes, I watched Top Gun through for the first time this past week. Mike D?

Mike D (49:33):

Never saw Top Gun? You were a rocket guy? Nevermind, sorry.

Josh (49:42):

Your audio’s not coming through great, Mike.

Mike D (49:45):

Hold on. Is this better?

Josh (49:50):

There we go.

Mike D (49:50):

All right.

Josh (49:51):

I think you dunked on me but nobody heard it, so sorry about that.

Mike D (49:53):

No, it’s all good. Yeah, Liftoff, the IRB. I know it’s a plus one, but it seems like it wasn’t that long ago that this was not even really plausible. So big shout out to the entire team, excited to see what that unlocks for the product and ultimately our members. Personally, I don’t know, not much. Try and keep it low key this weekend. I’ll plug the Cafe this afternoon, pretty pumped about that. Maz, you are correct, the AirPods are really not good for that long at all, at least in my case. That’s it.

Josh (50:39):

Yeah, I didn’t know they were disposable until after I bought them. Ryley?

Ryley (50:47):

Personally and professionally, I’m going to New York this weekend to spend a week there, so looking forward to putting my first points on the board for Levels and I guess being around the team while we do launch Liftoff and kind of get those first few weeks going. I am really excited for that.

Chris (51:03):

You’re on mute, Josh.

Miz (51:14):

You’re muted as can be, Josh.

Josh (51:17):

There we go. Rob?

Miz (51:17):

The AirPods.

Rob (51:20):

So number one, always fun to talk with Ben. Can’t wait to hear the outcome. Excited about Liftoff and can’t wait to see some data. Okay, that’s where the action is for me. Next week I will not be on the call, I will be at the Seattle Metabolic Health Symposium talking up Levels. The week after that I will be… Yeah, the week after that I’ll be at the University of Toronto for my daughter’s college graduation

Josh (51:51):

Packed schedule, enjoy it all.

Rob (51:53):

By the way, last week I turned 65, and I just want to let you all know, the only reason I feel 40 is because of all of you.

Josh (52:02):

That’s very kind of you. 25 years we’re knocking off, that’s amazing. Scott?

Scott (52:12):

Hi everybody. Oh man, work, we are heading toward Liftoff. It seems like every day something brand new pops up and it’s been really fun working with everybody to just handle it in real time. I kind of want to crush on the new developers, so Steven, Galit, Maxine, Ian. We got blessed with a brand new wave of people that are just very action forward, very put the team on their back. Especially around Liftoff, there were a couple times where we kind of needed somebody to just say, “I’m willing to pull a couple nights and weekends.” Although we don’t make it a point to sort of force that on people, to see it volunteered when it’s needed is really, really, really encouraging. So that’s been so awesome, so awesome for us as a team and to see just as a dev group as well.


On the work front, going to New York next week, which is going to be great, meet a bunch of people for the first time. Personally, it’s my five-year wedding anniversary today, so going to take it easy this weekend. We were pregnant with our first kid like two months after our wedding, and so we’re sort of just coming out of the early kid fog of having marriage time and so it’s going to be a good weekend of just hanging out with the wife.

Josh (53:23):

Very nice, congrats. Sonja?

Sonja (53:27):

So many things to be said about Levels-wise. Just to pick a new one that hasn’t been mentioned, I was really energized by the conversation that Casey had with former US Surgeon General Regina Benjamin this week. It’s just awesome to be able to have conversations like that and consider all of the other levers of influence that we can have to solve the metabolic health crisis. I’m really excited about some of those partnerships that we’re developing in the future, so that is my Levels one. Personally, it’s also going to be a chill weekend, kind of catching up from time off. But I had a blood lactate test, which was really fascinating and showed cardio improvement in my ability to buffer lactic acid, which is exciting because sometimes it’s hard to tell if you’re actually getting better when you do cardio, so the metrics were encouraging.

Josh (54:15):

Super cool, yeah, I need to do one of those someday. Sunny?

Sunny (54:21):

I’m still thrown by the fact that so many people haven’t seen Top Gun. I didn’t own a TV growing up. Nevertheless, it was a fun ride, go see it. Outside of that, I’m really excited that we are bringing on a new support associate here shortly. I get to work with Matt on the onboarding process. Basically, if you get training on my deck, I’m going to be very excited. So not only excited to work with a new person, but I also get to work on that onboarding process. Then Braden’s been so kind for the past five months dealing with all my questions, but we’re also getting into a little bit of like… Because I have questions that basically lead to SQL and I haven’t programmed in 25 years, so he’s very patient with me. We’ll dig into that slowly, but I’m excited for some personal development there. I’m doing some archery tonight. I used to be an archer, I haven’t done it again in about 15 years, heading back to the range tonight.

Josh (55:12):

That sounds fun. That’s awesome. Taylor, right at the buzzer,

Taylor (55:19):

Professionally, I mean we’re just firing on all cylinders. I’ll keep it short. There’s just so much going on, I don’t even know if I can say it all. It’s been fun, I’m glad everyone’s excited for the scoring. I’m trying to figure out exactly how we’re going to calculate those scores, so hopefully we’ll have more info on that next week. Then personally, we all got sick this week, so just recovering from that. I think Seattle has finally pushed into the summer, so I’m really excited for that. I’m excited to go to New York and hopefully go do some bridge jumping with Josh next week, should be fun.

Josh (55:52):

Come on down. All right, so async updates will be sent out separately. For those of you that didn’t see them yet, keep an eye out on that for Threads. Otherwise, awesome week. Thanks everybody for contributing. Welcome to the new folks. Lara, thanks for hanging out with us. Have a great weekend.