What is the biggest threat to health and happiness in the United States? According to Dr. Casey Means, co-founder of Levels, it may very well be our standard Western lifestyle. Sitting in front of screens all day long with a bowl full of processed snacks within reach is a recipe for disaster. In fact, millions of Americans are on a path to diabetes and chronic disease, whether they’re seeing the warning signs or not. Levels offers a way to gain critical health insights through continuous glucose monitoring. On Less Stressed Life, Dr. Means spoke with host Christa Biegler about why we need to approach our health in a whole new way.
4:38 – What dysregulated metabolism tells the body
Most chronic diseases have metabolic dysfunction at their core. The key becomes addressing metabolic dysfunction before it turns into a serious disease.
“What I noticed after about four and a half years of practicing was that pretty much all of the conditions I was treating were inflammatory in nature. It was all the things with ‘itis’ at the end, which usually means inflammations like sinusitis, thyroiditis…These got me stepping back and saying like, why is everyone so chronically inflamed? Inflammation is the immune system being triggered and upregulated continuously and that’s something we should look deeper into. There are so many environmental and lifestyle and nutritional causes of chronic inflammation. Why is this not part of our practice? Why do we reach so quickly for steroids and antibiotics, and then ultimately surgery, these fairly morbid interventions, when there could be some really low hanging fruit of attacking these more environmental causes of inflammation? I became really, really fixated on understanding the root causes of chronic inflammation. One of the key drivers of chronic inflammation is metabolic dysfunction. So dysregulated metabolism, elevated blood sugar, or blood sugar spikes, these things tell the body that there’s a problem.”
6:12 – The root cause of disease
Even when symptoms look different, the underlying core pathways are often the same. The way to treat these diseases is to help people become metabolically healthy by making better choices.
“What we know more and more, especially through the study of network and systems biology, is that a lot of these diseases are often thought as really isolated silos, like totally different things. You think like, okay, acne, depression, IDS, cancer, diabetes, these are all totally different. We’re going to treat them differently. But when we really look at this more connected network and systems biology perspective, we realize that there’s actually a lot of core fundamental biologic processes underneath the surface that are really related to all of them. I really think the future of healthcare is going to be figuring out how we can attack those core pathways that affect so many different conditions, these fundamental root causes of disease, which I think will be a much more efficient way to help people deal with our whole host of symptoms and conditions.”
10:50 – Thinking upfront in healthcare
Most medical interventions are reactionary. Instead of treating symptoms, medical professionals need to think about how to help patients lead healthy lives with the right diet and lifestyle for them.
“We have a dominant way of thinking and approaching conditions and it’s very, very strong and it’s very focused on reactionary intervention. So what we sometimes would call sick care instead of healthcare, meaning that we don’t tend to really focus or intervene until a disease state has manifested and then we approach it. And it’s a very singular way, we’re really just playing whack-a-mole with that condition at one time. It’s very rare that someone’s going to be thinking about chronic ear infections in the context of, oh, well, they also have IBS and they have Hashimoto’s and they have eczema, they have some anxiety, like how could these things possibly be related? No, we’re going to treat that ear infection, maybe put your tubes in and that’s it. That has worked very well for many conditions, but because the issues that we’re facing these days and the majority of morbidity in our country and healthcare costs is a chronic disease, these are diseases that don’t require just a little acute fix. They are conditions that have manifested over years, if not decades, and are very frequently related to diet and lifestyle. We just can’t use the same toolbox and that same approach if we really want to reverse these epidemics at scale. We really have to be thinking upfront.”
14:02 – The unintended consequences of western lifestyle
Easy access to sugary processed foods and a highly sedentary lifestyle are two of the many consequences of a western lifestyle that are leading to an epidemic of metabolic dysfunction in the US.
“Because of the way we’re living these days and what we have exposure to in terms of our food access and our general sort of Western lifestyles, a lot of those really promote poor metabolic efficiency and metabolic health. For instance, we have so much access to refined carbohydrates, refined sugars, and this is just creating a huge substrate load in our body of glucose. That glucose is one of our primary energetic substrates. When that goes into the bloodstream, it’s going to stimulate the pancreas to make insulin. And when that happens over and over and over again, multiple times per day, over years, you’re getting these glucose spikes. And these influenced spikes, as I’m sure many of your listeners know, this is going to lead you down the path of insulin resistance. What that means is that the cells become tired of hearing that intense insulin signal and they actually become a little bit numb to it. And so your body has to produce more insulin to get the same amount of glucose in the cell. And then this just creates a vicious cycle.”
15:26 – The diseases caused by metabolic dysfunction
The symptoms of metabolic dysfunction are extremely broad. It can look like almost anything based on where it’s showing up. It’s almost like every symptom that we can think of has some relationship with metabolic dysfunction.
“What also is happening is that as that insulin is elevated, it’s actually a signal to the body that we’ve got tons of energy from glucose. We don’t need to use fat, this other storage form. And so insulin is not only a signal to take glucose up into the cells, but it’s also a blocker on fat burning and fat oxidation because it’s telling the body there’s plenty of this other resource around. We don’t need fat. So by having that insulin elevated, you’re not going to be tapping into that fat burning. That is going to reduce metabolic flexibility, that is the ability to flip between glucose and fat burning. Of course, for someone interested in losing weight, it’s gonna be a huge barrier because you’re not burning through your fat for energy. That’s what, on the molecular surface, the movement towards metabolic dysfunction looks like. What’s really interesting is that the clinical picture of what metabolic dysfunction looks like is so incredibly broad. It can look like almost anything. Some of the conditions that are associated with blood sugar, dysregulation, or metabolic dysfunction, range from things as simple as acne, premature balding to things like infertility, polycystic ovarian syndrome, or erectile dysfunction.”
17:12 – High yield area to focus on in healthcare
There are many different treatments for PCOS, the leading cause of infertility. Dr. Means says that there is a lot more success to be had by fixing the underlying core process of blood sugar regulation.
“Metabolic dysfunction wears so many hats and I think we’re not fully aware that there are so many branches to this one tree. From my perspective, it is just a very high yield area to focus on in healthcare, because there are just many multifarious benefits that often you might just see melt away as you really nail this core fundamental pathway. Just an example, polycystic ovarian syndrome, the leading cause of infertility in the country, fundamentally a metabolic disorder where there’s too much insulin stimulating the ovaries that causes them to make more testosterone. It creates menstrual irregularity, people become infertile and you get all these other symptoms associated with high testosterone, like acne and hair growth and all this stuff. So in our medical culture, we might prescribe birth control pills for these people or exoticness hormones to meta control the hormone cycles. We may even prescribe Metformin, which is a diabetes medication, that is an insulin sensitizer. But neither of those things is actually going to affect the core process of blood sugar dysregulation, that if you attack there and put the investment of energy there could have so many other positive effects for that patient or that person. That’s the spectrum of metabolic dysfunction and the phases of it. And what’s hopeful about it is that no matter where you are on that spectrum, you can really always improve.”
21:45 – The problem with glucose spikes
Glucose can trigger chronic inflammation, oxidative stress, and cause glycation – a condition where blood sticks to different proteins and cellular structures, and changes their function.
“There are also things about glucose spiking on its own that are problematic. Glucose can trigger chronic inflammation. Glucose can trigger oxidative stress. It can trigger glycation, which is where high glucose concentrations in the blood stick to different proteins and other cellular structures and change their function. It can actually maybe even have epigenetic changes. So you just don’t want those frequent rapid spikes. And we know that stress can do this. There’s so much research out about this that’s really painting this picture right now. Studies that have been done that have looked at people in war zones and looking at their glucose over time and seeing just a rapid increase in metabolic dysfunction after living in a war zone, really interesting study out of Israel that looked at those people who have had adverse childhood experiences and future metabolic outcomes. Even acute stressors like perceived work-related stress events can cause an increase in glucose. So very, very interesting stuff. And actually acute traumatic experiences can acutely change your insulin sensitivity. So the way the cells are immediately sensitive to insulin. This is something we really want to think about. We always think about food in relation to glucose, but there are so many other factors. And I think stress is one of the huge ones.”
23:52 – Low awareness of metabolic health
Young, outwardly healthy individuals can compensate for poor metabolism for a long time before symptoms appear, making it seem like diabetes can arise out of the blue.
“I’m a firm believer in the concept that you can’t improve what you can’t measure and track. Without knowing where we’re at, how can we move in the right direction? I think a lot of us have no idea where we’re at in terms of metabolic health because as a young person, who’s generally healthy, you can compensate for a long, long time before you have just overt lab abnormalities before your glucose rises into the pre-diabetic range. Something that’s interesting is there are 128 million Americans who are pre-diabetic or diabetic. So that’s about a third of the country with an overt diagnosis of pre-diabetes or diabetes. Of those prediabetics, which make up 90 million of that 128 million, 90% don’t know they’re pre-diabetic. They go to the doctor and it’s a total surprise, or they just don’t know. Awareness is low.”
32:42 – An anti-oatmeal CEO
Thanks to CGM, one of Levels’ clients discovered that his body was not processing the glucose from oatmeal, which was spiking his blood glucose. He stopped eating oatmeal and it solved his brain fog and post-meal slump.
“Our core thesis is that to make sustainable behavior change, you have to really tighten the feedback loop and close the feedback loop between action and reaction and make it as one-to-one as possible. That’s really most amenable to the actual in-app experience as opposed to like the delayed retroactive report of some sort. Because one of our CEO’s was eating oatmeal for breakfast for 10 years. He always felt in the morning like he had to take his little mid-morning nap, and like a little post-meal slump. He wasn’t sure if it was his sleep was poor or too much caffeine or the food, but once he put CGM on, the first day he realized his blood glucose was spiking to 210, which is super, super high, every time he ate oatmeal. And then immediately when the glucose fell and dipped was when he would have his subjective brain fog post-meal slump. All of a sudden years of misattributing this information to all these potential variables, it was just very clear that there was a one-to-one relationship between oatmeal. And he actually never ate oatmeal again.”
36:35 – The phases of using Levels
When a new user starts measuring their glucose with Levels, the first step is setting the baseline. The next step is to move to the exploratory and discovery phases.
“There are multiple phases to using a technology like this, and really it starts with awareness and then moves into optimization and then moves into accountability. I think the very beginning is just like eating whatever you want, what you normally eat, and just seeing what happens and have these totally magical moments where you’re like, ‘oh my God, sweet potatoes sent me totally through the roof. I probably shouldn’t be doing it in this way’ and not even really getting too deep monopolization, but just learning. So really exploratory building metabolic awareness, then moving into some experimentation. What happens when I put a bunch of teeny on that sweet potato? What happens when I eat the sweet potato after a Peloton high-intensity interval training workout? I’m talking about really about a month’s framework here. So let’s say you’re using this for a month, which is what our current product is a one-month metabolic awareness experience. And then in that fourth week, you’re really actually taking what you learned from the experimentation and then trying to keep glucose low, flat and stable, which is what we want.”
Casey Means [00:00] One of the key drivers of chronic inflammation is metabolic dysfunction. So dysregulated metabolism, elevated blood sugar or blood sugar spikes. These things tell the body that there’s a problem. These things can cause upregulation of inflammatory cytokines.
Christa Biegler [00:15] Welcome to the Less Stressed Life podcast, where our only priority is providing those aha moments to uplevel your life, health and happiness. Your host, integrative dietician nutritionist, Krista Bigler, helps health conscious women reduce the stress and confusion around food, fatigue, digestive and skin issues at lessstressednutrition.com. Now onto the show.
Christa Biegler [00:40] Do you need to detox? January is really a time where the word detox gets thrown around and people spew all kinds of craziness on both sides of the fence. But here’s the thing, we need to show respect where respect is due, my friends. Detox is amazing and I happen to have a pretty intimate connection and knowledge on what detox looks like. And when it is slowed from waking up with a puffy face or your eyes being swollen or retaining water weight, or having skin stuff like acne, eczema, et cetera, pop-up or identifying as a sweaty person, not handling alcohol like I did when I was 21, not waking up energized, waking up in the middle of the night. You’ve heard some interesting eye symptoms I can trace to my detox systems. So, what do you do? Well, thank God. This is a podcast and not a Twitter post because it doesn’t fit in 140 characters. When people ask me questions, like, “What do you think of this chlorella supplement or dandelion tea or juice cleanse?” I want to sit down and give you the 101 on what’s happening inside your body, so you know exactly if and what that tea or supplement will or will not help. That’s why I’m doing a live detox masterclass on January 8th. Don’t worry, a replay will be available if you register for the live version. In my detox masterclass, you’ll get the detox 411 of what’s going on on the inside and outside of your body. Plus simple shifts you can make to make these systems work better. You’ll get how often you should give your body some love on your detox pathways so that your skin digestion, energy, and just your body in general, runs at its absolute best. You’ll also get my two week detox protocol that you can use then rinse and repeat to affect everything from how much fluid you’re retaining to improving sleep and energy, to how much you sweat, to that bear nose that you have. I’ve been wanting to do this forever and we’re finally doing it. So, just go to kristabigler.com/detox to take my ‘Do You Need To Detox?’ quiz and register for this jam packed masterclass. You do not want to miss it. So we’ll have this link in the show notes as well, but it’s kristabigler.com/detox. I’ll see you there.
All right today on the Less Stressed Life, we have a fun nerdy topic for you. We have Casey Means who is a Stanford trained physician, chief medical officer, and co-founder of the metabolic health company Levels, and associate editor of the International Journal of Disease Reversal and Prevention. I feel like these are big jobs. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech enabled tools that can inform smart, personalized, and sustainable dietary and lifestyle choices. It kind of sounds too good to be true, but I’ve been talking to her for the last 20 minutes and I’m really excited for what you guys are in for. So Dr. Means’ perspective is in, recently featured in Forbes Entrepreneur Magazine, The Hill, Metabolism Endocrine Today, Endocrine Web, Well and Good, and The How Not to Die series. She’s an award winning biomedical researcher with past positions at NIH, Stanford school of medicine and NYU. Welcome Dr. Means.
Casey Means [:03:45] Thank you so much, Krista. I’m so happy to be here.
Christa Biegler [03:47] Alright. Well, I can’t wait to get into the meat of this and I’m glad we went through it, but let’s get into- Okay. How does this start? I think, honestly, your story is the most powerful, so let’s start there because you’ve got a big job now. And so let’s talk about how this started. I think it’s fun to figure out, like I was telling you, I just got done interviewing someone who writes for Nat Geo and about stress. It’s like, you’re known for this stress resilience, and I think, yeah. How do you get into the next step of life? And it’s always your story. So tell us about how you got to working with metabolic dysfunction and we’ll talk all about that.
Casey Means [04:17] Absolutely. So it was kind of a circuitous path. So I came to digital health and really an obsession with metabolic health by way of ear, nose and throat head and neck surgery. So kind of an odd start, but you know, I trained as a conventional medical doctor. I then went into surgery. And so I was practicing, a trainee in ear, nose and throat, head and neck surgery. And what I noticed after about four and a half years of practicing was that pretty much all of the conditions I was treating were inflammatory in nature. So it was all the things with, you know, itis at the end, which usually means inflammations, like sinusitis, thyroiditis. And vocal cord granulomas, which are inflammatory masses of the vocal cords. Chronic ear infections, which are inflammation of the middle ear tissue that creates pus and fluid buildup. So kind of got me stepping back and saying like, “Why is everyone so chronically inflamed? You know, this is, inflammation is the immune system being triggered and upregulated constitutively, and that’s something we should look deeper into.” Certainly was aware of, there are so many environmental and lifestyle and nutritional causes of chronic inflammation. “And why is this not part of our practice? Why do we reach so quickly for steroids and antibiotics, and then ultimately surgery, these fairly morbid interventions when there seems to be, like there could be some really low hanging fruit of attacking these more environmental causes of inflammation?” So it became really, really fixated on understanding the root causes of chronic inflammation. And one of the key drivers of chronic inflammation is metabolic dysfunction. So dysregulated metabolism, elevated blood sugar or blood sugar spikes. These things tell the body that there’s a problem. These things can cause upregulation of inflammatory cytokines. And what’s interesting is that conditions of metabolic dysfunction, like obesity and diabetes, have upregulation of cytokines like interleukin-6 and TNF-alpha and CRP. And these are actually the exact same cytokines you see upregulated even in some ENT conditions. These seemingly very disparate conditions. But you know what we know, I think more and more, especially through the study of, you know, network and systems biology, is that a lot of these diseases we treat often thought were really isolated silos, like totally different things. You know, you think like, okay, acne, depression, IBS, cancer, diabetes, these are all totally different. We’re going to treat them differently. But when we really look at this more connected network and systems biology perspective, we realize that there’s actually a lot of core fundamental biologic processes underneath the surface that are really related to all of them. And so I think, really think the future of healthcare is going to be figuring out how we can attack those core pathways that affect so many different conditions. These fundamental root causes of disease, which I think will be a much more efficient way to help people deal with our whole host of symptoms and conditions. And so focusing on metabolic health, I became interested in, then the next question is like, how do we improve it? Like if this is a big problem for people and research shows that potentially 88% of the country has metabolic dysfunction, that was a study out of UNC a couple of years ago. 88% of the country with at least one biomarker of metabolic dysfunction. Okay. So if we’re going to move the needle on this, like how are we going to do it? And then we’re going to do it by helping people live healthier lives and make better choices. So it’s choices about food, it’s choices about environmental exposures. It’s choices about how people stress, how they exercise, how much they’re sleeping, how they’re tending to their microbiome, and those are all behaviors. And so ultimately the intervention needs to be something related to empowerment and behavior change. And that’s where I think digital health just really, really shines because the reality is we have our phones on us all the time. We’re very adept at this point at using them to generate data about ourselves. And so I think that there’s really neat opportunities to use them as a tool, to generate data about our own metabolic health and then help people strive to optimize it. So that’s sort of the journey from surgery to now, what I’m doing now, which is co-founder of Levels and building this tool that does exactly that. That helps health seeking individuals essentially understand and improve their metabolic health in real time.
Christa Biegler [08:19] I feel like you have a lot of stamina and you’re a very progressive doctor, because you don’t just jump from ENT and surgery into what you’re doing now. So it’s probably a bit more interesting, like even how that kind of happened, because it would be a side thing for a long time. There’s a lot of grit there, is what I’m saying. Right? A lot of other credits. So.
Casey Means [08:38] Thank you. I mean, I honestly blame so many of the authors that I was reading during that time, like all these functional medicine and longevity medicine doctors, because they planted these seeds in me. And I think once you start hearing these messages, it’s very hard to go back. Some of the key ones that I was reading during my residency, where people like Mark Hyman, you know, The Ultramind Solution. Dr. Sara Gottfried, she wrote The Hormone Cure. Terry Walls, Dr. Joel Fuhrman, Dr. Michael Greger. I was reading, you know, David Sinclair, Lifespan. Like all these people who are really talking about- Eric Topol. Just doctors who are thinking differently. And I would be walking through the hospital late at night on call and I’d have my audio book playing some of these voices. And once that really root cause approach to healthcare was sort of embedded in my brain, it’s really hard, I think, to turn back. So I blame/very, very grateful for all these thinkers who have really put their brain to the paper and shared these ways of thinking. I have to also shout out Jason Fung who wrote Diabetes and Obesity Code. These are some of the ones that just changed my life. And I really appreciate it.
Christa Biegler [09:45] I think also it might be important for someone to know, I think people are looking for this all the time and it is accessible, but it’s not necessarily everywhere. And why is that? I was telling a new client this morning, and I said, “You know, I think a lot of practitioners, we want to practice differently because the reason we change is either from inspiration or desperation.” And it’s usually desperation. And of course, I’m sure you felt that when you were doing what you were doing in your work, I was doing that as well. And it was like, “I can’t keep, this is like, I’m burning out here,” you know, of course. And so my point is there’s not necessarily straightforward uniforms. We don’t learn this in school, how to do root cause approach stuff so much. I mean, a little bit, not like in the ways that we apply it to clients now. Right? Or apply it to patients now. It’s not like that. So I think that’s the challenge. And the one of the beauties is that we’ve evolved because of dissatisfaction maybe, or the need to be better. And so we’ve kind of created all of our own avenues there, but it’s not like you can just go get trained to understand this. You kind of have to figure it out. Kind of like a lot of things, I suppose, like any profession, right?
Casey Means [10:47] Yeah, but it’s true. I do think it’s true in healthcare. We have a dominant way of thinking and approaching conditions and it’s very, very strong. And it’s very focused on reactionary intervention. So what we sometimes would call sick care instead of healthcare, meaning that we don’t tend to really focus or intervene until a disease state has manifested and then we approach it in this very singular way of like, we’re really just playing whack-a-mole with that condition at one time. It’s very rare that someone’s going to be thinking about chronic ear infections in the context of, “Oh, well, they also have, you know, IBS and they have Hashimoto’s and they have eczema. And they have some anxiety, like how could these things possibly be related?” No, we’re going to treat that ear infection, maybe put ear tubes in. And that’s sort of it. And that has worked very well for many conditions, but because the issues that we’re facing these days and the majority of morbidity in our country and healthcare costs is chronic disease, these are diseases that are not, they don’t require just a little acute fix. They are conditions that have manifested over years, if not decades, and are very frequently related to diet and lifestyle. And so we just can’t use the same toolbox and that same approach. If we really want to reverse these epidemics at scale, we really, I think, have to be thinking upfront. And that’s just not really what has been the dominant thought over the last 50 years or so, but I really see a movement happening. I see doctors thinking about this. A lot of these authors are very, very popular and so I’m very hopeful. And I also think the economics are moving in that direction too. You know, we’re moving towards more value-based care where it’s really an equation of outcomes over cost. We want better outcomes for a lower cost. And if we want that, it is always going to drive towards prevention because prevention is cheaper than treatment. And so I think there’s good forces at play.
Christa Biegler [12:34] Yeah. That’s nice because in policy, from a side note, though, they can’t assign, I think it’s called a CBO congressional budget office, they can’t assign a cost to prevention or they couldn’t when I used to go to DC and advocate for prevention. And so it kind of feels- So anyway, I think though, as consumers and grassroots, we drive the change. Right? Of course, because you can’t wait for someone else to change it for you. So we tend to take it into our own hands. So let’s get into the meat here, which is metabolic dysfunction and what we’re going to do about it. So I think about metabolic dysfunction, I think about metabolic syndrome, which feels like a trashcan diagnosis, kind of, right? It’s like an umbrella of stuff. Right? So kind of like inflammation. I talk about inflammation all the time. That is my jam. But let’s talk about what that looks like. What does it feel like? And then eventually some, a bit objective biomarkers, but metabolic dysfunction first.
Casey Means [13:21] Yeah, absolutely. So the way I like to think about metabolic dysfunction is actually to really start with like, what is metabolism? So metabolism is the set of cellular reactions and cellular processes that essentially create energy from our food and environment. So we take in, you know, food, things like carbohydrates and fat macronutrients. And ultimately to power every single cell in our body, we have to convert those basic substrates into usable energy. So things like ATP. And that has to happen efficiently. It has to happen in a way that doesn’t create, you know, undue byproducts that are dangerous, that there’s not an excess of substrates that we can’t use and then stores other stuff. It just has to happen really, really efficiently. And unfortunately, because of the way we’re living these days and what we have exposure to in terms of our food access and our general sort of western lifestyles, a lot of those really promote poor metabolic efficiency and metabolic health. And so for instance, like we have so much access to refined carbohydrates, refined sugars, and this is just creating a huge substrate load in our body of glucose. And that glucose, which is one of our primary energetic substrates, when that goes into the bloodstream, it’s going to stimulate the pancreas to make insulin. And when that happens over and over and over again, multiple times per day, over years, you’re getting these glucose spikes and these insulin spikes, as I’m sure many of your listeners know, this is going to lead you down the path of insulin resistance. And what that means is that the cells become tired of hearing that intense insulin signal and they actually become a little bit numb to it. And so your body has to produce more insulin to get the same amount of glucose in the cell. And then this just creates a vicious cycle where you’re becoming elevated insulin at baseline hyperinsulinemic. And what happens there is that then if this happens over the long period of time, ultimately your body actually is going to have trouble getting glucose into the cells at baseline. Like it’s going to become so resistant that you’re actually having trouble driving glucose as efficiently into the cell at all. You can’t overcompensate at some point. And then glucose levels really start to rise and your fasting glucose is going to go up. Your average glucose is going to go up. So we’ve got high insulin, high glucose. So that’s inefficient metabolism right there. But what also is happening is that as that insulin is elevated, it’s actually a signal to the body that we’ve got tons of energy from glucose. So we don’t need to use fat, this other storage form. And so insulin is not only a signal to take glucose up into the cells, but it’s also a blocker on fat burning and fat oxidation because it’s telling the body, “There’s plenty of this other resource around, we don’t need fat.” So by having that insulin elevated, you’re not going to be tapping into that fat burning, going to reduce metabolic flexibility, i.e. the ability to flip between glucose and fat burning. And of course, for someone interested in losing weight, it’s going to be a huge barrier because you’re not burning through your fat for energy. So that’s sort of what, on the molecular surface, the movement towards metabolic dysfunction looks like. And what’s really interesting is that the clinical sort of picture of what metabolic dysfunction looks like is so incredibly broad. It can look like almost anything. So some of the conditions that are associated with blood sugar dysregulation or metabolic dysfunction, they range from things like as simple as acne, premature balding to things like infertility, polycystic ovarian syndrome, erectile dysfunction, fatty liver disease, chronic kidney disease, of course, diabetes and obesity, things like chronic pain, fibromyalgia, depression, anxiety, brain fog, Alzheimer’s, peripheral vascular disease, hypertension, heart disease. There’s literally, you know, it almost feels like every symptom we could think of, there is some relationship between metabolic dysfunction, but this makes sense because every cell in the body needs energy to function. And so if those core pathways are off, are perturbed, are insulin resistant, whatnot, you can imagine how, where that’s kind of showing up in the body. What cell type is the symptom you’re going to get, but it can really look like anything. So metabolic dysfunction wears so many hats and I think we’re not fully aware of that, that there’s so many branches to this one tree. And so from my perspective, it is just a very high yield area to focus on in healthcare, because there’s just many multifarious benefits that often you might just see melt away as, “You really nailed this core fundamental pathway.” So just an example, polycystic ovarian syndrome, leading cause of infertility in the country, fundamentally a metabolic disorder where there’s too much insulin stimulating the ovaries that causes them to make more testosterone. It creates menstrual irregularity, people become infertile. And you get all these other symptoms associated with high testosterone, like acne and hair growth and all this stuff. So in our medical culture, we might prescribe birth control pills for these people or exogenous hormones to kind of meta control the hormone cycles. We may even prescribe Metformin, which is a diabetes medication that is an insulin sensitizer, but neither of those things are actually going to affect the core process of blood sugar dysregulation that if you attack there and put the investment of energy there, could have so many other positive effects for that patient in that person. So that’s kind of the spectrum of metabolic dysfunction and the phases of it. And what’s hopeful about it is that no matter where you are on that spectrum, you can really always improve. If you can get your blood sugar under control, minimize those daily spikes and those spikes over time, you’re going to create less insulin release in your body. You’re not triggering the insulin, it’s eventually going to come down and those cells are going to perk up again and be able to hear that insulin become more insulin sensitive again, and you can move in the right direction on the spectrum. So it’s actually a very hopeful part of healthcare because it’s not like a one directional path where once you’ve kind of gone down that you’re screwed. No. Like you can very much move in the other direction.
Christa Biegler [19:00] I loved that so much. And I’m going to recap it in slightly different words in a way, because we’re talking about, metabolic dysfunction can look like pretty much freaking everything, but at the very root of that is blood sugar instability, which can look like hunger, needing to pack a bunch of snacks in your bag. It can look like weight loss resistance. It can look like hormone dysfunction, PCOS, which you spoke to beautifully. Often doesn’t get diagnosed properly for years. I think it’s seven years is how long it takes for a PCOS diagnosis, irregular periods, maybe hair growing in the wrong place, et cetera. So you’re speaking the right language here, right? We’re looking at root cause approach. You thought about, “What is the biggest heaviest hitter that we know a lot about that we can influence and it could freaking change everything people complain about all the time?” Blood sugar.
Casey Means [19:44] Yeah.
Christa Biegler [19:44] So blood sugar is not for diabetics. Blood sugar is for everyone, to have awesome blood sugar because you need good energy. I mean, that would sum it up right there, is like people want good energy, but it’s so much dang more than that. Okay. So let’s talk about the importance of blood sugar. But also before we get to that, off air, we had a little chat about this and we were talking about stress implications on blood sugar. And I would love to talk about that actually really quick, before we go into just blood sugar alone.
Casey Means [20:08] Yes, absolutely. So the intersection with stress and glucose is absolutely fascinating. And it’s really fascinating because this is an area where evolutionary protections have essentially gone awry in our modern world. So it used to be that when we were stressed, it was often like physical stress. So it was like, you know, there’s the classic example of like you’re being chased by a lion, you know, and that’s a stressor. And so in that situation, your muscles need glucose to work very quickly and actively. So we have this pathway in the body where the stressor creates a hormonal cascade, usually involving cortisol and epinephrine. This signals to the liver, which stores a little bit of glucose for special needs like this, to dump that glucose into the bloodstream rapidly. You’ll see a blood sugar rise and that is to feed the muscles, which need it. And so that’s an evolutionary sort of advantage. But now so many of the stressors that we’re facing are chronic low grade stressors and they’re almost universally psychological stressors- honking, loud neighbor, text message coming in, a stressful email, a conversation, you’re giving a talk, whatever. These things just register the exact same way as our bodies as stress. And they will cause this hormonal cascade, the cortisol, the catecholamine hormones. And they will stimulate the liver to raise your glucose. Unfortunately, you don’t need to run anywhere. You’re sitting in your computer chair. Like you don’t actually need that glucose. So you get this glucose rise that is ultimately maladaptive, and we don’t want those glucose rises for clearly the reason that I talked about earlier, which is going to cause these insulin spikes, which over time can tend to lead towards insulin resistance. But there’s also things about glucose spiking in its own right that are problematic. Glucose can trigger chronic inflammation. Glucose can trigger oxidative stress. It can trigger glycation, which is where high glucose concentrations in the blood stick to different proteins and other cellular structures and change their function. It can actually maybe even have epigenetic changes. So you just don’t want those frequent rapid spikes. And we know that stress can do this. There’s so much research out about this that’s really painting this picture right now. So studies that have been done that have looked at people in war zones and looking at their glucose over time and seeing just like a rapid increase in metabolic dysfunction after living in a war zone; really interesting study out of Israel that looked at that people who have had adverse childhood experiences and future metabolic outcomes, and then even acute stressors. So like perceived work-related stress events can cause an increase in glucose. So very, very interesting stuff. And actually acute traumatic experiences can acutely change your insulin sensitivity. So the way the cells are just like immediately sensitive to insulin. So this is something we really want to think about. We always think about food in relation to glucose, but there are so many other factors. And I think stress is one of the huge ones. I would say, sleep and movement are other really big ones, but you know, food is necessary for metabolic health, but it’s not sufficient. We’ve got to also dial in the stress, the sleep, the exercise to really maximize our chances of this really optimal performing machine.
Christa Biegler [23:16] Yeah, I love it. It’s so great. So that’s all hunky-dory right? It’s so fun to learn about what’s going on in your body, but this is taking it a step further. We’re looking at objective measurements, which give us immediate feedback, and this is how we change habits. And this is how we change lifestyle, right? Because it provides us motivation, because we literally see it tangibly. And so frequently we have a hard time grabbing onto something because we don’t grab it. We don’t do something tangible. So this is where continuous glucose monitoring came in. Let’s talk about the history of continuous glucose monitoring, how it’s traditionally used and what the next frontier is for it and how it marries what we’re just talking about.
Casey Means [23:51] Yeah, absolutely. So I’m a firm believer in the concept that you can’t improve what you can’t measure and track. So, you know, without knowing where we’re at, how can we move in the right direction? And I think a lot of us have no idea where we’re at in terms of metabolic health, because as a young person, who’s generally healthy, you can compensate for a long, long time before you have just overt lab abnormalities, before, your glucose rises into the pre-diabetic range. And something that’s interesting is there’s 128 million Americans who are pre-diabetic or diabetic. So that’s about a third of the country with overt diagnosis of pre-diabetes or diabetes. Of those prediabetics, which make up 90 million of that 128 million, 90% don’t know they’re pre-diabetic. So they go to the doctor and it’s like a total surprise, or they just don’t know. And so awareness is low. And I don’t think the average person out there with acne or PCOS or eczema realizes that their glucose might have something to do with this because they’ve been told their glucose is normal, but that doesn’t take into account the full picture and how much our bodies might be pumping out that insulin to keep us in that normal range. So with all that said, the question is then how do we track it? So there’s been different ways to do this. One is a finger stick. So you actually just buy this little kit over the counter at the pharmacy. And it’s like a little lance. So it’s a little needle and you prick your finger and you use a test strip and it tells you in your home what your blood glucose is at that moment. These have been traditionally used for diabetic individuals and, you know, people do these like around one to five times a day to kind of see where their glucose is, when it’s after meals, if they need to dose their medication differently. In the past 10 years or so, there’s been a new technology that’s come online called continuous glucose monitoring. And this is a wearable sensor. You can think of it kind of like a Fitbit for glucose, and you stick it to the back of your arm. It’s about the size of two stacked quarters, very small and low profile, lasts on the arm for 14 days. And it’s actually picking up glucose every five to 15 minutes, depending on the brand, and sending it to your smartphone. So you have this vastly more robust data stream about what’s happening. So as opposed to maybe catching a post-meal glucose spike, you know, but you’re not quite sure if you got it at its peak or as it was going up or going down with a single finger prick measurement. Now you’re just seeing the whole curve, like the up, the down, the slope, how long it was elevated for. How much, you know, your stressful call elevated your glucose, how much your oatmeal have elevated your glucose. So it’s just so much more. And this has been used, it’s an FDA approved prescription only device for people with type one or type two diabetes. But as we’re learning more about metabolism and how metabolic dysfunction and blood sugar dysregulation is at the root of so many conditions, it really begs the question like, “Why wouldn’t we use this technology in everyone? To really help people get on top of this early and hopefully never get to that late stage.” And aside from just preventing future disease to just really optimize our current life, like, you know, help get rid of the hunger. Like if you can keep your glucose spikes down now, even if you’re totally healthy, that means that you’re probably going to be able to keep your insulin down and get into fat burning more. And that’s really the answer to hunger, is not relying just on glucose for your energy. If you can flip over into fat burning really efficiently, which is what metabolic flexibility is, less likely to get that starving hunger feeling when you haven’t eaten in a few hours. So even for those people who thought they have normal blood sugar, just kind of reducing some of that variability can just really up-level our current health and wellness. So what my company Levels does is we are bringing this technology to the mainstream market. So making it widely accessible for that just health seeking individuals without diabetes, to get access to these devices through our telemedicine network, and then have software that takes this raw data stream, just all these data points and convert it into actionable information. So helping people understand what aspects of their meals was really causing the glucose elevations. And then what aspects of lifestyle- sleep, stress, exercise, et cetera. We’re also potentially driving those results. So that’s what we do. And I think there’s just a lot of excitement out there. You see on the blogs and podcasts, people are pricking their fingers. People are using this for athletic enhancement. People are using this to get the extra edge. And so it’s really neat that there is a technology that’s going to, I think, take this all to the next level.
Christa Biegler [27:59] Yeah. So tell me, it makes sense to understand when meals are, because we usually think about blood sugar, as you said, around food, you know, pre and post meal, but how does the continuous glucose monitor understand in its algorithm that I had a stressful email or work call or whatever? Like what’s it, how is it kind of discerning that when it’s trying to give you feedback?
Casey Means [28:21] Well, the hardware itself is only going to pick up the glucose, but this is where the software overlay can be very, very powerful. So the software can pull in other data streams. So the heart rate data, the Apple HealthKit, the Google Fit data, and understand how much you slept the night before, what your heart rate variability was, how many steps you took when your heart rate was elevated, if you did a high intensity versus a medium intensity workout, all of those things. Pair that with the glucose curve and the food logging data, and start to make some higher level insights about what might be happening and which of those behaviors are actually driving what we’re seeing. And so you can imagine a situation in which, you know, you do some experiments like, “Okay, I’m having oatmeal for breakfast. And on Monday I’m going to have oatmeal alone, on Tuesday, I’m going to have oatmeal after having two hours less sleep, on Wednesday, I’m going to do oatmeal and then take a walk afterwards. And then on Thursday, I’m going to put oatmeal and I’m going to put 30 grams of fat of walnuts on top of it.” And all of a sudden you can really start to parse out like which of those extra variables were changing the way that you processed the glucose or processed those carbohydrates into glucose. And the fascinating thing is that everyone is going to have different responses. So if you and I could both eat the exact same bowl of oatmeal, and I could go up a hundred points on my glucose and you might go up five points. And this has been well studied. They’ve done research. There’s a really interesting paper that came out a couple of years ago called Personalized Nutrition by Prediction of Glycemic Responses that put continuous glucose monitors on a bunch of healthy people, gave them standardized meals and then looked at the glucose responses and they found that you would predict based on this idea of the glycemic index, that everyone would respond the same of food causes this much glucose elevation. But that’s not at all what happened. People were all over the place. A hundred people ate a banana and it was just spikes, totally different levels of spikes. And they looked at the predictive factors for this. And some of the predictive factors were microbiome composition, anthropomorphic features like body type, which can kind of tell us a little bit about insulin sensitivity. You know, whether you have more of a visceral adiposity versus a subcutaneous fat profile, and then how much sleep people got previously. So these other factors actually were mitigating how the carbohydrates turned into glucose in the blood. So testing those things individually can just be a really fascinating and personalized experience. And fortunately and unfortunately, we just can’t make generalizations for everybody about sort of what the optimal diet and lifestyle is because it’s so much an interaction between all these complexities about our underlying biochemical individuality.
Christa Biegler [30:54] That’s why we always have a pause as practitioners sometimes when, let’s just use genetic testing as an example. I don’t want to use a lot of genetic testing companies because they push out these very generic algorithm-based suggestions for people, which is inappropriate. And so this is a much more personalized. But so I understand, we’ve got our device, it’s like two quarters, it’s sticking onto your arm. And we’ll talk about the benefits of this versus pricking your finger. I mean, I think it’s like, “Duh, put it on once.” Like you said, it’s like dental floss basically, that needs to go in essentially. I mean, there’s a little bit of tool to do it, but it doesn’t have pain. No one complains about pain. Stays on for two weeks and then you swap it out for another one because you do this for at least a month to be able to get- So this is like, really you’re attracting the old biohacker who loves optimal health at the moment, but that’s essentially what you’re doing. And then it’s transferring this information when you hold your phone near it to your app. But in my understanding that it’s going to talk to other apps that you might be using to track other biometrics or other health markers, more so.
Casey Means [31:56] Yes. Yeah. So at this point it is integrated with Apple HealthKit and Google Fit to get that other wearable data that people might be using to start bringing that in as part of the data analysis.
Christa Biegler [32:07] Could you also enter that you exercised at a certain point or anything in the app? Is that like you can input something so it understands that?
Casey Means [32:14] You can, yeah. You can make notes about anything-food, exercise, stress, any other life events, super easily. If there’s something very specific you’re trying to track, like, let’s say you did an ice bath or something, you know, that’s not necessarily built in as an option that you can choose in our product, but you can write a note so that you can track that.
Christa Biegler [32:32] Right. And then can you export the data pretty easily? Like if you want to print it out and look at it.
Casey Means [32:36] Yeah. So, you know, most of the functionality of the app is really an in-app experience, but there’s an easy way to get sort of a report at the end that kind of, is more the PDF version of this. But the vast majority of the experience is focused around the in-app experience that’s really trying to drive this real time behavior change. So our core thesis is that to make sustainable behavior change, you have to really tighten the feedback loop and close the feedback loop between an action and reaction and make it as one-to-one as possible. And so that’s really most amenable to the actual in-app experience as opposed to like the delayed retroactive report of some sort, because like one, our CEO, he was eating oatmeal for breakfast for like 10 years. And, you know, he always felt like in the morning, like he had to take his little mid-morning nap, like he’s, you know, in a little post-meal slump. And he kind of wasn’t sure if it was his sleep was poor or too much caffeine or the food, but once he put glucose CGM on the first day he realized his blood glucose was spiking to like 210, which is super, super high every time he ate oatmeal. And then immediately when the glucose fell and dipped was when he would have his subjective sort of brain fog post-meal slump. So all of a sudden years of sort of misattributing this information to all these potential variables, it was just very clear that there was a one-to-one relationship between oatmeal. And he actually never ate oatmeal again. And now he eats the avocado and eggs for breakfast. But you know, certainly it’s not about eliminating things like that because there’s lots of ways you can modify a food to make it less glycemically unfriendly, adding fat protein, et cetera. But yeah, so it’s just, that’s really our core premise, is like how can we make it as real time for people to understand a one-to-one relationship between something they’re doing, what the objective data is and how they actually feel. And that trifecta, I think, is really at the root of behavior change.
Christa Biegler [34:27] Right. I mean, we were picking on food there, but I would be so curious to know if, does a full day of clients, back to back to back, what does it do to my blood sugar? Am I having a stress response to blood sugar? It’d be so fun because there’s days I don’t do that, right? And there’s different feelings at the end of the day, but that could be due to so many things. It’d be so interesting to see if, does this? And I do manipulate variables, but you were talking about people can have a lot of generally quite a few variables, and be able to kind of see what this feedback is. And one of the things I do with clients is kind of try to back down on lots of variables on purpose. Like, I hope this makes sense. If you have too many variables at once, you can’t tell why the windshield is dirty. And so I try to crank up the variables very tightly for a little bit, to try to one, clear off some windshields, then add things back to see if it’s what’s hitting the windshield, et cetera, if this makes sense. Right?
Casey Means [35:16] Totally.
Christa Biegler [35:16] And so it just reminds me, I just think there’s like this, I’m excited about the potential utility here. Right? Of course. Because again, it’s one giant recourse but, I always say, for example, just hitting this again, this is going to be good for anyone who already has something. Well, let’s say if you have an irregular cycle, right, this would be good for you because if you have an irregular cycle, that’s one out of the two ticks you need on the list for PCOS. You only need two out of the three major symptoms. So if you already have an irregular cycle, addressing blood sugar is going to be relevant. Addressing blood sugar is going to be relevant for any hormones because blood sugar, it affects everything. Right? So I’m just thinking about literally anything and how useful and important it could be. So tell us a little bit more, like you’ve basically gone through some of the tactical pieces. I mean, you’ve gone through a great background. You’ve given us some tactical that, “Oh, there’s wearable continuous glucose monitoring devices.” When I was thinking about this originally, I wasn’t thinking about it being a patch I guess, as much as sometimes you see other wearables that are a little bit bigger, but you’re right. This is super progressive. It’s like the wearable market. It’s very noninvasive. So what comes next? So we’ve got the wearable, there’s the app, what do people do with this data overall? I know that they can change behaviors, but like, why don’t you use your story a little bit and how you changed behavior?
Casey Means [36:33] Yeah, absolutely. So I think there’s multiple phases to using a technology like this, and really it starts with awareness and then moves into optimization and then moves into accountability. So I think the very beginning is just like eating whatever you want, what you normally eat and just seeing what happens and, you know, have these totally magical moments where you’re like, “Oh my God, sweet potatoes sent me totally through the roof. I probably shouldn’t be doing it in this way.” And not even really getting too deep an observation, but just learning. So like really exploratory, building metabolic awareness. Then, you know, moving into some experimentation. So like, “What happens when I put a bunch of tahini on that sweet potato? What happens when I eat the sweet potato after a Peloton high intensity interval training workout, what happens?” And then the end of it sort of, and I’m talking about really about a month’s framework here. So let’s say you’re using this for a month, which is what our current product is, a one month metabolic awareness experience. And then in that fourth week, you’re really actually taking what you learned from the experimentation and then trying to keep glucose low, flat and stable, which is what we want. We want it to be just, you know, really just very gently rolling hills, no big spikes and dips. And so that’s kind of what I think you can start to do in that first month, but I have a little bit of a different case. I’ve been wearing this now for the 18 months since we started this company, and I can’t imagine at this point really taking the sensor off. I think I was really learning how to optimize probably for two, three, four months. And then once it was just very clear to me, like what I had to do in relation to my meditation, my mind body practices, my sleep, my exercise, my food pairing, my food timing. When I kind of got all of that sorted out, it really was then more about staying on track. So seeing your data be bad, it’s not a positive feeling. And so you want to keep in the green zone and you want, it also helps that I’ve got, all my coworkers can see my data. And so there’s a bit of a peer pressure component. So that’s been really my experience is like. Awareness, experimentation, optimization, and then now accountability. And I think for me personally, so I’m plant-based, I’m vegan. I eat tons of carbs. I eat like probably two cups of beans every single day. And for me, it’s been a fascinating journey of really optimizing my plant-based diet. I was already eating whole foods plant-based. So not like refined stuff. I wasn’t even like a bat, you know, sort of a process to vegan diet. It was very, very whole foods based, but there were still foods within that that were just sending me absolutely through the roof. So like white rice, sweet potatoes, corn, grapes, oatmeal. These things were sending me into pre-diabetic ranges. And so it helps me just figure out how to really minimize some of those massive spikers for me. I definitely moved more away from grains. Like probably I rarely eat rice anymore. And now I’m very into cauliflower and broccoli rice, and I make it myself in my Cuisinart and I even make sushi with cauliflower rice. So it’s been this fabulous- And I love that now, probably even more than rice and it doesn’t do anything to my glucose. And so, just learning all those little tips and tricks, I’ve moved really from pasta to zucchini noodles. I’ve learned that I’m not going to give up sweet potatoes or grapes or corn. They’re very healthy foods, but now I make corn chowder that has whole coconut milk and cashews blended into it and all that fat really buffers that glucose spike. So it’s just really about learning to modify. And that was just such a fun process. And so now I really see it as like, how can we have these diets that we want to eat that are like? I’m never going to become a carnivore or like a hardcore standard keto diet person because that’s not in line with my sort of food philosophy. So, but how do I take the diet I want to eat and then reduce all the collateral damage of it by making it a more intelligent, thoughtful, personalized biofeedback informed diet? So I think that’s really going to be the future of nutrition, is biofeedback informed, personalized diets. And I just would be very suspect of anyone saying like, “This is the right diet for everyone,” because I don’t think that’s possible given what we know about the microbiome and genetics and all these other factors that impact our response to the same foods between people. So the more we can personalize it and personalize it in that closed loop way, I think is going to be really empowering for people to shape the diet they want without the collateral damage.
Christa Biegler [40:38] I like when there’s recurrent themes. And so we’ve talked about empowerment and I always, sometimes people say to me, and I think it’s the best gift ever. They’ll say at some point, like I have so much more awareness about this and that’s perfect. And this is, I love it. I don’t know what we called, if this was the stages of improvement, but really it was awareness, experimentation, optimization and accountability. And I’ve never thought about it like that before, but I’ve used all of those words all the time. And so I’ve never put them in that list and I love it. And it would be so cool to put, like it’s fun to assign: How long do I spend in this phase, in this phase, in this phase? I like mnemonic devices. And I like things that I can remember where I’m going with something or kind of a linear plan. It helps us stay focused in center on where we are, because we’re naturally impatient creatures. So we kind of just want things to change right away. And so being aware of kind of where we need to fall in the steps of things. I think it’s just cool to talk about what comes after this step of awareness and how you preserve, and help keep those things. So. So such a fun conversation. I really appreciate you guys reaching out and for sharing Level with me. And I know you’re in this beta test phase and this podcast may publish in approximately a month, month and a half, two months. And so I think, maybe still be in that phase unless that’s going to change. So maybe speak to where the company is in two months. I know you said you’re definitely doing intensive testing before getting super wide audience. So where are you guys at now?
Casey Means [41:56] Yes. So we are, like you said, we’re in a closed beta program. So we’re really refining the product with a limited number of customers. And we have about a thousand people go through the program to really refine our product and aiming for more of a full launch in about three to four months. But in the meantime, we really encourage people to go to the website levels health.com, sign up for the wait list and you’ll get on our newsletter and really high quality educational pieces from academic researchers who are writing really cutting edge stuff on metabolic health that’s coming out in our newsletters. Yeah. And certainly follow us on Instagram and Twitter @levels. There’s really fun things you can learn about other people’s experience who are in the beta program and kind of get teed up to figure out some experiments you want to run for yourself when using a CGM. So yeah, in two months we’ll probably still be in that closed beta program, but yeah. Please connect with us for sure.
Christa Biegler [42:44] Yeah. And we talked about if you’re still in the closed beta program that we’ll have a code for you guys to skip the wait list. So if you do want to get into the closed beta, because I think education accelerates you to the front of the line and you’ve just spent 40 minutes being educated about the powers of glucose monitoring. So if you feel like, “I am not going to wait for this,” then we’ll have that code for you in the show notes.
Casey Means [43:05] Yeah. Yeah, absolutely. So yeah, we definitely would love to have listeners who are interested in this and, you know, committing the time, like you said, to really be able to try this out. So we’ll have that code available and that gets you, yeah basically to, into the closed beta and to the front of the line. So-
Christa Biegler [43:20] Awesome.
Casey Means [43:21] We’ll be excited to connect with people.
Christa Biegler [43:22] Well, I’m excited to do the follow-up on this after I’ve tried it. So thank you so much for coming on today and for talking and doing all the great science chat that we love here.
Casey Means [43:30] Thank you so much, Krista. It was wonderful to chat with you.
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