#106 Tracking Blood Sugar & Optimising Metabolism with Dr Casey Means
Dr. Casey Means is a Stanford-trained physician and the Chief Medical Officer and Co-founder of metabolic health company Levels. Her mission? To maximize human potential and reverse the current epidemic of preventable chronic disease. The solution lies in continuous glucose monitoring, which empowering individuals to make smart, personalized, and sustainable dietary and lifestyle choices using innovative technology. Dr. Means joined Vivien Allred on Hormones in Harmony to discuss metabolic health, the role of glucose, and Dr. Mean’s personal approach to glucose monitoring.
2:21 – Food is the foundation of health
Medical education has been slow to adapt, however research shows that lifestyle and diet make the difference between a healthy or dysfunctional body.
“There’s been a boom of nutrition research and I do think the onus is on physicians to really incorporate nutritional recommendations into their practice. This is really a lifeline that we can give to patients to help them, empower them to take control of their health. And certainly if a doctor’s not talking about nutrition in some way I think it’s probably you might need to find a new doctor. Nutrition is really – it’s the key. Food is the key substrate of our body. It’s also a signaling molecule that tells our body what to do. And so in every single health condition, the foundation of healing should really be based on what we’re putting in our body.”
7:58 – Metabolism is turning food into fuel
Good nutrition is providing the body with the proper fuel and metabolism is the process by which the fuel becomes energy. Good metabolic health is when you are effectively utilizing the fuel you are taking in.
“The metabolic piece is just so, so fascinating. We throw around the word metabolism in our common lexicon, but I think it’s really such a beautiful process. Every single cell in our body, we have trillions of cells, they all need energy to function. Without proper energy our cells just don’t really work, and when cells don’t work well, aren’t processing energy well, we get dysfunction. That’s when tissues start dysfunctioning and then symptoms and disease emerge, but fundamentally those cells need efficient energy production to work. And unfortunately, with our standard Western diet that we’re following it actually really does a lot to mess with these efficient metabolic processes that we have to make energy.”
12:20 – There are two fuel tanks: fat and glucose
The body is able to turn both fats and glucose into energy. However, increased consumption of sugar means the body relies on this more easily available energy, impacting our blood sugar and energy regulation.
“Normally we want to be able to bounce back and forth between using glucose or fat for energy. Glucose is a breakdown product of carbohydrates and then fats obviously come from fat in our diet. We get a little bit of energy from protein, but the vast majority is from fat and glucose. And in an optimal situation, our metabolism is using both of those substrates to generate energy. Unfortunately, because of our processed Western diet, we are eating astronomically more levels of carbohydrates than we ever have before. We’re eating these really easily digested, refined carbohydrates and sugars more than we’ve ever done in human history. It’s estimated that we’re eating 10 times more sugar per year than we did about a hundred years ago. So that’s a lot for our bodies to process. And what happens when we eat all that sugar and all that glucose and it gets into our bloodstream, is that it overwhelms the system and the cellular machinery.”
17:30 – With the right intervention, you can eat what you like
As you improve your metabolic health and understand how your body reacts to certain inputs and outputs, you have more freedom to eat what you like when putting the correct conditions in place.
“So I think that when people basically do interventions that move their body towards metabolic health and really build a healthy body that’s able to process carbs effectively and that is not being overloaded by these crazy refined foods, then I think you can get to a place where you can process fruit and starchy vegetables and whole grains in a way that is functional and that the body can handle. So I think as long as we’re really focusing on whole foods and really high quality types of carbohydrates – unrefined, unprocessed, organic – I think that the body should be able to handle those once it’s really been metabolically optimized.”
19:19 – Broccoli is better than M&Ms – not all carbs are created equal
It may seem obvious that broccoli is better for you than candy. It’s important to consider the variety and quality of nutrients in different foods, rather than just focus on macronutrients like carbohydrates.
“I think you have to step back and say, is a thousand calories of M&M’s going to do the same thing to the body as a thousand calories of broccoli?” There’s absolutely no way. They’re going to be vastly, vastly, different. Part of this is that whole foods are amazing…The foods often include lots of things in them that are helpful to the body. So in broccoli, for instance, which has carbohydrates in all the cell walls of this plant, it’s also got tons of fiber. And so that fiber is going to go into the body and the microbiome is going to process that fiber and turn it into short chain fatty acids, which are signaling molecules that our body absorbs that actually are anti-inflammatory and promote metabolic health. So that’s one thing, one point for the broccoli over the M&M’s, which have no fiber.”
28:44 – Each person has a different food tolerance
Unlike previously thought, there is no one size fits all approach to nutrition. Studies have shown that each body responds to glucose differently, and in different conditions.
“We typically have thought about glucose as like the glycemic index scale. So like, ‘Oh, we all will eat a slice of bread and that means your glucose is going to go up this much,’ and this is why it has a glycemic index of X. But what they actually found in this paper is that you could give a piece of bread to all these people and have completely different responses. Some people might have flat glucose, some people might have a 50 or 60 point glucose rise, and it’s like, how could this possibly be going on? It’s the same amount of carbohydrates. But there’s so much between the mouth and the bloodstream, and it’s very different for each person.So they then found what are the predictive factors that determine how you’ll respond.”
32:15 – Forget macros, it’s all about micros
Discussions around diet tend to focus on macronutrients. However, it is the micronutrients which enable the body to process food effectively. The best source of micronutrients is through whole foods and plants.
“We talk mostly about macronutrients in terms of metabolic health. We talk about fat and carbs and protein to some extent. But we really I think missed the boat on micronutrients. And for our metabolic processes to work properly, especially inside the mitochondria, we actually need dozens of vitamin and mineral co-factors to make these enzymes function. Some of the key ones are manganese, magnesium, zinc, vitamin C, vitamin D. There’s chromium, there’s many others, but they actually are like lock and key necessary for these cellular machines to work. And on a processed diet, you are just not going to get these co-factors in the levels that you need them. You have to be really…looking at your day and saying, Okay. I have, what? 1,500-2,000 calories worth of food that I’m going to eat today. How can I get the most out of that food to basically make my cellular machinery work? And to me, a very plant dense diet really got me a lot of that.”
41:28 – Live stream your health with CGMs
Previously, glucose monitoring involved taking a snapshot of glucose in a moment, many times a day. With CGMs, you get a constant, live stream of feedback on your blood glucose throughout the day.
“So you can imagine the finger prick is like a photograph of your glucose, and the CGM is like a movie of your glucose. So you are able to actually just see so much more with continuous glucose monitoring. You can imagine we’ve talked a lot about spikes after meals. With a finger prick it would be very hard to really ascertain the pattern of a spike after a meal. You could prick your finger 40 minutes or 60 minutes after a meal, but you don’t quite know if you’re catching your glucose on that upswing or at the peak or on the downswing. So you’d have to prick your finger many, many times after a meal to actually get what you can just get from wearing a continuous glucose monitor.”
46:23 – The optimal blood glucose range
Dr. Means suggests that the current measures for glucose in the medical community are too generous. The ideal range should be low with gentle peaks, rather than sharp rises and falls.
“So for me I try to stay between 70 and 110 for all day. So I try and never go above a value of 110 mg/dL. And yeah, I just really like to keep it in this low and gentle range and try to not get above 15 to 20 points after a meal. So if I eat and I’m starting at 80, I don’t really want to go about 100. So about a 15 to 20 point delta. To me, what that saying to my body is, ‘okay, you’ve got some carbs in there, you’ve got some glucose. Release a little bit of insulin. Take it up.’ But it’s not this massive insulin. I’m not asking my pancreas to go crazy and just dump insulin out.”
48:51 – Curb night-time sugar cravings for good sleep
We all know that getting a good night’s sleep is good for your health. However, research shows that your glucose and sleep go together. Eating high carb meals before bed leads to night time sugar crash.
“There’s a couple of reasons why glucose can go low at night. So one is that if we eat high carbohydrate meals late at night, so for instance eating dessert right before bed, we can get a glucose spike and then an insulin surge right before bedtime. That can send you on this bumpy glucose road throughout the night. Something that’s quite interesting about nighttime is that we’re actually more naturally insulin resistant at night. So because of melatonin being released to help us get tired at night. Melatonin makes us get sleepy. Melatonin also has an effect on insulin sensitivity. We are more sensitive to carbs when we eat them in the evening versus if we eat the same thing at noon. So you can imagine you’re eating this dessert, you’re going on this glucose roller coaster overnight, bouncing around, having trouble absorbing the glucose into the cells because you’re a little bit insulin resistant at night. That can just do tons to your sleep.”
55:45 – Forget carb-loading: fat-load for exercise endurance
Rather than reaching for a bowl of pasta before a big run, evidence shows that the body can adapt to using fat for fuel and that this can benefit physical fitness as well as metabolic fitness.
“I would also say it’s something that people can work towards. It’s like the first time you work out without having eaten anything beforehand, it’s probably going to feel terrible because your body’s not adapted to using fat for energy. And so I’ve tended to ease into that over months where each workout, my body’s learning a little bit more to tap into fat burning for energy. And then after doing this for months or more…It’s very second nature for the body. But these aren’t just like on/off switches, you have to develop the adaptive capabilities to do these things. And there’s been some really interesting research in low-carb endurance athletes like Iron Man athletes and marathoners who are on ketogenic, low carb diets. So they’re basically not eating really any carbs and they are doing these crazy endurance events. And you look at their blood during the training events and you can see that they’re actually burning completely different fuel than someone on a regular carb filled diet.”
1:05 – Stabilizing blood sugar is the key to a healthy life
Balanced blood sugar is shown to lead to balanced levels of energy, cognition, and mood, so tracking how you metabolise food is going to give you a more stable, happy, and healthy life.
“Controlling your blood sugar is the gateway to improving your life, and it’s easy and basically free. I would just really promote orienting diet around glucose control as something that you’re thinking about, because ultimately as we control our glucose, we improve our ability to make energy effectively in the body. And when we make energy effectively in the body, our lives are better. It’s really that simple.”
Vivien Allred: [00:00:00] Hello, and welcome to the Hormones in Harmony Podcast. I’m your host, Vivien Allred, Naturopathic Nutritional Therapist and hormone enthusiast. If you want to learn how to rebalance your female hormones, regulate your menstrual cycle and reclaim your vitality. Then you are in the right place. Each week I will be delving into different conditions, such as PCOS, endometriosis, infertility, hypothyroidism, acne, and hair loss. Stay tuned for interviews with expert guests, Q and A’s and solo episodes that are all intended to help you move from hormonal chaos to hormonal harmony.
If you’d like to submit a question for me to answer on the podcast, then you can email them to [email protected]. The information shared on this podcast is intended for educational purposes only and is not designed to replace the advice of your health practitioner. That said, let’s get into today’s episode.
Hi, everyone. Welcome back to the podcast. Today I’m joined by my guest, Casey Means, who is a medical doctor. She’s a Stanford trained physician, chief medical officer and co-founder of metabolic health company Levels. And she’s also an associate editor for the International Journal of Disease Reversal and Prevention. Her mission is to maximize human potential and reverse the epidemic of preventable chronic diseases by empowering individuals with tech enabled tools that inform, smart, personalized, and sustainable dietary and lifestyle choices. Dr. Mean’s perspective has been recently featured in Forbes, Entrepreneur Magazine, The Hill, Metabolism, Endocrine Today, Endocrine Web, Well + Good and Dr. Michael Greger’s video series (he is the author of “How Not To Die”). She is an award-winning biomedical researcher with past research positions at the NIH, Stanford School of Medicine and NYU.
So welcome, Casey, to the podcast.
Dr. Casey Means: [00:02:02] Thank you so much for having me.
Vivien Allred: [00:02:04] And I’m really interested in your journey with your career. So I’m guessing that Stanford was just like a pretty standard medical education. Did you have any education on nutrition and the importance of blood sugar regulation and those types of things?
Dr. Casey Means: [00:02:21] Yeah. So in medical school, really, the main focus of blood sugar really is for learning about diabetes, so Type 1 and Type 2 diabetes, so these conditions of metabolic dysfunction. I would say, you don’t learn too much in medical school about why glucose might matter for someone who doesn’t have diabetes and something that was so interesting to me is that there’s research suggesting that people actually show signs of metabolic dysfunction up to 13 years before they actually have a diagnosis of diabetes. The blood sugar actually is something that will elevate on the standard blood tests very late in this process. So I think there’s a huge opportunity for people to be aware of their metabolic health and above and beyond just single time point glucose measurements much, much earlier. The vast majority of cases of Type 2 diabetes are preventable. The research we have suggests that in women about 83% of all diabetes, Type 2 diabetes could be prevented through modifiable lifestyle and dietary changes. And so that’s a huge opportunity to really intervene earlier and to have people be more aware of their metabolic health before that time point when the glucose starts rising on these blood tests.
So that was really interesting to me and you asked about nutrition. So in terms of nutrition training in medical school. We really don’t get a lot. Medical students get on average around 10 hours of nutrition training in all of medical school. And this is very interesting because the vast majority of the illnesses we’re seeing in the hospital and the primary care clinic are chronic diseases that are related in some way to diet and lifestyle.
So diet is a huge lever that we should and can be pulling to help our patients reach their optimal health and so that 10 hours, I think, we’re going to start to see that probably going up more and more as we really understand how dietary interventions can prevent and even reverse chronic disease.
Vivien Allred: [00:04:23] Yeah, that’s crazy. So all of the people… A lot of my clients and listeners, they get really frustrated with the doctors. So they go in there asking about certain diets and how that could impact the hormonal imbalance and they get really frustrated. But I always have to remind them that they just don’t have the education. They’re not withholding information from you to try and harm you. They literally don’t know the effects of certain foods, good or bad. So I just throw that in and remind them that a lot of places have that 10 hours. Some places even less, I’ve heard.
Dr. Casey Means: [00:04:57] Yeah, absolutely. And there are some great resources out on the web. There’s nutritionfacts.org, which is a wonderful nonprofit website by Dr. Michael Greger and he says there’s over 500,000 published articles on PubMed that talk about nutrition and medicine and health. And that would be very, very hard for anyone to go through all of those and be able to incorporate that into their clinical practice, especially if the guidelines that they’re going off of don’t necessarily include dietary recommendations. This is really going out on your own and figuring it out. So something that he does at that website is really try and cull the information and distill it down. That’s always something that I recommend for my physician colleagues to check it out and just start learning about how much research actually has been done on nutrition. And it’s more than I think we are taught to believe, because we don’t get much training on it in medical school,
Vivien Allred: [00:05:51] And I believe that the resources and things are 20 to 30 years outdated when you’re in medical school. So that’s maybe part of it as well. Like all of this new research that’s coming out about gluten and leaky gut, it’s not going to be in the hands of physicians probably for another few decades. Do you feel like that’s true?
Dr. Casey Means: [00:06:11] I’ve heard that before and I’ve heard… One paper that I was looking at said that it’s on average about 17 years between when a research finding is discovered and when it makes it into clinical practice. And I think that there is a lag time for a reason. Doctors want to practice medicine that’s highly evidence-based and that there’s really strong, fairly unequivocal research that suggests that it’s going to have benefits that outweigh the harm. I think the delay is rooted in good intentions, which is that we want to really prove that things work before we do them and before we change our guidelines. But I do think there is an opportunity, especially now there’s been a boom of nutrition research and I do think the onus is on physicians to really incorporate nutritional recommendations into their practice. This is really a lifeline that we can give to patients to help them, empower them to take control of their health. And certainly if a doctor’s not talking about nutrition in some way I think it’s probably you might need to find a new doctor. Nutrition is really, it’s the key. Food is the key substrate of our body. It’s also a signaling molecule that tells our body what to do. And so in every single health condition, the foundation of healing should really be based on what we’re putting in our body.
Vivien Allred: [00:07:25] Totally agree. Food is information and the building blocks. Our body just doesn’t create things from nowhere. It’s based on the food that we’re eating. So in this episode, I want to talk all about blood sugar and metabolic health and insulin resistance. But I think we should start off by just giving a basic science overview as to what happens when food enters our body. With a meal what’s actually happening physiologically, because I don’t think people actually understand or know. They just think it goes in, something comes out the other end and we get some energy from it.
Dr. Casey Means: [00:07:58] Yeah. So digestion is an amazing and complex process that really brings in all sorts of organ systems in the body, from our brain to our nervous system, to our gut, to our endocrine system and all of our hormones, to our liver. It’s just, it’s such an amazing complex well orchestrated event that happens when we eat. And really one of the purposes of eating is to basically harness energy from our food into a form that we can actually use in our bodies. So we take in energetic substrates, like fat and carbohydrates and protein, but our cells can’t just use those macromolecules. They have to be converted into something that we can use, a currency that our body recognizes, things like ATP, and this is done through our metabolism. That’s what metabolism is, it’s that conversion process. So the food goes in, it’s broken down by our GI lining and also the microbiome, the bacteria in our gut, and then these smaller particles are absorbed into the bloodstream where they then can be stored or can be used to generate energy.
The metabolic piece is just so, so fascinating. We throw around the word metabolism in our common lexicon, but I think it’s really such a beautiful process. Every single cell in our body, we have trillions of cells, they all need energy to function. Without proper energy our cells just don’t really work, and when cells don’t work well, aren’t processing energy well, we get dysfunction. That’s when tissues start dysfunctioning and then symptoms and disease emerge, but fundamentally those cells need efficient energy production to work. And unfortunately, with our standard Western diet that we’re following it actually really does a lot to mess with these efficient metabolic processes that we have to make energy.
So normally we want to be able to bounce back and forth between using glucose or fat for energy. Glucose is a breakdown product of carbohydrates and then fats obviously come from fat in our diet. We get a little bit of energy from protein, but the vast majority is from fat and glucose and in an optimal situation, our metabolism is using both of those substrates to generate energy. Unfortunately, because of our processed Western diet, we are eating astronomically more levels of carbohydrates than we ever have before. We’re eating these really easily digested, refined carbohydrates and sugars more than we’ve ever done in human history. It’s estimated that we’re eating a hundred times more sugar per year than we did. I’m sorry, 10 times more sugar per year than we did about a hundred years ago. So that’s a lot for our bodies to process and what happens when we eat all that sugar and all that glucose and it gets into our bloodstream, is that it overwhelms the system and the cellular machinery, the mitochondria, that takes sugar and turn them into energy, they get overwhelmed and they get dysfunctional.
And the second thing that happens is it affects our hormonal system. We have to secrete insulin every time we take in that sugar and those carbohydrates, because insulin is required to get that glucose into the cells. And when we overload that system, the insulin is just having to be spewed out at these super high levels. And over time, our body actually gets numbed to that insulin. It’s seen way too much of it in these super normal amounts and we become insulin resistant to protect ourselves from all this glucose that’s trying to be shoved in. And so that’s a big problem for a number of reasons. We ended up having high insulin levels in our blood at baseline because we are resistant to it, so our pancreas actually has to overcompensate, make more insulin to just get the glucose into the cells, these resistant cells.
And then the other thing it does is it blocks fat from being burned. So insulin is a signal to the body that, “Hey, we’ve got tons of glucose around. We don’t need fat for energy. We’ve got this other energy source in huge supply.” And so it’s a break on fat burning. And the problem with that of course, is that one, our bodies are naturally designed to burn both fat and glucose. And so by blocking fat, you’re taking away this key process in the body.
The second thing is that it means that you’re probably going to have difficulty losing weight or maintaining a healthy body weight because you’re storing all this fat and not burning it. And in the US we have 72% of Americans are overweight or obese, and you can see how this really links back to sugar, because sugar is the thing that’s causing the hormonal response, the insulin response that is then blocking the fat from being burned and promoting fat storage. So really our modern industrialized, highly processed diets have just taken over this most basic fundamental process of producing energy in the body. And you can see how if that process is screwed up it could generate symptoms all over the body because every cell in the body needs energy to function. So where that process is showing up in the body is where you’re going to see symptoms. If it’s happening in the brain, where we have insulin resistance and difficulty with energy production, that could look like any number of brain symptoms, it could look like Alzheimer’s, depression, anxiety, chronic pain, fibromyalgia, fatigue. Those are all conditions associated with blood sugar dysregulation. If it’s happening in the ovary, it could look like polycystic ovarian syndrome, which is essentially insulin resistance of the ovaries. That’s the leading cause of infertility. If it’s happening in the liver, it could look like fatty liver disease.
So it’s just amazing all the different faces of metabolic dysfunction, blood sugar dysregulation and it really comes down to the fact that this is such a core evolutionarily conserved, fundamental pathway in the body that we’re unfortunately co-opting with our diets.
Vivien Allred: [00:13:27] And each of those conditions that you just mentioned with PCOS, that’s the infertility, but then there’s also the period problems and the hirsutism and the acne that come as a result of that.
So rather than just trying to treat the symptoms, and I described this as being like the leaves of a tree, rather than just trying to tweak those you need to get to the root of the problem. And I think you agree about insulin resistance, blood sugar imbalances as the key root cause thing. Rather than just tweaking the estrogen and the progesterone, you need to actually find out why the imbalance in the first place.
Dr. Casey Means: [00:13:58] Yeah. I think it’s such a great point and especially with polycystic ovarian syndrome, PCOS. So like you mentioned it’s a cause of infertility because of hormonal imbalances, but also has all these other symptoms related to excess of male hormones, androgens like testosterone and you can see acne, hirsutism, which is excess hair growth, visceral abdominal obesity all of which are associated with high testosterone. And when you really think back to the physiology, what’s happening is that insulin levels are elevated in the blood because their body is insulin resistant, and that insulin, actually there’s receptors for insulin on ovarian Theca cells. And so the Theca cells, when they’re stimulated by insulin actually produce male hormones. Also insulin drives the ovaries to make more Theca cells. So you’re actually just stimulating this other hormone that is causing both the menstrual irregularities, these other symptoms like acne and hair growth, and then as well as downstream leading to infertility. So you could say, “Oh we’ll just throw more female hormones on this – estrogen, progesterone, birth control pills, etc., oral hormones and we could treat the acne with doxycycline, or tretinoin, antibiotics or topicals or things like that. But when you think about the root cause and how that insulin is really driving the problem, you step back and say, “Whoa, what if we just change the diet to become more insulin sensitive again, a diet and a lifestyle that… We very much know how to lower insulin in the body. You have to focus on not getting those glucose spikes, which means not getting the insulin spikes, and over time, you’ll regain that insulin sensitivity. Of course, exercise and good sleep and stress management and a diet rich in micronutrients, all these things are also going to support bringing the glucose and the insulin levels down. But there’s been great research in the PCOS field showing that low-glycemic diets and ketogenic diets actually are very effective for women in normalizing their hormone levels and reducing symptoms. And so there is, I think, a lot of hope in the nutritional area. But from speaking to many of my friends in the OB-GYN community, many are not aware of these dietary intervention studies that have been done and are certainly not practicing nutritional therapy on PCOS patients by and large.
But yeah, this year 2020 very great study, looking at ketogenic diet and PCOS with just very unequivocal results showing improvement in metabolic parameters and hormones. That was a 12-week study with an average 20 pound weight loss on this ketogenic diet. One thing I really loved about that particular study is that they did what I would call a very healthy ketogenic diet. They called it a Mediterranean keto diet. They focused on really quality fat sources and it was low carb, but the carbs they did include were very healthy nutrient rich vegetables and low-glycemic fruits and things like that. So it was a really well done study.
Vivien Allred: [00:16:46] Do you actually see those types of dietary interventions dealing with the root of the problem actually addressing the inability to burn glucose and address insulin resistance? Or are they just a band-aid, like you’re removing the problem? But what would happen if you added those carbs back in, will that person still be metabolically unfit?
Dr. Casey Means: [00:17:05] You’re saying that after that intervention, if they then added carbs back in what…?
Vivien Allred: [00:17:10] Yeah.
Dr. Casey Means: [00:17:10] Yeah. That’s a good question and honestly, there’s not research that I know of that’s like a crossover study where after the intervention they bring the carbs back in. I think there are two things here. With our standard diet, we say, ” it’s a high carb diet.” But it’s not just that our standard Western diet now is high carb. It’s that it’s monumentally, overloading the body in a super physiologic way with its refined carbohydrates and sugars that we just… I mean, there’s no way our body can process all those carbs. So it’s not like carbs are a problem for the body. It’s that these frankenfoods that are just not real food are astronomically higher levels than our body can process.
So I think that when people basically do interventions that move their body towards metabolic health and really build a healthy body that’s able to process carbs effectively and that is not being overloaded by these crazy refined foods, then I think you can get to a place where you can process fruit and starchy vegetables and whole grains in a way that is functional and that the body can handle. So I think as long as we’re really focusing on whole foods and really high quality types of carbohydrates, unrefined, unprocessed, organic, I think that the body should be able to handle those once it’s really been metabolically optimized.
But I can’t say for sure, given that I don’t think that research has been done, but I do think really anyone should be able to expect to process healthy whole food carbs in a way that’s not going to be detrimental to the body. But that takes work to move in that direction when we’ve been, maybe had years or decades with these other foods that can be very damaging.
Vivien Allred: [00:18:49] Yeah. Because those are the people… I don’t know if you’ve heard of the, If It Fits Your Macros. That was a big trend awhile ago and they were just like, “A carb is a carb, a sugar is a sugar. I need to reach 40% of my daily intake from carbohydrates. So I’m going to get it from M&M’s. It doesn’t matter where it’s coming from.”
So what would you say…? Because obviously when whole wheat bread breaks down in the body, it turns to glucose. What’s the difference between that and processed refined sugar?
Dr. Casey Means: [00:19:19] Yeah. I think you have to step back and say, Is a thousand calories of M&M’s going to do the same thing to the body as a thousand calories of broccoli?” There’s absolutely no way. They’re going to be vastly, vastly, different. Part of this is that whole foods are amazing in that they… The foods often include lots of things in them that are helpful to the body. So in broccoli, for instance, which has carbohydrates in all the cell walls of this plant, it’s also got tons of fiber. And so that fiber is going to go into the body and the microbiome is going to process that fiber and turn it into short chain fatty acids, which are signaling molecules that our body absorbs that actually are anti-inflammatory and promote metabolic health. So that’s one thing, one point for the broccoli over the M&M’s, which have no fiber.
The second thing is that broccoli is going to be filled with antioxidants and we know that in metabolic processes, like in the mitochondria, when we produce energy, we make free radicals or reactive oxygen species. And antioxidants basically are our compounds that come in and quench those free radicals. They neutralize them. So some of that metabolic damage that happens through our energy producing processes, the plant actually has the stuff in it to basically alleviate that stress that happens in the body. So that’s two points to the broccoli over the M&M’s.
The third thing. Is that these plants have genetic activators in them that are really important for health. So cruciferous vegetables like broccoli have isothiocyanate compounds like sulforaphane in them that are going to be activators of numerous genes. Things like Nrf2, which is a gene that promotes longevity and promotes production of proteins that are antioxidants as well and that are going to help with some of the cellular stress. And so in that food, you’re not only getting, you’re getting carbohydrates, but you’re getting all this other stuff in there that is protective for the body and that helps the mitochondria. When you’re just eating that load of M&M’s and refined sugar, you’re basically just getting that sugar alone and it’s just going straight into the body with nothing protective.
Yeah. So I focus very much on whole foods and thinking about this is not just about the substrate, it’s not just about sugar or carbohydrates, it’s about building, giving the body the things it needs to build a well-functioning metabolic system. And the whole metabolic system, it’s not just about glucose. It’s about mitochondria. It’s about hormonal health. It’s about the microbiome. It’s all these other things that play into it. And so you have to support that with food, with whole food.
Vivien Allred: [00:21:53] And I definitely do want to talk more about some lifestyle things and more dietary strategies. But a lot of people have questions around fructose, because we hear that is a contributor to fatty liver and insulin resistance and diabetes. So again, how does that differ from fructose in fruit or is that the same thing? Can we overdo that and run into problems?
Dr. Casey Means: [00:22:16] Yeah. I think we can overdo fructose and fruit. I think a lot of the fruit that we’re seeing today has been bred to basically be hyperpalatable to the human palette. So if you look at an old, an ancient heritage apple, these are going to be a fraction of the size of a normal apple and going to have a fraction of the amount of fructose that our fruit has now. So you go to the stores, these huge apples, and these things might have 50 grams of sugar in an apple. They’re basically sugar bombs. And so yes, it’s fruit. Yes. It’s going to have some antioxidants and maybe a little bit of fiber, but it’s certainly not the same food that we were evolved to eat. So I would really encourage people to focus on foods that are local, non-GMO, organic, that look more like fruit used to look smaller, less sweet. I tend to focus on unripe fruit. So I’ll eat unripe pears, an unripe banana that is more like the texture of a plantain. This is going to have more fiber that hasn’t been broken down into sugar, and focus on servings too, smaller servings and something that certainly I do. I wear a continuous glucose monitor, of course, too. This is what my company Levels does is we provide access to continuous glucose monitors for individuals who want to personalize their diet. It’s pretty fascinating to eat a piece of fruit, a big juicy apple and see what happens to your glucose. And I’ve had fruit from Whole Foods, a very healthy grocery store, spiked my glucose up to pre-diabetic levels before when I just eat it by itself versus eating other types of fruits where it might be a much more gentle response. So for me really choosing the foods that work for my body and don’t spike my glucose is really important.
And the second thing is fruit is essentially what I would call naked carbohydrates. It’s no protein, no fat, and honestly, very little fiber. People say fruit has fiber, but most fruit has less than five grams of fiber. So it’s not a ton. And fat protein and fiber all buffer a glucose response in the blood. So I tend to really focus on pairing fruit with a protein or a fat source. So like a nut butter, almond butter, tahini, a non-dairy yogurt, chia seeds, things like that to basically minimize the collateral damage of the fruit. So it’s really all just about being, I think, really thoughtful about how we’re balancing these things and then making smart choices.
A fruit is not a fruit. You have to think deeper than that, I think, if you want to minimize the glycemic response.
Vivien Allred: [00:24:45] I’m really into local eating as well. I’m trying to promote that because for me, in the Northwest of England, in Manchester, eating pineapples that have been shipped from the Dominican Republic or Mexico, it doesn’t make sense for my body and it’s not going to be the same as someone eating them fresh from the tree. It’s going to act completely different. And then knowing in the US, you have a huge issue with genetically modified plants these days. So that’s just another factor making them not as nutrient dense and not as recognized by our genes.
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Have you found any reasons that people can react differently to certain carbohydrates?
I’ve not used your company. I don’t know if you are currently shipping internationally. We can talk about that towards the end, but I use the FreeStyle Libre option that’s available in the UK, I think in Europe as well. That’s a CGM, so it goes on the arm and I did cover some of my journey on Instagram. I think I’ve got it served as a highlight if you scroll back a little bit, but that was really eye-opening to me.
I personally have PCOS. I was eating sweet potatoes. So I was choosing the “healthier” version of the potato, but it was spiking my blood sugar through the roof too high, but then when I’d have something like buckwheat or gluten-free oats or rice, the same amount of carbohydrates, the same serving size, the same protein along with it, it was a completely different response.
So have you found any… Is it genetics? Is it gender? What does it differ from? Is it your muscle mass? Have you found any trends with the people who use your monitors?
Dr. Casey Means: [00:28:44] Yeah. That’s so interesting about your sweet potato response. I had the exact same thing. I did an experiment where I basically did 100 grams of a bunch of different carb sources and sweet potatoes, corn and grapes were my highest. It was just absolutely through the roof with 100 grams of cooked sweet potatoes. So I really avoid sweet potatoes now, to be honest, and sometimes there’ll be sweet potato fries with a meal or something and I’ll have a couple. It always spikes me. Same page on that one.
But I think to answer your question, the best thing to point towards is a study that actually looked at this. There’s an amazing paper out of the Weizmann Institute in Israel that was published in Cell in 2015 and it was called “Personalized Nutrition by Prediction of Glycaemic Responses”.
And this paper took a bunch of healthy people and put continuous glucose monitors on them and gave them standardized meals and then saw what happened to their glucose. We typically have thought about glucose as like the glycemic index scale. So like, “Oh, we all will eat a slice of bread and that means your glucose is going to go up this much,” and this is why it has a glycemic index of X. But what they actually found in this paper is that you could give a piece of bread to all these people and have completely different responses. Some people might have flat glucose, some people might have a 50 or 60 point glucose rise, and it’s like, “How could this possibly be going on? It’s the same amount of carbohydrates.” But there’s so much between the mouth and the bloodstream, and it’s very different for each person.
So they then found what are the predictive factors that determine how you’ll respond? One of the biggest ones they found was microbiome. So they stool tested everyone and based on people’s stool composition, when they fed that into a model, it could help predict how people would respond. A couple of strains that have been found to be really important for metabolic health are the Bacteroidetes and Firmicutes and so the ratio of those two types of strains can predict obesity and also diabetes risk and that’s pretty interesting.
The other things that they found were related to how people would respond were proximity to last time exercising, how much sleep people had gotten, and then what they’d call anthropomorphic features, which basically means body type. So people’s body type could predict how they responded to these carbs.
And the reason that’s important is because body type actually can tell us quite a bit about insulin sensitivity. So if you have more abdominal obesity or abdominal fat, and that means really fat around the organs, that’s called visceral fat. That is suggestive of insulin resistance, because high insulin actually promotes fat storage around organs, as opposed to just like under the skin. So that was also related.
So really our insulin sensitivity, sleep, exercise, microbiome composition – all have an impact on how we actually will respond to particular carbs in terms of how much it elevates our glucose.
Vivien Allred: [00:31:33] So interesting. I’m pretty sure, correct me if I’m wrong, you promote more of a plant-based or vegan diet. Is that correct?
Dr. Casey Means: [00:31:40] I personally am plant-based, so I eat only plants. I follow mostly a whole foods plant based diet and I do take fish oil though, because I am very keen on getting high levels of omega-3, which you can get from nuts and seeds, but the EPA and DHA, which is one of the downstream omega-3 is mainly found in fish, also algae, but that’s my one non plant-based thing I do.
Vivien Allred: [00:32:06] Have you been eating like that for awhile? Or have you changed because of tracking your blood sugar and seeing an increase with animal protein and things?
Dr. Casey Means: [00:32:15] For me, my plant-based eating preceeded my use of CGM and starting this company, I really came to it because my background is very much in personalized genetics and I was very fascinated with the nutrogenomics field, which is basically how food nutrients changed gene expression. So food goes into our body and it actually turns into a signaling molecule in the body. We break down the food and then all these chemicals get released into our bloodstream and some of those actually go into ourselves and change the expression of genes. And what I found during those studies was that so many of the things that turn on the very helpful genes in the body, so like prolongevity, antioxidant genes, the genes that are involved in good immunity, many of these things are actually turned on by plant compounds and a lot of the bad genes are turned off by plant compounds as well. So for instance, like in turmeric there’s the compound curcumin, which actually acts as a co-factor for transcription factors that turn down the expression of the NF-kB pathway, which is one of our master inflammatory genes. So it was just so fascinating to me, “Oh my gosh! Plants really pull the levers on our genome.” And so I started experimenting with really a plant forward, very focused diet on how to optimize health and it just was so transformational for me in my mind and my body that I’ve stuck with it. What was so interesting about adding CGM to the mix though, continuous glucose monitoring, is that I actually learned how to refine that diet even more to make it as metabolically friendly as possible. So plant-based diets typically are higher carb than a more omnivorous diet because you’re eating a lot of plants which have carbohydrates. And so what I found was that there were these foods that I was eating regularly, specifically grapes, corn, oatmeal, sweet potatoes, rice, all of which for me, really spiked my glucose. So I learned to either minimize those foods, replace them with other types of plant-based foods or pair them with other things like fat, protein and fiber to minimize the glucose spike. So to me, it was really about optimizing a plant-based diet and removing the collateral damage that you can get from basically being like, “I think I’m eating healthy because it’s plant-based,” but actually knowing that certain things are spiking your glucose, you can work to improve them. So now I feel like I’m on this very metabolically optimized plant-based diet, which I just love. And and there’s just some really easy, fun swaps that have been game changers for me. So instead of rice, I eat cauliflower or broccoli rice, and instead of pasta noodles, I eat zucchini noodles or shirataki noodles or konjac root noodles. Instead of tortillas I’ll maybe eat almond flour tortillas or flax tortillas or coconut tortillas, or even better yet a colored green wrap. I’ll use sometimes seaweed as a wrap for a burrito. And these things are all totally delicious, but don’t do anything to my glucose levels. So you end up being able to get all the benefits of the plant nutrients, but have stable glucose, which means stable energy, stable mood, stable cognitive function throughout the day and not going on these huge up and down swings.
I think the other thing metabolically that I’ve been really interested in from a plant-based standpoint is that, we talk mostly about macronutrients in terms of metabolic health. We talk about fat and carbs and protein to some extent, but we really, I think, missed the boat on micronutrients and for our metabolic processes to work properly, especially inside the mitochondria, we actually need dozens of vitamin and mineral co-factors to make these enzymes function.
Some of the key ones are manganese, magnesium, zinc, vitamin C, vitamin D. There’s chromium, there’s many others, but they actually are like lock and key necessary for these cellular machines to work and on a processed diet, you are just not going to get these co-factors in the levels that you need them. You have to be really, I think… Looking at your day and saying, “Okay. I have, what? 1500, 2000 calories worth, of food that I’m going to eat today. How can I get the most out of that food to basically make my cellular machinery work?” And to me a very plant dense diet really got me a lot of that.
I’m certainly not against some animal protein in diets. I just think we just need to be super thoughtful about what is the molecular information we’re putting into the body every day, and we only have a certain amount we can actually eat and we need to maximize it because that’s the purpose of food. And yeah, it’s just being really thoughtful about that and CGM has just added a whole fun dimension to the diet.
Oh and sorry, just one last thing. With microbiome, because it has such a huge impact on metabolic health, plants have fiber and that’s going to feed the microbiome. So that’s a big factor for me as well of why I choose the higher fiber plant foods is because I want to feed that microbiome so that they make those metabolic byproducts that are going to be helpful.
Vivien Allred: [00:37:07] The GI-MAP stool test that I sometimes use with clients, it does show you that ratio, so when you were mentioning the Firmicutes, the Bacteroidetes, there is that ratio, and it does correlate pretty well with those metabolic issues and obesity. It tends to be an elevated ratio, so I definitely agree with that. And I’m guessing you’ve seen hundreds, if not thousands of results now from your users of Levels.
Do you have people who really don’t do well with a lot of plant foods and do better on a more animal based ketogenic diet? And does that differ with genders? What do you find works best, just as an overview? I know it’s different for everyone, but is there anything specific to female hormones, women’s health that you think works best when it comes to nutrition?
Dr. Casey Means: [00:37:51] Yeah. I don’t think there’s ever going to be like a one-size-fits-all diet for people. I think based on where people are at, for instance, where your microbiome is starting out at, is going to have an impact on what diet works for you right now. So I think we very much need to see ourselves on this continuum of really optimizing our diet now. But over time that might shift and we may be able to actually tolerate more carbohydrates better as we improve our metabolic health and our insulin sensitivity.
So we have people all across the range from vegans, who have perfect flat glucose, and people who are almost like carnivores, who have low flat glucose. So there’s very different ways to get that. And so I would say, I honestly can’t say that there’s one specific diet. What I would say is that over time using a CGM, you will learn which carbohydrates are causing big glucose spikes for you and as you minimize those, everyone tends to move towards better glucose and I would say moving away from the processed foods or the foods, especially plant foods that are extremely high in carbohydrates, so like the starchy foods, those tend to drive some glucose spikes. So I would say people tend to move away from those during their process.
We have seen dozens of customers who have had instant oatmeal for breakfast for years and have then found that that spikes their glucose to 180, 200 – really high levels. So I have seen that as a trend where people have really moved away from high carb breakfast s and switched to more higher protein and fat breakfasts, and that’s been transformational for a lot of people.
And in terms of women, nothing trend-wise diet that I can speak to specifically for women at this point, but I will say, we do know that glucose and insulin sensitivity changes throughout the cycle in our follicular phase, so pre-ovulation, we tend to be more insulin sensitive. So glucose levels might be better. And it’s thought that estrogen has a protective effect on metabolic health and then in the luteal phase, so post-ovulation, the estrogen-progesterone ratio goes down. So you are going to have less estrogen compared to progesterone, and that actually is associated with more insulin resistance. And so people may find that in the first half of their cycle, they’re a little bit more tolerant of carbohydrates and doing a little bit better on that front and then as they get closer to their cycle and their period that they actually are less carb tolerant and are seeing more variability in their glucose. So that’s pretty fascinating.
And then it at menopause when estrogen rapidly declines, that is actually when we see women as a whole do worse metabolically. So men and women tend, in the early years, to sort of track each other in terms of obesity and diabetes and then at menopause women start exceeding men in terms of obesity and diabetes. And part of this is thought to be due to the fact that estrogen declines and people become more insulin resistant at that time. And as we talked about earlier, that insulin resistance can lead to higher baseline insulin levels, block our fat burning, lead to excess fat storage weight and move us towards that metabolic dysfunction. So that really has to be unique. Yeah.
Vivien Allred: [00:41:05] So don’t get stuck on one diet forever. It might change week by week with your cycle, with the seasons, with your menstrual cycle history. So I always promote being flexible and not being so dogmatic when it comes to diet, because what’s working for you now may not work for you in pregnancy, when you’re a new mum. So many different variables.
Dr. Casey Means: [00:41:26] Yes.
Vivien Allred: [00:41:28] And could you tell us the difference between the regular finger prick glucose test versus the continuous glucose monitor. What is the difference? Or can someone use either?
Dr. Casey Means: [00:41:39] Yeah. Absolutely. So a finger prick monitor is basically a lancet, so a small needle and you prick your finger and you get a drop of blood and then you can get a single time point glucose measurement.
So you might wake up in the morning, prick your finger and see what your fasting glucose is in the morning before you’ve eaten anything. And that can be very helpful. Then there’s a continuous glucose monitor, which is a wearable sensor that you wear generally on the back of your arm and it does a very small painless internal probe that just goes just under the skin. And that’s actually measuring glucose every five to 15 minutes, depending on the brand of hardware, 24 hours a day and sending that information to your smartphone.
So you can imagine the finger prick is like a photograph of your glucose and the CGM is like a movie of your glucose. So you are able to actually just see so much more with continuous glucose monitoring. You can imagine we’ve talked a lot about spikes after meals. With a finger prick it would be very hard to really ascertain the pattern of a spike after a meal. You could prick your finger 40 minutes or 60 minutes after a meal, but you don’t quite know if you’re catching your glucose on that upswing or at the peak or on the downswing. So you’d have to prick your finger many, many times after a meal to actually get what you can just get from wearing a continuous glucose monitor.
And there are many aspects of a continuous glucose monitoring curve that we’re learning are actually very indicative of underlying metabolic health. So for instance, if your glucose goes up after a meal and then goes quite high and stays elevated for a while, and then comes down. That’s a lot of glucose exposure. You can imagine that’s a big high, wide curve. That’s a lot of glucose in your blood. That’s really associated with probably being a little bit more insulin resistant versus someone who goes up a little bit and comes straight down within about an hour or an hour and a half. Those people are processing the glucose well, getting it into bloodstream quickly, likely to be more insulin sensitive.
Then you can also look at variability. So how much people are swinging up and down throughout the day, people who look like mountains and valleys all day versus someone who’s much more like flat and gentle rolling hills. Those people with those spikes and valleys tend to be more insulin resistant. So glycemic variability is associated with worse metabolic health.
You can also, of course, test your fasting glucose on a continuous glucose monitor by just checking your glucose first thing in the morning, and you can also get average glucose, so 24-hour average glucose levels. And that’s pretty interesting because that mirrors a standard diagnostic test that we use in medicine called the Hemoglobin A1c, which is a blood test that doctors will sometimes order, which tells you your three month average glucose. But with a continuous glucose monitor, you can actually see that average glucose every single day.
And I think what’s so fascinating about that is that… What people quickly realize is that, we don’t have the same fasting glucose or average glucose every day. It actually bounces around a little bit. You can have a day of perfect eating, you exercised, you got good sleep, you didn’t have a lot of stress and your fasting glucose might be like 72, really low and healthy. Then the next day you drink some alcohol, don’t work out, skimp on sleep, eat a ton of carbs and your fasting glucose might be like 85 the next day. And so it really helps, I think people realize, Oh wow! I have a lot of control over where I’m going in terms of metabolic health and the choices I’m making every day have a massive impact on all these parameters. My post-meal spikes, my glycemic variability, my fasting glucose, my average glucose.” So I think it’s extremely motivating, the continuous glucose monitor to basically take control about a lot of these choices and realize how much agency we have to impact this. So I think you just get a lot more of that than a finger prick, because you’re just getting that snapshot.
But certainly, both are great and for most people, I would say, I would do one or the other, at least to try to just see where you’re at on the spectrum.
Vivien Allred: [00:45:30] I started with the finger prick ones for awhile because, to begin with, the CGMs were only really used by diabetics. They were by prescription. So it’s not until companies like Levels and FreeStyle Libre, the one that I use, they started making them more accessible to the general public, which is amazing. So I was pricking my finger and it was going black and it was bruised and just so painful. And I definitely noticed that as well, because some days it looked like my glucose was fine after eating, but when I started with the CGM, I would see my glucose was spiking at 20 minutes. And I was only checking at 40 minutes or 60 minutes after eating. So I definitely agree with that one.
Do you have a reference range, what people should be shooting for optimal health? And maybe you only know them in the US, so if you don’t know the UK value conversions, I’ll put them in the episode journal, because I know those are two different readings
Dr. Casey Means: [00:46:23] Right. Yes. The mmol/L versus mg/dL. Yeah. So for me I try to stay between 70 and 110 for all day. So I try and never go above a value of 110 mg/dL. And yeah, I just really like to keep it in this low and gentle range and try to not get above 15 to 20 points after a meal.
So if I eat and I’m starting at 80, I don’t really want to go about 100. So about a 15 to 20 point delta. To me, what that saying to my body is, “Okay, you’ve got some carbs in there, you’ve got some glucose. Release a little bit of insulin. Take it up.” But it’s not this massive insulin. I’m not asking my pancreas to go crazy and just dump insulin out. If I were to have a meal that spiked my glucose, 50, 60, 70 points, which is very easy to do on a standard Western diet, you can just imagine your pancreas having to dump out tons more hormone and what can happen is a phenomenon called reactive hypoglycemia where you have such a big carb surge, glucose surge, you got this big insulin surge, and then all that insulin basically soaks up all that glucose and you end up dipping below where you actually started before the meal, and that’s reactive hypoglycemia. And that phenomenon is associated with anxiety. It’s associated with fatigue. So when you think about post-meal, post big lunch, you got to take a nap. What might be happening is you’re experiencing reactive hypoglycemia. So the more we can keep the glucose stable and low, the less we’re going to be likely to have that big insulin surge and that reactive issue.
Yeah, so I try and stick between 70 to 110, ideally between 70 and 100, not go more than 15 to 20 after meals. I try and keep my average 24-hour glucose in the 80’s, and I like to keep my fasting glucose between about 72 and 80.
Vivien Allred: [00:48:14] So if someone’s hungry, every couple of hours, they’re getting those shaky jittery feelings then that’s classic hypoglycemia, even those with sleep issues. Could you talk about the sleep connection? So for those who are waking up every couple of hours, especially to urinate in the middle of the night and high blood sugar, because I remember when I first had my CGM in, I would see in the morning that it was dropping too low at certain points of the night, even though I wasn’t waking up. Obviously, that’s going to affect my recovery and my deep sleep and all of that. So it could be that I wasn’t recovering as well as I could be because of some blood sugar instability.
Dr. Casey Means: [00:48:51] Yeah. So there’s a couple of reasons why glucose can go low at night. So one is that if we eat high carbohydrate meals late at night, so for instance, eating dessert right before bed, we can get a glucose spike and then an insulin surge right before bedtime. That can send you on this bumpy glucose road throughout the night, because you have… Something that’s quite interesting about nighttime is that we’re actually more naturally insulin resistant at night. So because of melatonin being released to help us get tired at night. Melatonin makes us get sleepy. Melatonin also has an effect on insulin sensitivity.
We are more sensitive to carbs when we eat them in the evening versus if we eat the same thing at noon. So you can imagine you’re eating this dessert, you’re going on this glucose roller coaster overnight, bouncing around, having trouble absorbing the glucose into the cells because you’re a little bit insulin resistant at night. That can just do tons to your sleep.
One of the mechanisms of why it affects sleep is that high glucose can cause your body temperature to go up just slightly, almost imperceptibly. But temperature has a huge impact on our deep sleep and when our temperature is elevated, it can cause problems with sleep, even if we’re not really perceiving it. So it has an effect on that.
Aside from that, it is also important to remember though that glucose monitors have this phenomenon called pressure induced sensor error, which is where if you lay on the sensor and put weight on the sensor, it can have an erroneously, low reading. So some of the very, very low glucose spikes at night actually could be pressure induced sensor error. That’s just something to remember for people who get nervous about, they might see their glucose go down to 30 or 40, very, very low levels at night, and that very well could be pressure induced sensor error. But it also could be natural phenomenon with this bumpiness that happens with high carb meals late at night.
Also something that’s interesting is that glucose dips during REM sleep naturally. During all that activity of REM sleep, glucose tends to be about 5% lower than it is in other phases of sleep. So it’s really fun to compare glucose data with Oura ring or Whoop or Eight Sleep data or any of these things and see if you can track glucose dips with your REM cycle.
Vivien Allred: [00:50:55] Yeah. I’ve got my Oura ring. That’s how I was tracking and I could definitely tell my HRV was lower when my glucose was dipping. So I could really find the best type of meal to eat in the evening. What time is best to eat in the evening? It all makes a huge difference.
Some people like to track things like the blood pressure, the heart rate, the pulse. Why would you recommend someone test the blood sugar over those things?
Dr. Casey Means: [00:51:21] Yeah. I think that they’re all really, really important. It’s so awesome that we now have these tests that we can do at home and track these things. So I wouldn’t say one is necessarily more important than the other. I think that in terms of actionability though, and making changes to our behavior, real-time biofeedback is key. To make sustainable behavior change, we actually need to close the loop between actions and reactions. So you need to know that, Okay. I did this thing and it caused this effect, so now I’m not going to do this thing anymore, or I’m going to do more of this thing.” Blood pressure testing can’t really do that for you. You take a reading and it might be a little high, but it doesn’t tell you exactly what to do. The machine doesn’t tell you, “Okay. Go run a mile or go walk for 20 minutes, don’t eat your oatmeal in the morning or donate that candy bar.” it doesn’t close that loop. A continuous glucose monitor actually does, so you can eat oatmeal and see that you spiked to a glucose value of 200, which is very, very high and know that oatmeal alone is probably not the best option for you. And that is where the magic of behavior change happens. So the more we can close the loop, the better we can deal.
The other thing I’ll mention, something really interesting about blood pressure is that it’s actually thought that blood glucose and insulin resistance are one of the causative factors of high blood pressure. So high blood sugar and high insulin have a number of mechanisms that directly impact our blood sugar. One is that it affects the hormonal system, the renin angiotensin system, and actually causes us to increase our blood volume and keep sodium inside the body. The second thing that high glucose and high insulin do is impact the sympathetic nervous system, our fight or flight response, and causes constriction of blood vessels. Insulin is a pro-growth signal in the body, and it can actually cause growth of the muscles around blood vessels, smooth muscle hypertrophy, and it can cause constriction of the blood vessels. So there are many reasons why controlling our blood sugar actually could manage blood pressure.
So that’s another reason that they’re good to test together or separately. But I think in terms of really driving the changes in our lives that we need to build a better body that’s more functional metabolically, I think the closed loop biofeedback is really critical.
Vivien Allred: [00:53:33] Great! I just wanted to ask with your personal glucose limit of 110, would you say that is a good goal for most people? Or is that just individual to you? What would you recommend?
Dr. Casey Means: [00:53:44] Yeah, I think that’s a pretty… I think it’s reasonable for most people. I think it’s a healthy range for most people to shoot for. It’s definitely more narrow than what you would see from standard criteria. Basically we don’t have awesome guidelines right now for, “Okay. You’re a healthy individual who is trying to optimize your health. This is what you should shoot for.” All we’ve really got are standard criteria, which is basically saying that two hours after a meal you want to be below 140, but I think that’s far too lean yet. That would be very high to have your glucose be that elevated two hours after a meal. If you look deeper into the research. You actually find that probably lower and narrow ranges is better for human health and the people that do best with their health tend to have lower glucose levels. Another example, right now we’re told that a fasting glucose less than 100 is normal. Like you don’t basically need to worry about anything if your glucose is less than 100 for fasting. But if you actually look at the research, what they’ve found is that as you move up in your fasting glucose, even within the normal range, you are significantly more likely to develop heart disease, have a stroke, or develop diabetes down the road. And it’s actually probably most healthy to be in the 70’s and 80’s for our fasting glucose. Once you get up to the 90’s, 90 to 100 for your fasting glucose, you almost certainly have an underlying metabolic problem that is starting. But you wouldn’t really know that from our standard criteria. You have to really dig into the literature to see that the increase in risk actually starts much before a fasting glucose of 100.
Yeah, so I definitely just implore people to, especially doctors, to really read this literature and think deeper and push people, their patients, to strive for a narrower range that’s lower and probably healthier.
Vivien Allred: [00:55:29] Yeah. We can say the same with thyroid, not waiting until you get to full blown hypothyroidism or full blown diabetes before you actually do something about it. There’s an optimal window, basically just black and white, either you have a problem or you don’t, but there is a lot of gray area.
Dr. Casey Means: [00:55:44] Yes.
Vivien Allred: [00:55:45] Last couple of things I wanted to ask though, I know when I had my CGM in, exercise made a huge difference, both good and bad. So for example, after eating a meal like sweet potatoes and I noticed my glucose was rising. If I would just go and have a quick 10 minute brisk walk, that would massively reduce that glucose increase. But then when I do maybe a hit class or high intensity interval training, or more like an intense sweaty workout, my glucose would actually increase. Is that something to avoid or is that just a natural thing that happens?
Dr. Casey Means: [00:56:18] Yeah. So that’s a fascinating phenomenon that’s actually based in hormones as well. So when you do a high intensity workout, something like above your VO2 of 80 or something like that, think about a heart rate of about 80% max or higher. What happens is that’s actually a stress signal to your body. Your body’s like, why are you running so hard? What is going on? Is there a threat? And it actually releases cortisol and epinephrine, our stress hormones, and those travel in the bloodstream to the liver and actually we store about two hours worth of glucose as energy in the liver as glycogen, and it will basically tell the liver, “Dump some of this glucose into the bloodstream because the muscles need it right now. We’re trying to escape some threat. Dump out the glucose. Put it into the bloodstream for the muscles.” And so you’re seeing that on your continuous glucose monitor. You’re seeing an elevation right after starting a high intensity workout. This is very, very different from a food-related spike for a couple of reasons. One is that our muscles can actually take up glucose without insulin. There’s an insulin independent mechanism of getting glucose up. It’s actually the contractile aspect of muscles. It’s able to just take up the glucose without insulin. So you’re not getting that big insulin surge that you get with food. And the second thing is that our body actually is needing, it’s using that glucose. So we have an ATP energy demand and your body’s supplying the energy for that. The third thing is that it’s actually a very good thing because you’re clearing out your glucose stores when you do that. That spike is not from something you ate. It’s from something that you were storing and when you can clear out some of that liver glucose… So let’s say it was a fasted workout. You had had no calories before that. First thing in the morning, you see that glucose rise because your liver is actually processing that glucose and putting it into the bloodstream for your muscles to use. As you burn through that glycogen and that glucose, you’re moving towards a time when you’re going to actually have to need your fat for energy. So as you burn through your glycogen and your stored glucose, you use up glucose as a source of energy and because your insulin is low because you haven’t eaten, your body will just switch to start using fat when you’ve run out of that. So that’s really moving towards metabolic flexibility, meaning that you’re bouncing between using fat or using glucose for energy, which is an optimal state of metabolic health.
But you can imagine, let’s say you drink a Gatorade, which has 40 grams of sugar before your workout. You’re going to use that glucose first and then if you run out of that glucose, which you probably won’t, because it’s a massive amount of glucose, your body will then turn to the liver to break down some glucose from the liver and only then when you burn through that, you start burning more fat. And so by doing a high intensity workout, maybe without having a lot of exogenous oral dietary glucose on board, you’re moving yourself towards that metabolically flexible state. So I think there’s a positive to that. And on a glucose monitor, you shouldn’t necessarily be worried by seeing a spike during a high-intensity workout.
Vivien Allred: [00:59:21] And I would caution working out intensely fasted for those people listening with adrenal thyroid issues because they could actually crash and feel worse afterwards. So put that little caveat there.
Dr. Casey Means: [00:59:32] And I would also say it’s something that people can work towards. It’s like the first time you work out without having eaten anything beforehand, it’s probably going to feel terrible because your body’s not adapted to using fat for energy. And so I’ve tended to ease into that over months where each workout, my body’s learning a little bit more to tap into fat burning for energy. And then after doing this for months or more, you can really just… It’s very second nature for the body. But these aren’t just like on/off switches, you have to develop the adaptive capabilities to do these things. And there’s been some really interesting research in low-carb endurance athletes like Iron Man athletes and marathoners who are on ketogenic, low carb diets. So they’re basically not eating really any carbs and they are doing these crazy endurance events. And you look at their blood during the training events and you can see that they’re actually burning completely different fuel than someone on a regular carb filled diet. You basically see that they are fat oxidizing through their whole workout and doing very little carb oxidation, whereas a regular athlete eating a standard diet is doing mostly all carb oxidation during the workout and almost no fat oxidation. So the body has this amazing capability, but you definitely… That takes a ton of time to adapt, to be able to do that.
So just totally agreeing with what you’re saying. I wouldn’t just all of a sudden try and run 10 miles fasted. You’re probably going to feel terrible.
Vivien Allred: [01:01:05] For our listeners who are thinking they’re like, “Oh, I have excess body fat. I’ll give it a try. So just work towards it as being your goal.
Dr. Casey Means: [01:01:11] Yeah. And I would also say that you can… A first step is just moving from eating normal workout type foods, which are super high sugar like Gatorade and gels and these protein shakes that have tons of refined sugar. Moving away from those into just healthier carbs around meals. You don’t need a ton of sugar to replete your glycogen and give you energy. You actually just need more of one of those gentle glucose elevations. So something I use the continuous glucose monitor for is to make sure that if I’m eating carbs before or after a workout, I don’t have a huge spike and a dip, but just a gentle elevation because I don’t want that insulin spike and drop during or before or after a workout, because that’s going to zap your energy. You really just want to give your body the fuel it needs, but not more than that. And so it does really help shape your workout fuel to make it useful and do what you want it to do, which is give you energy, replete your glycogen, but not crash you.
Vivien Allred: [01:02:12] The diet work for you, not against you.
And I want to end on… I always ask a few questions at the end for my guests. So the first one is: what’s your go-to breakfast? So I’m guessing oatmeal on its own is out of the window for you personally. So what is your typical go-to?
Dr. Casey Means: [01:02:29] For me, my breakfast is all about vegetables and protein and healthy fats. So first of all, I generally don’t eat until around noon for my breakfast. I do try and get a long overnight fasted window where my body has no… From maybe 7:00 PM at night to about noon the next morning, because that’s going to allow my body to be in a low insulin state and do some of that fat burning which we want. We want to generate those ketones from fat, which are good for the body. Then at around 11:30 noon I’ll typically have either a huge veggie stir fry with beans or a salad with beans or tofu. I’m really looking to get 10 to 13 servings of vegetables a day, and so to do that, you have to eat vegetables at breakfast. I typically make a dressing of tahini and apple cider vinegar and sometimes some liquid aminos. The vinegar actually is an insulin sensitizer. So that’s important to me to have in there. Tahini, I love because it’s a whole food fat that actually has lots of fiber in it and protein, and it’s not a refined oil that’s going to be more likely to be oxidized. So I’ll typically use nut butters and tahini in my salad dressings. Yeah, a ton of colorful vegetables. And then I always do beans of some sort, because I’m trying to get typically 50 to 75 grams of fiber a day and again, if you don’t start with breakfast, you’re not going to get there. So if I can get 10 to 15 grams of fiber from beans or legumes, nuts and seeds in my breakfast, I’ll do that. So yeah, typically just a bunch of greens that I’ll either eat in a salad or in a stir fry and then some sort of whole food fat and protein source on top and usually some vinegar of some sort for the insulin sensitization.
Vivien Allred: [01:04:13] Is there a book that you’d recommend on the subject of metabolic health, blood, sugar, insulin, or just nutrition overall?
Dr. Casey Means: [01:04:21] For sure. Yeah. I would definitely recommend people read the book, “Why We Get Sick” by Dr. Ben Bikman. It’s an amazing book about metabolic health and is pretty life-changing. Other books I’d highly recommend is “The Obesity Code” by Jason Fung or “The Blood Sugar Solution” by Dr. Mark Hyman. Those are all three great books about metabolism. And for anyone who’s got any brain type symptoms. So whether it’s fatigue, anxiety, depression low energy, pain, things like this, I highly recommend Mark Hyman’s book, “The UltraMind Solution”. It’s a really amazing book that ties in metabolic health to brain health.
Vivien Allred: [01:05:00] Great. I’ll link to those in the Show Notes and I’ve read a few of them and I agree that they’re great.
Is there a piece of takeaway advice? If you were to sum everything up from this podcast episode for the listeners, what would you say?
Dr. Casey Means: [01:05:13] I would say, controlling your blood sugar is the gateway to improving your life and it’s easy and basically free. I would just really promote orienting diet around glucose control as something that you’re thinking about because ultimately as we control our glucose, we improve our ability to make energy effectively in the body and when we make energy effectively in the body, our lives are better. It’s really that simple. So that is my focus.
And then the second practical tip is to eat more fiber. I think we are getting on average about 12 grams of fiber per day for the average American. I don’t know how it is in England, but we need probably five times that in my opinion. And when we make our microbiome happy, we make our brains and our bodies happy. I just say, yeah, load up on the beans, nuts and seeds and try and up the fiber.
Vivien Allred: [01:05:58] And the very last question is, where can people find more from you personally? And if they’re interested in your product, the CGM from Levels, tell us a bit more about who that’s available for. Are you shipping just in the US or you also do worldwide?
Dr. Casey Means: [01:06:15] Yeah. So right now we’re just shipping in the US, unfortunately, but we’re very much planning for an international expansion. You can find us at levelshealth.com. We have tons of educational information at levelshealth.com/blog. A lot of great guest experts writing there about metabolic health. You can find us on Instagram and Twitter @levels, and you can see a lot of fun experiments that people are doing with their glucose monitors. Then me personally, I’m @drcasey’s kitchen on Instagram and Twitter. So drcasey’s kitchen and I actually talk a lot about metabolic health and plant-based diets.
We’d love to hear from anyone and yeah, for anyone who is in the US who wants to sign up for Levels, join our wait list on the website and we’ll send you information about when we’re going to be able to get you off the wait list. The program includes one month of continuous glucose monitors and then software that helps you understand that data.
Vivien Allred: [01:07:08] Perfect. Yeah. We have lots of US listeners, so they will be definitely interested in that, I know. And yeah. Thank you. This has been a really important conversation. I’ve mentioned probably blood sugar, the importance of blood sugar, pretty much every podcast episode, because it is related in so many ways, but I’m really glad that we had a deep dive and you really educated us on the importance of doing so, not only for our current symptoms, brain fog, fatigue, sleep issues, hormone issues, lots of future health, reduction of disease risk. It really does influence our health in 20, 30 years. So thank you so much, Dr. Casey.
Dr. Casey Means: [01:07:44] Thank you so much for having me.
Vivien Allred: [01:07:46] I really hope you enjoyed this episode. If you did, and you would love a free copy of my hormone friendly recipes guide, please leave me a rating and review and I will email you a copy as a thank you gift. All you need to do is screenshot your rating and review and send it to me at [email protected]. This guide contains delicious gluten, dairy, grain, and refined sugar-free recipes and all the meals contain specific hormone superfoods. Don’t worry. There are no boring, solid recipes included. Come and say hi over on Instagram @vivanaturalhealth as I share a ton of free content every day, and you can get to know more about me and how I stay hormonally healthy. If you haven’t already, check out my website, vivanaturalhealth.co.uk for my blog and many free guides, which cover everything from clearing acne to gut health and hair loss.
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