198: How to Test and Improve Your Metabolic Health | Casey Means, MD

Casey Means, MD is a Stanford-trained physician, Chief Medical Officer and Co-Founder of metabolic health company Levels, and Associate Editor of the International Journal of Disease Reversal and Prevention. 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.

In this episode of The Genius Life with host Max Lugavere, Levels Chief Medical Officer and Co-Founder Casey Means shares why she left a career as a surgeon to found Levels and focus on metabolic health. She explains that her mission is to maximize human potential and reverse the epidemic of preventable chronic disease. It sound like a lofty goal, but it’s made possible by empowering individuals with tech-enabled tools that can inform personalized and sustainable dietary and lifestyle choices.

Whack-a-mole medicine

Dr. Means found herself frustrated as an ENT surgeon when she realized that we live in a reactive, medication-driven healthcare system.

We’re in a reactive system that waits until diseases manifest, and then we play whack-a-mole medicine where unfortunately we treat each condition as if they’re totally separate different things, as if they’re isolated silos. And that feeds into the system that we have where we give a different medication for every single condition. And unfortunately, the reality is this doesn’t really work. Healthcare costs are going up in our country, $4 trillion now. They’re going up every single year and people are getting sicker, people are getting heavier, getting more depressed, it’s just not working. And so as a physician, I’m sitting there taking people to the operating room every day. It is a huge thing to operate on someone. You’re cutting into their body. And then they’re coming back for revision surgeries and just thinking I’m not really making the impact that I want on helping people be healthier.

Blood sugar is key in energy processing

It’s no secret that Americans blood sugar is out of whack. Dr. Means helped found Levels to try to curb the growing epidemic.

Blood sugar is one of those key parts of our energy processing in the body. And we’re just eating way too much blood sugar. And basically the average American is having trouble processing blood sugar in this country, and that’s leading a metabolic disease. Over 50% of Americans have prediabetes or Type II diabetes, it’s insane. That number should be close to zero. And more broadly, a recent study in 2018 from UNC showed that 88% of Americans have at least one biomarker of metabolic dysfunction which means impaired blood sugar, cholesterol, or weight. And so this is clearly one of those elephants in the room that we have to solve…that led me to starting Levels which is the company that I co-founded and chief medical officer of, which is a company that gives people access to biosensors, continuous glucose monitors that can actually track their glucose 24 hours a day, seven days a week and see exactly how food is affecting their body in real time and get a real sense of what their blood sugar is.

Metabolism is how we transform food

All of our cells need energy to function. It’s best if they get the right type and amount of energy.

Simply put metabolism is all the chemical and cellular reactions that are happening in the body that produce energy from food. It’s how we transform the food that we eat in to energy that we can use. And then if we’re not using that energy, how we store it, and this is fundamental to all aspects of health because if you think about it, all we are really is 37 trillion cells. Our entire structure we of course have trillions of bacterial cells as well. But every single one of those 37 trillion cells in our bodies need energy to function properly. And when cells don’t function properly because they’re not making the energy they need, depending on which cell type that’s happening in, it could look like totally different symptoms.

A sugar overload

Did you know that we eat 20x the sugar humans ate 100 years ago? That type of excess confuses and gums up the body.

The modern Western world is hijacking our cellular physiology, our core basic pathways of how to produce energy. And the reason that’s happening is because one of the factors is food certainly and sugar is a big one. We’re eating probably almost 20 times more sugar than we were eating a hundred years ago. The average American you’ll see different statistics, but eating somewhere around 60 to 152 pounds of sugar per year. We should probably be eating less than one pound of sugar per year. So that’s just monumental load on the body gums up the system.

Don’t follow the American path

If you follow the crowd when it comes to American diet and lifestyle, Dr. Means says that you will get sick – it’s just a matter of when.

If you just go on the normal treadmill of just American culture, you will get sick. That’s almost a guarantee if you just do whatever that’s in norms, sitting, eating packaged foods which make up 70% of our calories these days, letting your phone beep in the middle of the night so you’re getting poor sleep, you’re going to get sick. And so you really have to do something differently these days if you want to escape that. And the beauty is it’s fairly simple, but you do have to be vigilant and you have to be aware. And that’s where I think education, what you and many others are doing in the nutrition space and the wellness space, but also potentially things like monitors which is really why I’m excited about Levels is that it gives people the data in their own hands.

Prioritize whole foods

Our bodies evolved knowing how to process whole foods that appear in nature.

I’m of the camp that if it’s a whole food that’s unrefined, it’s a good thing for your body. Our body knows deal with whole foods and if we’re primarily eating those, we’re going to do well. Now, there are ways to even eat certain whole foods in a way that is actually more optimal for the body. So for instance, if you’re eating the berries, you can find many ways to mitigate a glucose spike by eating the berries with additional fiber fat or protein to not have such a glycemic excursion, and I actually think that is probably better for the body. So what that might look like is some whole milk yogurt or full fat cashew, non-dairy unsweetened yogurt with some chia seeds and flax seeds on top and the berries.

Keep glucose stable

The key to overall health is keeping glucose stable, which the Levels CGM tech makes possible.

The more we can keep our glucose flat and stable, the better for long-term health. That doesn’t necessarily mean we always have to add fat and protein to every car we eat, but there’s other adjuncts like the walking and exercising, making sure we’re eating our higher carb meals after a good night sleep and not when we’re sleep deprived because our glucose responses are always going to be higher, and our insulin response is if we eat them after a really poor night’s sleep. So there’s just these ancillary things that you can do to think about the context with which that meal is coming into your body to minimize that metabolic response.

Ask for a glucose test

Consider asking your doctor to conduct a fasting glucose test to get a picture of your current metabolic health.

Unfortunately, we don’t test for insulin resistance in standard medical practice. And a lot of doctors would think you’re crazy if you’re like, I want to test insulin levels, I want to test insulin sensitivity, there are tests to do those things. So a lot of more progressive doctors like in the functional medicine space and the longevity space, it’s like fasting insulin is one of the first tests they’ll do because that is going to rise far before your fasting glucose. The reason for that is because that insulin is rising to compensate, to keep that glucose down until the system gets too far out of whack and then it can’t compensate anymore and the glucose starts rising, but you can imagine the body can compensate for a long time before that happens.

Diet is personalized

The best diet for you will be unique to your glucose reactions. That said, minimally processed food and limited sugar and carbs will always be a great start.

It’s really hard to give a blanket statement of what people should eat, because I do think it is quite personalized, but I think there’s some print that we can all use that can be helpful which is really focusing on whole foods, focus on clean foods that came from the earth that are minimally processed that are not covered in pesticides and that hopefully come from good soil and are filled with nutrients. That’s number one. if we can create like that being a primary source, really clean meats, clean proteins, clean plants, you’re going to be 90% of the way there. Moving further than that, so that’s what to put in and then it’s like what to take out. I would say the more we can minimize or eliminate the refined sugar, refined carbohydrates and refine seed oils, again, that’s going to take us a lot of the way there.

Max Lugavere:

What up fam? Welcome to Episode 198 of The Genius Life.

Max Lugavere:

[inaudible 00:00:03] body and the brain don’t stop. There’s so much more. There’s so much more. The Genius Life.

Max Lugavere:

What’s going on everybody> welcome to another episode of The Genius Life. I’m your host, Max Lugavere, filmmaker, health and science journalist, an author of The New York Times bestselling book Genius Foods and The Genius Life. On today’s show, we welcome the wonderful Dr. Casey Means. Dr. Means is on a mission to maximize human potential and reverse the epidemic of preventable chronic disease.

Max Lugavere:

She’s a Stanford-trained physician, associate editor of the International Journal of Disease Reversal and Prevention, and a lecturer at Stanford University. Dr. Mean’s perspective on health have been recently featured in The New York Times, Wall Street Journal, Men’s Health, Forbes, Business Insider, and more. And lastly, she is the chief medical officer and co-founder of the very popular metabolic health company Levels.

Max Lugavere:

Levels is making CGMs AKA Continuous Glucose Monitors rain, and we’ll get to the bottom of what they do and whether they can be useful to you in the episode ahead. Over the next hour, and somewhat minutes, we discuss metabolic health. Today’s episode is so important. Metabolic dysfunction is the single largest health crisis facing the world. And unfortunately, we don’t talk about it enough which is why I love what people like Dr. Means are doing, talking about it in a way that combines Western medicine with the power of food, exercise and lifestyle.

Max Lugavere:

Dr. Means is going to define metabolism for you, and then she’s going to share the characteristics of one’s diet and lifestyle that may predispose them to metabolic illness which is so common today, about nine in 10 adults. Nine in 10 adults have so form of metabolic illness. And this can manifest in the form of lipid dysregulation, blood sugar dysregulation, and many other features, high blood pressure, you name it.

Max Lugavere:

Dr. Means presents what I think could be referred to as a unifying theory of metabolic disease. And she offers action tips to help prevent and or reverse metabolic disease as well. So this is going to be a very informative episode of the show. I do hope that you listen closely and also listen all the way to the end. Guys, here’s a hot take. The CBD market has become extremely saturated.

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Max Lugavere:

All right guys, we’re just seconds away from this chat with Dr. Casey Means, it is a good one. Please, head over to YouTube, youtube.com/maxlugavere, hit the Subscribe button. You could even watch this episode on YouTube if you so choose. I put thought into what I wear when I tape these recordings and you’re missing all of my keen fashion sense by just listening to these episodes. Instead, you can go to YouTube, youtube.com/maxlugavere and watch them.

Max Lugavere:

We’d really love to connect with you over there, and we’ve got some really cool new content formats coming down the pike. So the way to find out about what we’re up to first is to be a subscriber on YouTube. Text me 310-299-9401, love to hear from you there. And with all that said, let’s now dive head first into episode 198 with the epic Dr. Casey Means talking all things, metabolic health. Here we go. Casey Means, how’s it going?

Dr. Casey Means:

Great. How are you Max?

Max Lugavere:

Thanks for coming out to LA.

Dr. Casey Means:

Thank you so much for having me. It’s great to be here.

Max Lugavere:

What up? What brings you to town?

Dr. Casey Means:

I was here for the Recode Conference at the Beverly Hilton. So speaking about the future of bio wearables, biosensors and glucose monitoring and metabolic health with Kara Swisher. It was a lot of fun.

Max Lugavere:

I hear you know a thing or two about these topics.

Dr. Casey Means:

I love these topics. I could talk about them all day.

Max Lugavere:

So talk to me, share your background with me and my audience if you can, let’s start there.

Dr. Casey Means:

Sure. Absolutely. So I’m a medical doctor by training and I actually trained as a head and neck surgeon. So I did my undergrad in medical school at Stanford, and then went up to Oregon to do surgical training. And in ENT head and neck surgery, I’m treating all of these conditions that are essentially disorders of inflammation. It was like all day long sinusitis, thyroiditis, laryngitis, all these itises, and it is the suffix in medicine that means inflammation.

Max Lugavere:

Interesting.

Dr. Casey Means:

Yeah. And so I’m throwing steroid prescriptions at everyone, steroids tamped on the immune system, and you also do antibiotics all the time. And then when those things don’t work, you take them the operating room. You bust a hole in their sinus or their ear or whatever, and you suck out pus and you send them on their way. And after a while, I really started stepping back and saying, “Where is all this inflammation coming from?” Why don’t we talk about what the root cause of this is?

Dr. Casey Means:

Inflammation is a sign from the body that there’s a threat and that something’s going on. What is that threat? And I’d been fortunate to have a bit of a background in functional medicine. I’d been reading Mark Hyman since I was young and had a sense of some of these things and that really in our modern world, a lot of the triggers of information are our diet and lifestyle as you well know and a big driver of them is metabolic dysfunction.

Dr. Casey Means:

And so started putting some of these pieces together and looking at some of the physiology of these conditions I was treating day in and day out and realizing you can’t actually operate on the immune system. It doesn’t make sense. You may operate on the downstream symptoms of a condition, but you’re not actually sending that patient away with optimized cellular biology. You’re not actually fixing the root cause of the problem.

Dr. Casey Means:

And when you look at some of the top hop killers in the United States which are heart disease, cancer, stroke, Alzheimer’s, dementia, diabetes, all of these we also know have a lot of inflammation going on with them. And when you create this Venn diagram of the cytokines or immune mediators that are upregulated in these conditions, the one for all the ENT conditions are the same for all the ones that are these chronic disorders. It’s like Interleukin 6 and TNF alpha and not to get too wonky, but there’s clearly something going on that’s related to all of these things. Why don’t we treat it that level in medicine?

Dr. Casey Means:

Well, because we’re in a reactive system that waits until diseases manifest, and then we play whack-a-mole medicine where unfortunately we treat each condition as if they’re totally separate different things, as if they’re isolated silos. And that feeds into the system that we have where we give a different medication for every single condition. And unfortunately, the reality is this doesn’t really work. Healthcare costs are going up in our country, $4 trillion now.

Dr. Casey Means:

They’re going up every single year and people are getting sicker, people are getting heavier, getting more depressed, it’s just not working. And so as a physician, I’m sitting there taking people to the operating room every day. It is a huge thing to operate on someone. You’re cutting into their body. And then they’re coming back for revision surgeries and just thinking I’m not really making the impact that I want on helping people be healthier.

Dr. Casey Means:

I’m certainly sucking the puss out, but I’m not actually making these bodies healthier or doing anything to actually impact the rest of their overall holistic health. So that was my journey towards really stepping away and looking into kind of what the root causes were. And that led me towards the path of really being pretty obsessed with metabolic disease because it’s underlying so much of the pathology we’re seeing in this country right now and metabolic disease, what that really means is that bodies have a problem processing energy in the body.

Dr. Casey Means:

They have a process using it, making it, storing it. And what this shows up as is obviously, overt diseases of metabolism like diabetes and obesity, but I think what people might not realize is that it’s actually underlying so many of the other conditions we’re seeing like we were just talking about, cancer, heart disease, stroke, dementia, even other subtle things that aren’t necessarily killers, but other pain points like erectile dysfunction, infertility, gout, depression, anxiety, et cetera.

Dr. Casey Means:

So we’ve got to as doctors figure out how to fix this and how to help people with this if we’re going to actually make a big dent in the chronic disease epidemic that we have in this country. And so started thinking about levers of how do we do that and one of the best ways that we can do that is how people manage their blood sugar because blood sugar is one of those key parts of our energy processing in the body. And we’re just eating way too much blood sugar. And basically the average American is having trouble processing blood sugar in this country, and that’s leading a metabolic disease.

Dr. Casey Means:

Over 50% of Americans have prediabetes or Type II diabetes, it’s insane. That number should be close to zero. And more broadly, a recent study in 2018 from UNC showed that 88% of Americans have at least one biomarker of metabolic dysfunction which means impaired blood sugar, cholesterol, or weight. And so this is clearly one of those elephants in the room that we have to solve. And as a physician, I just said like, “If I’m going to be fulfilled in my career and feel like I’m really doing something meaningful, this is the issue I have to address, this is underlying so much of the morbidity. I can certainly help people doing ENT procedures, but I’ve got to focus my energy on something that really is going to, I think, have a bigger impact.”

Dr. Casey Means:

And so that led me towards ultimately creating a functional medicine, private practice, moving away from ENT and then thinking about how to really scale solutions. And so that led me to starting Levels which is the company that I co-founded and chief medical officer of, which is a company that gives people access to biosensors, continuous glucose monitors that can actually track their glucose 24 hours a day, seven days a week and see exactly how food is affecting their body in real time and get a real sense of what their blood sugar is so that they can hopefully know what’s going on with their metabolic health, track it over time, figure out how to optimize it and just stay out of this whole mess of metabolic disease that’s just completely plaguing our country.

Max Lugavere:

I love that. I don’t want to talk about metabolic health, but let’s take a step back before we do that. And can you just define metabolism for the audience? Because I, I feel like that’s a term that people hear a lot these days along with inflammation, but you’re a physician. So what actually when you say metabolism, what does that mean?

Dr. Casey Means:

Yeah, so simply put metabolism is all the chemical and cellular reactions that are happening in the body that produce energy from food. It’s how we transform the food that we eat in to energy that we can use. And then if we’re not using that energy, how we store it, and this is fundamental to all aspects of health because if you think about it, all we are really is 37 trillion cells. Our entire structure we of course have trillions of bacterial cells as well. But every single one of those 37 trillion cells in our bodies need energy to function properly.

Dr. Casey Means:

And when cells don’t function properly because they’re not making the energy they need, depending on which cell type that’s happening in, it could look like totally different symptoms. If that’s happening in the brain, it could look like dementia, chronic pain, depression, anxiety, fibromyalgia, Alzheimer’s dementia, all conditions associated with poor metabolism. If it’s happening the ovary, it could look like polycystic ovarian syndrome leading cause of infertility in the US, a metabolic condition.

Dr. Casey Means:

If it’s happening in the penis, it could look like erectile dysfunction which is also a metabolic disease. Metabolic dysfunction causes the blood vessels to narrow causing problems like that. If it’s in the heart, it could look like stroke, et cetera, et cetera. We could literally go through any organ system. And if there’s a metabolic problem, meaning the way that a problem with how energy is produced, you can see symptoms showing up. We tend to look at all those disparate things when in fact for many of them, one of the key contributing factors is this just core pathway of producing energy being screwed up.

Dr. Casey Means:

And really, the reason it’s screwed up is because the way we’re living in the modern Western world is hijacking our cellular physiology, our core basic pathways of how to produce energy. And the reason that’s happening is because one of the factors is food certainly and sugar is a big one. We’re eating probably almost 20 times more sugar than we were eating a hundred years ago. The average American you’ll see different statistics, but eating somewhere around 60 to 152 pounds of sugar per year.

Dr. Casey Means:

We should probably be eating less than one pound of sugar per year. So that’s just monumental load on the body gums up the system and then of course, industrialized seed and vegetable oils which you talk about a lot, these things cause oxidative stress which hurts our mitochondria which are the energy factories of the cell, also create metabolic dysfunction. And then lots of other things in our industrialized food is causing this issue, but then it’s other things like it’s stress, it’s sleep deprivation, high cortisol, it’s lack of physical activity, it’s micro nutrient deficiencies, it’s microbiome perturbations, it’s exposure to environmental toxins.

Dr. Casey Means:

These all cripple our cellular biology in the way that our cells make energy, and so we’re unfortunately facing this situation where we have just this energy problem in the vast majority of bodies in the United States and it’s showing up as dozens of some symptoms because when cells can’t make energy, they’re dysfunctional. When cells are dysfunctional, tissues are dysfunctional. When tissues are dysfunctional, organs are dysfunctional and that’s what symptoms and disease is.

Dr. Casey Means:

We really have to start looking at it in that way. And so that’s really simply what metabolism is, that’s how we produce energy and it’s fundamental to every single cell in the body and we want it to work properly.

Max Lugavere:

And I think it’s so great that you guys are setting out to tackle this from the standpoint of diet and nutrition because that’s definitely one of the more impactful factors. Of course you mentioned our activity levels, sleep plays a role, the microbiome. It’s almost in a way I would describe it as energy toxicity. We’re eating too much.

Dr. Casey Means:

Yeah, absolutely. And the energy toxicity thing is really interesting because we have too much energy in the terms of calories coming into the body, but we’re not using it properly because we’re disrupting our mitochondria’s ability to process it. And so a lot of it’s being stored and that’s why you’re seeing so much in the way of the overweight and obesity epidemic with 74% of Americans dealing with overweight or obesity, it’s astronomical.

Dr. Casey Means:

And this is downstream of cellular problem that we have so much power to improve and we can improve it rapidly in our own lives, but it does take awareness to this and really being vigilant. If you’re an American today, more likely than not, you’re going to be chronically ill by the time you’re an adult, that’s really sad. And also, if you just go on the normal treadmill of just American culture, you will get sick. That’s almost a guarantee if you just do whatever that’s in norms, sitting, eating packaged foods which make up 70% of our calories these days, letting your phone beep in the middle of the night so you’re getting poor sleep, you’re going to get sick.

Dr. Casey Means:

And so you really have to do something differently these days if you want to escape that. And the beauty is it’s fairly simple, but you do have to be vigilant and you have to be aware. And that’s where I think education, what you and many others are doing in the nutrition space and the wellness space, but also potentially things like monitors which is really why I’m excited about Levels is that it gives people the data in their own hands. And so you get to move past these systems that I think in many ways are manipulating people like the food industry which is literally designing food to take you to your bliss point.

Dr. Casey Means:

It’s designed to make you just feel like you’re desperate for it to induce lectin resistance so that you’re actually actually hungrier, to cause these blood sugar spikes in crashes which actually make you crave more. We know how the brain works. These foods make us dependent on them. And so to have some data that serves as agency and some recourse in the face of monumental challenges we’re facing today to be healthy is really cool because like an example is, and this isn’t even necessarily a junk food, but I was eating oatmeal frequently for breakfast because of course, doctors tell you that you should eat oatmeal to be healthy and for your cholesterol and the box literally says heart healthy on it.

Dr. Casey Means:

This is a great source of whole grains. So I eat one little package of instant oats and this is actually … For this particular experiment, I ate two packages of instant oats with nothing on them. No sugar, no berries, no nothing. Blood sugar went up 80 points. I never want my blood sugar to go 80 points. Usually, after a meal, I want it to go up maybe 20 or 30 glucose points, but usually not above 110 milligrams per deciliter. I went up to about 170.

Dr. Casey Means:

So we know that big glucose spikes like that which is called glycemic variability, that directly is actually an independent predictor of future risk of diabetes, obesity, heart disease, and stroke. Your body does not like these big blood sugar spikes no matter what people tell you about like, “Oh, well in a normal, healthy person, these don’t matter. That’s not true.” Glycemic variability is an independent predictor of future downstream problems. So for me in my body, in one breakfast, I can say, “This is not heart healthy. This is not something I should be eating if I want long term cardiovascular health, and this is just not a good food for me.”

Dr. Casey Means:

At least in that permutation. Certainly there’s ways to hack oatmeal. You can eat steel cut oats or groats and add fat, fiber and protein and blah-blah-blah, but that is not heart healthy. So through that, I have agency, I’ve cut through food marketing. I’ve had agency in the face of a healthcare system that is giving me really generic advise unfortunately because doctors are not trained in nutrition. And I think the average doctor has really good intentions, but the reality is that the healthcare system profits off people who are sick and that’s built into the system and we get paid to take care of sick people.

Dr. Casey Means:

And so none of it’s aligned or incentivized with my optimal, for arriving in health. And by having the data myself, I’m able to make small microdecisions like that, that are actually allowing me to make choices that are right for my body.

Max Lugavere:

Yeah, so true. What are the potential harms though that can come from a transient and acute blood sugar “spike?”. If you’re eating a banana or I don’t know, what’s something that I ate that has or a piece of like gluten-free sourdough bread and maybe you’ve had a workout earlier in the day and you have a transient excursion in your blood glucose levels. What are the risks to come from that?

Dr. Casey Means:

Well, the first thing I’ll say is that the body is extremely resilient. And so one time things I’m not too worried about and no one should freak out over a single glucose spike. This is really we’re talking about trends over time.

Max Lugavere:

Got it.

Dr. Casey Means:

And the body being affected over time. However, there are things that can happen acutely. And there’s four main things about a glucose spike that I think are well-established in the literature that are worth being aware of. So a glucose spike, a high one is going to cause a few downstream things. One is it can cause glycation of things in the body. Glycation is sugar sticking to things like fat, protein, DNA, whatever, and proteins and that sugar sticking to molecules which sometimes is called rusting of the body leads to dysfunction in those things.

Dr. Casey Means:

So you don’t want glycation and when blood sugar is high, it’s going to stick to more or stuff. The second is oxidative stress. So the generation of free radicals in the body, these reactive molecules that can cause damage to parts of the cell, and the third is inflammation. A lot of blood sugar in the body in the bloodstream really quickly says to the body that something’s different, something’s off, something’s a little weird and that can generate some acute inflammation and the fourth which is the actual, the one that will affect you and that you can notice is reactive hypoglycemia.

Dr. Casey Means:

So basically when you eat a bunch of carbohydrates, it’s going to be transformed into your bloodstream, into glucose. Your body is then going to release insulin from the pancreas as you know which will let you take that glucose into your cells for use or for storage. But when the glucose spike is high, your body really will send out a big insulin surge. And sometimes it can overshoot and basically suck up tons of glucose really quickly into your cells and lead to a dip, actually lower glucose than before your meal.

Dr. Casey Means:

And that little phase is called reactive hypoglycemia. And often that can be associated with anxiety, mood lability, fatigue, maybe some brain fog and cravings for sure. And so a lot of what I’m thinking about when I’m eating is how do I avoid reactive hypoglycemia and how you can avoid it is by keeping things much more gentle rolling hills in your glucose, never having that huge insulin surge, you’re just staying around a safe median level during the day. I think glucose variability often translates into variability in my actual day, subjectively whether it’s mood, energy, athletic performance, brain sharpness.

Dr. Casey Means:

And so for me, one of the best life hacks of my life has been just figuring out how to keep glucose more stable so that my days feel just more stable. So those are the four acute things, the bigger picture thing that you want to think about with those glucose spikes is how it’s actually ultimately leading you down the spectrum of metabolic disease because as I said, one and glucose spike isn’t going to do it, but if you’re doing that five times a day, day after day, week after week, year after year, decade after decade, that is causing problems that are going to lead you down that road of metabolic disease.

Dr. Casey Means:

And the way that happens is that those repeated insulin spikes from the glucose, the cells are having to respond to all that insulin. And ultimately they’re going to say, “This is too much, we can’t force more glucose into these cells.” And the cells become numb to insulin which is called insulin resistance. And they actually block that signal and the body responds by producing more insulin to overcompensate.

Dr. Casey Means:

So now you’ve got insulin levels going up in the body to try and sort of force more glucose in. And this is essentially, this insulin resistance is the process towards type two diabetes and all the other associated conditions. For people who are worried about weight or trying to lose weight, this is directly related to that because that insulin, that hormone has many, many effects. One is to get the glucose in the cells, but it’s also a signal to the body to not burn fat because what it’s saying to the body is we have tons of glucose around for energy and our two main energy sources in the body are glucose and fat.

Dr. Casey Means:

And so when that insulin’s high, it’s saying, “We don’t need to burn fat. We’ve got tons of glucose stop burning fat.” And so for anyone who’s on a weight loss journey, those repeated glucose spikes are just directly working against you essentially. So those are the main reasons why we want to keep it more flat and stable.

Max Lugavere:

Yeah, I love that. We definitely consume too many carbohydrates. I think the average American today consumes about what is it? 300 grams of carbs a day and clearly, the best way to reduce the glucose area under the curve in our bodies is to just eat less of it. Hey guys, quick pause. I want to let you know about my friends over at BiOptimizers and what they’re up to. They make some of the best digestion supporting nutrients and supplements that I’m aware of.

Max Lugavere:

I love their HCL breakthrough product which I definitely take. I’m not Joshing you guys. Does anybody say that anymore? I don’t know, I don’t care. But when I’m eating a big protein and fat heavy meal, I love to pop a few of their HCL breakthrough products which contain digestive enzymes that are very helpful when it comes to digesting protein and fat and the like as well as HCL which supports stomach acid. Stomach acid is so important, it’s this chemical that we produce in our stomachs, hydrochloric acid that people love to demonize because it’s associated with heartburn and the like, but the truth is most people don’t have enough stomach acid, even some people with heartburn.

Max Lugavere:

So the best way to support digestion and to make sure that you’re extracting all of the vital nutrition from the food that you’re spending so much money on is to make sure that you’re digesting it well. And that’s why I love the products that BiOptimizers makes whether it’s their HCL breakthrough or their MassZymes which I take sometimes, I’m a huge fan. If you’d like to try anything that BiOptimizers makes, all you got to do is head over to bioptimizers.com/max, and that’s spelled B-I-optimizers, B-I-O-P-T-I-M-I-Z-E-R-S/max, and you’ll get instant access to an exclusive 10% off coupon that you can use for anything on their side or you can use code max10, but I use their products regularly.

Max Lugavere:

I also offer them to guests and friends. It’s a great way to make sure that your digestion is running at full capacity. So yeah, check them out, bioptimizers.com/max or use code max10. I think that you’re going to enjoy their products. And now back to my chat with Dr. Means. My concern then is how do we get this message out there without pathologizing healthy sources of carbohydrates, right?

Max Lugavere:

The big bowl of berries which we know are grateful our brains, or I don’t know what are some great, sweet potatoes, things like that. These are not dangerous foods, right? So my question to you is then is for somebody who’s wearing a continuous glucose monitor who then goes and eats a bowl of berries or a sweet potato and they see their blood sugar spike, how do we allay their fears and let them know that this is actually okay to eat. I don’t even want to use the language once in a while. I mean, you can have a sweet potato every day if you want, right? You’ve got bigger fish to fry if that’s what you’re concerned about.

Dr. Casey Means:

Totally. It’s a great point, and I think the answer is it’s really, it’s about nuanced education and that’s why with Levels like we’re a small company still, but a good portion of our team is all our education team and our content team because honestly it is complex to work through these things. And I think you mentioned the bigger fish to fry. I think big picture, one of the bigger fish to fry with having access to these monitors is for the person who’s not necessarily making these micro optimizations like should I eat raspberries or blackberries, but like-

Max Lugavere:

That’s me.

Dr. Casey Means:

Right. It’s the people who are drinking two cans of soda a day and who are eating really sweet breakfast because they actually think that that’s okay, that cereal is an okay thing to eat for breakfast which it’s not, or it’s fine to eat, but it’s not going to align with optimal health.

Max Lugavere:

It’s not optimal, yeah.

Dr. Casey Means:

Yeah. Everything’s okay depending on what your goals are, and so those are the things where it’s just like, “Oh my God, I actually thought this was okay.” But being able to see the data, it’s just amazing how seeing the data, feeling what you’re feeling in your body, so the subjective response like, “I don’t feel great. I feel tired.” Seeing that, that aligned with a spike and then knowing what you ate, that trifecta of choice data and subjective feeling I think is really the essence of behavior change.

Dr. Casey Means:

And so that’s really for the larger population and the bigger population in the US who’s eating a lot of ultra processed foods. That’s what I think this is going to bring to their lives. Now, to actually answer your question though with berries and sweet potatoes, I’m of the camp that if it’s a whole food that’s unrefined, it’s a good thing for your body. Our body knows deal with whole foods and if we’re primarily eating those, we’re going to do well.

Dr. Casey Means:

Now, there are ways to even eat certain whole foods in a way that is actually more optimal for the body. So for instance, if you’re eating the berries, you can find many ways to mitigate a glucose spike by eating the berries with additional fiber fat or protein to not have such a glycemic excursion, and I actually think that is probably better for the body. So what that might look like is some whole milk yogurt or full fat cashew, non-dairy unsweetened yogurt with some chia seeds and flax seeds on top and the berries.

Dr. Casey Means:

And so that might actually if let’s say we’re going to have a 50 point glucose spike with a pine of blueberries, it might be a 10 point glucose spike if you have it with some of these other foods, especially the fiber, I’ve noticed that to be one of the biggest things. So I’m now adding chia seeds and flacks to almost everything and with the sweet potatoes as well. I had a cup of sweet potatoes, I’ve done a lot of experience, experiments with the continuous glucose monitor on and actually sweet potatoes caused a huge spike for me, probably around 60 or 70 points.

Dr. Casey Means:

It was just one cup of baked sweet potato. That was it, nothing on it. And that’s a lot. I actually don’t want. I would not probably eat them by themselves because it is causing a large glycemic excursion. But when I eat sweet potatoes that … Well, a few things, if I eat sweet with, again, fiber on them. So adding a bunch of other vegetables, maybe adding a whole fat, whole food fat dressing like a tahini or something like that.

Max Lugavere:

Yum.

Dr. Casey Means:

Yeah, and take a walk afterwards for 20 minutes or, we know with resistant starches, if you take the sweet potato, cool it in the fridge and then reheat it, it’ll actually likely cause less of a glucose response because when you cool the sweet potato, it changes the carbohydrate structure so that it creates resistant starch and is less digestible. You could also eat protein and vegetables before you eat the sweet potato which we know that if you eat protein or roughage, they’ve studied if you have a salad before a high carb meal, it actually has less of a glucose response.

Dr. Casey Means:

So salad, chicken, or whatever before the sweet potato, maybe you can have a lower glucose response. So there’s a dozen things you can do around the sweet potato to actually get all the beautiful nutrients that has the beta carotenes and all that stuff and have less of glycemic excursion. And so that’s getting really nuanced and nitty-gritty, but I think it’s a cool way to design your meal such that you’re getting all the beautiful stuff from the food, but with less of the collateral.

Max Lugavere:

Yeah. I like that. I wonder what would be … Because if I’m about to eat a bowl of berries which have a certain caloric value, what I then want to add a tablespoon of fat or whatever, to the berries and then just be adding empty calories from fat?

Dr. Casey Means:

Well, it depends on how you respond to it. So the really interesting thing about glucose is that everyone responds differently to the same food. So you and I could eat the exact same bowl of berries and have totally different responses. And this has been studied in some really interesting research in the past five years. There was this great study from the journal cell from five years ago called personalized nutrition by prediction of glycemic responses.

Max Lugavere:

Was that the microbiome study?

Dr. Casey Means:

It was. Microbiome plus they found 137 factors. That was the big headline was the microbiome, but in their algorithm, they actually put in over a hundred things that were related to why people responded differently, but the take home from the paper was that you can give 800 nondiabetic “healthy people” the same standardized meals and what we would expect based on what we thought which is that each food has an inherent property to raise glucose that everyone respond exactly the same.

Dr. Casey Means:

And that’s how the glycemic index chart works is like, “Oh, if you eat a piece of white bread, it has this glycemic index, so it’s going to raise or blood sugar this much.” And they found the opposite. They found that people reacted completely across a huge spectrum to the same food. So people were eating the exact same standardized cookie and some people would go up none and some people would go up 80 points and it was just absolutely fascinating.

Dr. Casey Means:

And one of the big factors that they saw as, as predictive of how they were responded was microbiome composition. So that’s one thing with the berries, maybe you don’t spike to berries which is great. But I know that I actually do spike to several of the low glycemic berries, a pint of blueberries or something. So for me, may be that I add them to the fatty, the yogurt and add some fiber. It might just be that I decide to not do that because I don’t want more empty calories like you said, and I just take a 15 minute walk afterwards which has a massive impact on how you respond to it or maybe I do them right after my high intensity interval training workout when my muscles are super primed to be insulin sensitive and to take up glucose.

Dr. Casey Means:

So there’s all these different ways to approach it, but I do think overall the more we can keep our glucose flat and stable, the better for long-term health. That doesn’t necessarily mean we always have to add fat and protein to every car we eat, but there’s other adjuncts like the walking and exercising, making sure we’re eating our higher carb meals after a good night sleep and not when we’re sleep deprived because our glucose responses are always going to be higher, and our insulin response is if we eat them after a really poor night’s sleep. So there’s just these ancillary things that you can do to think about the context with which that meal is coming into your body to minimize that metabolic response.

Max Lugavere:

I think it’s fascinating that you become essentially prediabetic on just one a night of bad sleep because I wore the Levels CGM for two weeks and I sleep pretty well. I don’t think I recall having like a night of bad sleep during that period, but that would be fascinating to measure and see. Is that what your data is showing you as well?

Dr. Casey Means:

For me, we haven’t necessarily seen it on large scale. We haven’t done that analysis yet, but for me personally, there’s no question. It’s just a frame shift up my whole day. If I’m on a couple poor nights of sleep or if I’m traveling, especially, and we just recently did a study with whoop where we actually saw that people’s recovery score and their metabolic score seem to correlate and recovery score is largely driven by how your sleep quality was.

Dr. Casey Means:

And so that’s not surprising to me at all, but if I’m on a really poor sleep and I know my glucose is going to be basically 10 points higher all day, I tend to do a little bit more of a keto day. And if I’m exercising and doing Peloton slept for eight hours, like sure, I can probably, I’m more insulin-sensitive that day, there’s no question. And I can probably tolerate a little bit more carbs.

Max Lugavere:

One of the most fascinating things I learned when I was wearing the Levels was that your blood sugar can spike for reasons other than what you’ve just consumed. I was sitting in my brother’s infrared sauna, shout out to Clearlight Saunas, and I was shocked to see that my blood sugar actually, there was a pretty significant spike from that. And I posted that on my Instagram. And of course, I got a lot of people asking me questions like, “So does that mean saunas are bad for you?” But walk us through that. How does that work? How would sitting in a sauna cause your blood sugar to spike?

Dr. Casey Means:

Yeah, so there’s two reasons, one which is less fun of an answer which is that it may have been sensor error because he actually really does impact the sensor quite a bit. They’re pretty temperature sensitive, but it’s also possible that it was your physiologic response and that was likely stress-mediated. So heat and cold are both acute stressors for the body. And the body has this really interesting hormonal response where basically under times of stress whether it’s what we would consider positive hormonic stress like a sauna or chronic low grade, not good stress, just like psychological living the modern life of emails and honking and low sleep.

Dr. Casey Means:

So any type of stress though releases catecholamine hormones and cortisol in the body and this actually goes to the liver and signals to the liver to break down its stored glucose. The liver stores a few hours worth of glucose in chains called glycogen, and it’s like our debit account, our short-term savings account for energy, the long-term account being the fat stores and the short-term being the liver.

Max Lugavere:

That’s the savings account.

Dr. Casey Means:

The savings account. Exactly. And so those hormones tell the liver, “Break it down. The body’s stressed, we’re having something going on and we need glucose to fuel the muscles and the brain right now.” And so it can be like a rapid, rapid response where let’s say you’re giving a talk at work and you’re stressed out. Five minutes into it, you might start seeing your glucose go up.

Max Lugavere:

Wow.

Dr. Casey Means:

It’s really amazing how quick it is that maybe what’s happening in the sauna, we’ve certainly seen that with people in ice baths, who we know it’s not sensor error because they’ve actually kept their arm with the sensor on it outside of the bath and they see a spike. And then the other time we see this reaction happening is when people are doing really high intensity training workouts where usually they have to be above about 80% Vo2 max or roughly 80% max heart rate.

Dr. Casey Means:

That is a stressor, an acute stressor for the body. Again, probably a hormetic good stressor, adaptive stressor, but it will make your glucose go up. So if you’re doing a light jog or a walk, glucose will usually stay stable or go down. But once you go up to that above 80% Vo2 max, it sends the stress signal of the body. And so often during CrossFit workouts, Peloton workouts, you can see a 20, 30, 40, some people see a 60 point rise in their glucose. That one while it is stress mediated, I would not consider a bad glucose response.

Dr. Casey Means:

And the reason for that is because unlike the other stressors like psychological stress or chronic stress with the workout, you’re activating your muscles to take all that glucose up and your muscles are becoming more insulin sensitive during that workout. And something really cool about muscle as a tissue is it actually doesn’t require insulin to … It has an insulin independent way of taking up glucose. Just the contraction itself will soak up glucose.

Dr. Casey Means:

So you’re dumping this glucose from the liver, but there’s a sink for it, it’s taking it in. And we know that those workouts just acutely making more insulin sensitive. So overall, a workout spike is not something to worry about, it’s a different physiologic process, but the stress spikes, I think those are really good feedback because we don’t want to be … That’s where you’re basically releasing glucose, but there’s not a sink for it. You’re not running from a lion. You’re not actually using your muscles.

Dr. Casey Means:

Glucose is just sitting in the bloodstream and your body is going to need to require generate insulin to take that up. That’s not good, and especially in our stressful modern lives, if that’s happening like multiple times a day, day after day, that’s not a positive thing. So yeah, so that’s some of the thinking behind the-

Max Lugavere:

That’s fascinating. So for people that go to their doctors and they get their annual physicals and they see that their blood sugar, either their fasting blood sugar is elevated or their A1C is higher than they would like it to be, that could be purely from stress. Right? Chronic stress.

Dr. Casey Means:

I think it’s a huge contributor. Yeah. There are people who are on perfect dialed in diets, really low carb, whole foods, healthy fats. And if you’re still chronically stressed and not really dealing with the stress well, you can see metabolic issues.

Max Lugavere:

Fascinating.

Dr. Casey Means:

So that’s a key lever. I’d say food is in my opinion always going to be the key, the top on this what are the areas we can intervene on, but sleep, stress and movement are both right there. And they all need to be dialed in for optimal metabolic health. And if you’re seeing your numbers not where you want them to be and you feel like your diet is just perfect, I’d really be thinking about the sleep, the stress management and how can we fit more movement in throughout the day and not just one big workout a day, but how can we really move throughout the day?

Dr. Casey Means:

Walk for two or three minutes every hour, it’s not just about the one workout a day. The research that actually shown that the people with the best glucose levels are the ones who move consistently throughout the day. So those are just definitely ones to think about if people are plateaued.

Max Lugavere:

So important. I try to get 10,000 steps a day and I fail miserably most days because I live in LA, you’re always in your car. It’s such a big problem. But I feel so much better on the days that I’m able to get close to that goal or when I’m traveling in other cities, it’s a lot easier to walk. I’m from New York City which is where … Yeah, New York is the place. You could easily do like 20,000 steps in a day in New York.

Dr. Casey Means:

Without trying.

Max Lugavere:

And it’s just getting to and from work or something. Hey guys, I woke up this morning with four important questions that I felt the need to ask you. One, are you fed up with having no idea what you should be eating? Two, are you struggling to lose one eight and feeling hopeless? Three, have you been following fad, infringed diets and feel like crap? And four, are you tired of spending so much money monthly on health products that don’t actually work?

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Max Lugavere:

You get access to all of that for only $27 a month at maxlugavere.com/vip. Again, that’s maxlugavere.com/vip. Those three simple letters could change your life. You’ll find the link of the show notes. Now back to my chat with Casey. Talk about labs and how physicians typically diagnose metabolic illness. What are some of the features that you would see on a lab that would make you think, “Oh, this patient is metabolically unwell.”

Dr. Casey Means:

Yeah, so in terms of the standard lab tests that you’re going to hear about when you go into the doctor’s office. The three ways that we diagnose frank pre-diabetes or diabetes in the this country are fasting glucose in oral glucose tolerance tests and hemoglobin A1C. Those are the three tests approved by the American Diabetes Association to tell us about where we fall on this spectrum. And with fasting glucose, if you’re fasting glucose is under a 100, you’re considered normal or non-diabetic.

Dr. Casey Means:

If you’re between 100 and 125, you’re considered pre-diabetic and 125 or above 125 is considered Type II Diabetes. With the oral glucose tolerance tests, it has its own ranges. And then for hemoglobin A1C which is basically a marker of how much sugar has been sticking to your red blood cells, it’s more of a marker of like a three month average of your blood sugars. That’s done in a percentage of how, of your hemoglobin in the red blood cells that’s been glycated or have sugar stuck to it and if you’re below 5.7%, you’re considered non-diabetic, 5.7 to 6.4 pre-diabetic and 6.5 or above, Type II Diabetes.

Dr. Casey Means:

So these tests are really blunt instruments in terms of understanding, and unfortunately, the problem with these tests is that they miss so much pre-disease. They miss telling people that they are creeping up on the spectrum of a problem and that their cellular physiology is problematic and it waits way too long. And so there was a fascinating paper in The Lancet which is a premier medical journal from a couple of years ago that basically showed that once your fasting glucose has gone on into the range where someone would tell you, you have a problem, you’ve probably had insulin resistance for over 13 years beforehand.

Dr. Casey Means:

But unfortunately, we don’t test for insulin resistance in standard medical practice. And a lot of doctors would think you’re crazy if you’re like, I want to test insulin levels, I want to test insulin sensitivity, there are tests to do those things. So a lot of more progressive doctors like in the functional medicine space and the longevity space, it’s like fasting insulin is one of the first tests they’ll do because that is going to rise far before your fasting glucose.

Dr. Casey Means:

The reason for that is because that insulin is rising to compensate, to keep that glucose down until the system gets too far out of whack and then it can’t compensate anymore and the glucose starts rising, but you can imagine the body can compensate for a long time before that happens. So the interesting thing about fasting glucose is that we bucket people into this under a hundred as normal or healthy category which is really an unfortunate fallacy to tell people that if you are not at a 100 yet, you’re totally fine.

Dr. Casey Means:

What the research has actually shown is that as you move up in the normal range of fasting glucose, you have a much higher risk for downstream problems which is not surprising, but that’s not the way we approach it. If you’re in that bucket, you’re fine. If there’s not a red flag on the chart that your doctor is seeing, I would say most of the time, the doctor is going to say, “Yeah, everything looks good.” Which is not true.

Dr. Casey Means:

If you’re up at 97, 98, 99, you are far down that spectrum of insulin resistance and metabolic disease. It’s not like something magical changes when you flip over a hundred into like 100 and 101. Probably things have been going on for years and there’s a huge opportunity to get to write the ship, and it’s very possible to just move right back into a healthy range. And so when you look at the research, it’s actually probably more optimal to be between 72 and 85 for your fasting glucose, not up in the 85 to a 100 range.

Dr. Casey Means:

So I’d love to see more research showing the long term outcomes of the differences within the normal range that we can give people more of an optimal range to shoot for as opposed to just this bucket of you’re not in the “pre-diabetes” phase yet. We really need to be looking at things more as like we’re on the spectrum are you, not which bucket are you in because the body doesn’t work in buckets. We are this complex physiologic process. And it’s not like a light switch goes on and all of a sudden we have a problem tomorrow when today we’re fine.

Dr. Casey Means:

The really cool thing about lab tests is that we can actually suss out where we are on the metabolic spectrum by looking at our cholesterol panel and discerning some clues from that without … If your doctor’s not willing to order a fasting insulin test, you can look at your cholesterol panel and get a general sense of what’s going on with your insulin sensitivity which is cool.

Max Lugavere:

Well, why wouldn’t a doctor be okay with that? Is it not covered by insurance or what?

Dr. Casey Means:

It’s not covered by insurance for most people, and it’s just not part of our standard guidelines for how we diagnose these things. And I think this again comes back to our really reactive medical system and the efficiency of the medical system. Glucose is cheap and easy to measure from a public health standpoint, it literally takes one drop of blood to measure fasting glucose, it’s very simple. And so it’s become the standard and we have learned and really, it is a downstream lagging indicator of a physiology problem.

Dr. Casey Means:

We’re not actually testing for the physiology problem, we’re testing for the downstream result of that problem. And I think part of that is that we may not have necessarily known the physiology when we were figuring out what these public health tests were going to be. And so medicine takes a long time to catch up with the research. It can take up to 20 years for something that was published in the research to make it into clinical practice, and I think we’re in that awkward in between right now where we realize insulin is really the problem, but we’re not testing it yet.

Dr. Casey Means:

But through conversations like this and research that’s happening, I think we’ll get there. The other sad thing about healthcare is that oftentimes, the things we test are based on the things that we can actually treat. So we have medications to bring glucose down. We don’t necessarily have medications that like directly impact insulin sensitivity. We do have some like Metformin, but when we have medications that really very clearly can track that marker like glucose, we tend to favor those.

Dr. Casey Means:

But overall, if you’re listening, ask your doctor for insulin test, you want it to be low. Ideally definitely under 10, a lot of people say under eight or under five for optimal insulin sensitivity, but on the cholesterol panel, some really important things to look at are the triglycerides because triglycerides are a general marker of what’s happening with carbohydrate processing in our body. Typically, you will say they should be under 150. I know a lot of doctors who want them to be under 100, some under say under 70.

Dr. Casey Means:

And so if triglycerides are riding above 150, that’s really something to dig into. And if you’re seeing triglycerides a little high, fasting glucose is a little high, that’s a signal, there may be something going on. The other thing that’s a really important ratio that you can calculate is triglycerides to HDL ratio. HDL is what we consider our good cholesterol. And we want HDL to be high and triglycerides to be low. So we want that ratio to be quite low.

Dr. Casey Means:

Some people say potentially one. So basically, your triglycerides and your HDL being the same which would be very, very hard to achieve because you can imagine then you’d have if your HDL was 70 which is high and triglycerides were really low at 78, the ratio would be one, that would be very, very hard to accomplish. Some doctors will say less than four. So essentially four to one ratio between triglycerides and HDL, I think that’s too high. Some will say that it varies by race.

Dr. Casey Means:

So I believe Robert Lustig who wrote Metabolical, I’d have to double check this, but I think he says 2.5 or 3.5 based on whether you’re Caucasian or of African-American descent, but we can maybe link to that. But the general take home point is that we want that triglyceride to HDL ratio to be low because that seems to be a great surrogate marker for insulin sensitivity. So that’s getting into the weeds, but I would just say people should focus on their, take the cholesterol panel you got last year, that’s on your, you know, online portal, take a look at your triglycerides, take a look at your triglyceride to HDL ratio and you see where things are standing and maybe bring it up with your doctor.

Max Lugavere:

Yeah, what about LDL? That’s a contentious topic in the online nutrition space. Some say that it doesn’t matter at all. Some say that it’s still the most important causal player in cardiovascular disease. What’s your position?

Dr. Casey Means:

Yeah, I think what we’re learning is that probably one of the most important things with relation to LDL is the particle size of the LDLs in our body. So LDL is not just one thing, there’s actually different types of particles that make up that total LDL number. And some of the important ones we talk about are small density, LDL and large density LDL. With large DNC LDL being likely safer and less promoting of cardiovascular disease and small density LDL which you can think of like little pellets are actually much more dangerous.

Dr. Casey Means:

They lodge into the blood vessel walls, they cause inflammation. And the hardening of the arteries that we think about with heart disease. So we want more large density, less us, small density. And what’s interesting is that that triglyceride to HDL ratio that I was just talking about may actually be somewhat predictive of where you skew on the small density LDL compared to large density LDL where if that ratio is lower, it’s likely that you’re favoring large density, safer pattern of LDL so.

Max Lugavere:

Also refer to as pattern A.

Dr. Casey Means:

Pattern A and pattern B, right.

Max Lugavere:

Yeah.

Dr. Casey Means:

So you want those fluffy big particles basically. And so while the LDL number, if it’s really, really high, I think above like 200 or so, you want to start to thinking about what’s going on for sure. But the first thing I would do is figure out what the particle size are. So that would be asking your doctor for a what’s called advanced lipid testing or NMR lipid test which will break down the LDL into the particle sizes and give you a sense of what your risk is.

Dr. Casey Means:

But what we know is that a low sugar diet and a low carbohydrate diet will bring that small density LDL down. It’s it is likely the sugar and the insulin that is driving that small density pattern. And so very different than what we’ve been taught with it’s all about fat and cholesterol and this and that. It’s likely the insulin and the sugar that’s driving the dangerous pattern.

Max Lugavere:

Fat also plays a role though like the types of fats that your diet is composed of primarily saturated fats we know reduce the amount of LDL receptors on the liver, on the surface of the liver which obviously are important in terms of sucking back up those LDL particles before they have the opportunity to become small and dense. So especially for people who are genetically prone to dyslipidemia becoming, just being a little bit more conscious of the fat composition of their diets.

Dr. Casey Means:

Absolutely. And there’s certainly genetic factors as well with this where certain genetic phenotypes are going to respond worse to saturated fat in terms of how it’s affecting their overall cholesterol levels. And so that’s a much deeper conversation, but I think big picture, we probably need to be thinking deeper about LDL and what it means. And I’d like to see everyone getting essentially a particle size test in the future because I think it just helps us give us a little bit more understanding of what’s going on inside our bodies.

Dr. Casey Means:

And certainly, also on the fat conversation, the industrial seed oils and vegetable oils and these crappy oils that we’re eating in massive quantities these days, these directly also lead to insulin resistance. They lead to problems with our mitochondria oxidative stress, they can generate the insulin resistance. So that’s another thing that we really want to get out of our diet to promote our overall metabolic health and the cholesterol levels we want to see.

Max Lugavere:

Yeah, seed oils are the worst, just the processing of them. It’s so intensive, and we don’t have the long-term data like what it’s like for a human being to be consuming such high amounts of these oils over the course of a lifespan because they’ve only been in the modern food supply for what? 40 years at this point.

Dr. Casey Means:

Yeah, I think if anyone wants to, super horrified.

Max Lugavere:

50, 60 years probably, but to that degree, we just don’t know the effect and the processing, it’s like a horror show. You guys can go to YouTube. You can watch canola oil being made, it’s disgusting.

Dr. Casey Means:

It’s like a horror film basically, it’s really bad. It will make you never want to eat canola oil again.

Max Lugavere:

So I know that you’re obviously co-founder Levels all about personalized nutrition, but what are some general guidelines that you can give for people in terms of how to compose and think about their dietary pattern? Is it like low carb diets for everybody? Keto diets for everybody? What’s the recommendation? Where’s the starting place, and then where can people go from there in terms of catering their diets to their own bio-individual individuality, their activity levels, performance needs and so forth.

Dr. Casey Means:

Yeah, so I think it’s really hard to give a blanket statement of what people should eat, because I do think it is quite personalized, but I think there’s some print that we can all use that can be helpful which is really focusing on whole foods, focus on clean foods that came from the earth that are minimally processed that are not covered in pesticides and that hopefully come from good soil and are filled with nutrients. That’s number one.

Max Lugavere:

That’s asking a lot Casey.

Dr. Casey Means:

I know, but if we can create like that being a primary source, really clean meats, clean proteins, clean plants, you’re going to be 90% of the way there. Moving further than that, so that’s what to put in and then it’s like what to take out. I would say the more we can minimize or eliminate the refined sugar, refined carbohydrates and refine seed oils, again, that’s going to take us a lot of the way there.

Dr. Casey Means:

And in terms of other things that I think are quite valuable for the body like in my opinion, fiber is a really helpful thing for the human gut and for blood sugar control. So really whole unprocessed foods, avoiding the ultra refined products that are in so many of our foods, really supporting our microbiome with fiber and tons of healthy phytonutrients. It’s like the base of how I think and where I think a lot of people in the nutrition space have landed.

Dr. Casey Means:

People can quibble about how much meat to eat and this and that, but I think really clean foods that are as minimally processed as possible is the key to getting a lot of the way there. Then in terms of refining, I think you can take any dietary pattern. So just to get back to your question, should everyone be keto, should everyone be low carb? I don’t necessarily feel that way. I’m not necessarily low carb or keto. I eat mostly a plant’s diet with some fish and eggs, but the cool thing about monitoring is that you can actually take any dietary pattern that you do and optimize it.

Dr. Casey Means:

I used to be fully plant-based and I put on a CGM at a continuous glucose monitor and realize that so many of the things that I thought were quite healthy were causing super big glucose spikes for me. The grains and it wasn’t even a lot of processed foods, but a lot of the grains were causing huge glucose spikes for me and the oatmeal and stuff like that. And so I got rid of some of those, found some grains like millet that are grain-like things like millet that worked for me, cauliflower rice, broccoli, rice.

Dr. Casey Means:

I can have all the same foods that I love, but I just use those alternatives. So finding out those swaps that work for me, and then within just plants in general, figuring out which vegetables than which fruits cause these exclusive response. Fortunately, there’s lots of different varieties of these things. So pick the ones that actually work best for you. So that’s optimizing more of a plant-based diet which again, I’ve added in some animal products at this point, but if you’re keto, it can also be really helpful for optimizing.

Dr. Casey Means:

There’s a lot of keto people who are following a super strict regimented keto diet and never touching like a bean and never touching a carrot and never touching fruit because they think they need to really do none of that to stay in ketogenesis. Then they put a CGM on and they actually figure out they can liberalize their diet.

Max Lugavere:

Wow.

Dr. Casey Means:

They can add into carrots, they can add in a little bit of berries or maybe apple with almond butter or whatnot. And we’ve seen that a lot with the keto community, actually loosening up a little because they realize they don’t spike their glucose and it doesn’t kick them out of ketogenesis because they’re testing their ketones as well and everything’s smooth sailing. Then there’s people who you maybe don’t do really well on a super hardcore ketogenic diet, but they don’t do well with a ton of meat or whatnot, they know they do a little bit better with carbs, they still want to generate ketones for health purposes, and then they can actually dial in fasting to basically buffer a little bit of a higher carb diet, but still being ketogenesis and being able to monitor that on a CGM is really interesting.

Dr. Casey Means:

But yeah, same with paleo, really any type of strategy that people have, you can create little micro optimizations to get whatever benefit you get from that diet, how it aligns with your value system, but not have necessarily collateral damage of glucose spike. So that’s what I love about it. It’s really diet agnostic and allows anyone to refine what works for them.

Max Lugavere:

We talked a lot about like the downside to having frequent and prolonged glucose spikes, but are there any benefits to occasionally spiking or glucose? To thyroid function, to lectin levels. Is there any reason why we might occasionally want to have a big carb rich meal?

Dr. Casey Means:

Yeah, so really the answer to this, we look to sort of traditional cultures and animals as well because there is a reason that animals right before they hibernate eat a ton of fructose rich foods and ripe fruits and berries and things like that before they go and hibernate it’s because they literally want to store fat because they’re not going to be eating for months at a time. And in certain traditional cultures or indigenous cultures where it’s a little bit more of like feast or famine, being able to like eat a lot of fructose really drive forward some of those fat storage pathways and then have that ability to have energy stores, that can be a positive thing.

Dr. Casey Means:

In our modern world, in the Western world, we’re unfortunately have taken those evolutionary pathways that allow us to store energy in our body for times of needs. And we’ve just hijacked them and we’ve given way too much substrate to those pathways. And now we’re dealing with the ramifications of that, but I would say for people, if there are people who are looking to store energy, a glucose spike or a lot of fructose in the body are going to drive some of those fat storage pathways.

Dr. Casey Means:

So I wouldn’t necessarily say that’s a good thing for the average modern American, but there is a very real evolutionary benefit of why we have glucose spikes and why that spikes insulin and why that leads to that storage. And there’s actually an amazing book coming out in a few months that I was able to review which is called Nature Wants Us To Be Fat which is all about why it’s evolutionarily advantageous for these pathways to work the way they do, but how our modern world essentially unfortunately taking advantage of those.

Dr. Casey Means:

But in terms of just like general health benefits for having a glucose spike, there’s none that I can really think of. I would say again the one spike here and there, your body’s designed to respond to it. It’s not going to cause long-term damage. So no one should freak out about a single glucose spike. It’s really more the patterns over time.

Max Lugavere:

I’m totally on the same page in terms of my own diet. I definitely eat a lower carb diet, although I definitely will enjoy whole fruit. I’ve been going to town lately on pineapple because I discovered Tajín which is this Mexican spice with it’s a lime and salty, just amazing thing that you can sprinkle on watermelon, pineapple, mango. It’s almost better than sex. It’s the best thing ever.

Max Lugavere:

My question is that was a bit of a, I went to The Bahamas there, but my question is so for people that … Is there a danger to demonizing blood sugar spikes for perhaps a certain population that might then avoid carbohydrates completely and then suffer health consequences from that. There are a lot of women that follow me that don’t really do as well on super low carb diets. So I wonder if we run the risk of pathologizing carbohydrates and then sending the message that low carb diets are optimal and then making a whole lot of people feel like miserable for it.

Max Lugavere:

And then also of course there’s been some pushback from communities like eating disorder, people with disordered eating and stuff like that. So I just want to yeah, address two demographics or for anybody else for whom we want to make sure aren’t suddenly becoming scared of incorporating carbs into their life.

Dr. Casey Means:

Yeah, it’s such an important point. And the reality is like those, these are things we think about all the time as we’re designing the product because it is nuanced. And I think people are often shocked when they hear that the co-founder of this company is primarily a plant-based person because they’re like, “Wait, that’s a lot of carbs. How does that align?” And it’s like we were just talking about like.

Dr. Casey Means:

You can absolutely make that work for a flat, pretty stable glucose response. It takes a little bit of trial and error and figuring out what foods actually work for your body. So I think the reality is that this does not need to drive people to a keto or a super low carb diet. I think it will promote the idea that eating foods with refined carbs and refined sugar are leading to problems on the glucose monitor. And I do hope that they will help people avoid those foods because people don’t really need to eat those.

Dr. Casey Means:

But a lot of foods with carbohydrates that have a good balance of fiber in them like root vegetables and beans and legumes don’t cause a glucose spike. And so I don’t see this necessarily driving people away from those. And again, it’s very variable person to person, but I for instance do not have a glucose spike of more than 10 points with beans, lentils and several fruits like fairly unright pears, apples, things like that. So the monitor in a sense like doesn’t necessarily drive people to totally avoiding carbs.

Max Lugavere:

So I think we need to uncouple this notion that carbohydrates cause glucose spikes, it’s like certain carbohydrates for certain people.

Dr. Casey Means:

Exactly.

Max Lugavere:

Cause glucose spikes and it’s not just carbohydrates or even food for that matter that can lead to spikes. Yeah, I think that’s an amazing take home.

Dr. Casey Means:

Yeah, I like to say a carbon in the mouth is not glucose in the bloodstream. There’s a whole lot that happens between a carbohydrate that goes in your mouth and what shows up in your bloodstream, trillions of bacteria interacting with it and a lot of complex physiology. So that is something that I think is important to remember. But I think in terms of the refined stuff which will most likely cause a glucose spike in most people, that is cool to be aware of and to realize that’s not serving my goals and maybe I can find a healthier, more whole foods alternative for that doesn’t spike glucose.

Dr. Casey Means:

But the question about eating disorders, I think that’s a really, really important one and Peter Attia has a great episode on this, his AMA about continuous glucose monitors because he’s used them in patients for a long time. And he basically says he actually does not prescribe them to anyone who has a history of any disorder because it can cause this fixation and I haven’t seen this actually happen in my own practice or with Levels, but theoretically, I can imagine it could cause one more and to kind of fixate on and really be harmful in that sense.

Dr. Casey Means:

What I will say is that we’ve seen actually more of the opposite of that which is that people who have been focused on nutrition and finding the perfect diet and following every nutrition book and influencer, and hasn’t really been able to find the perfect it for them or reach their health goals, that can be an obsession. That’s the orthorexia that people talk about where it’s this obsession with wellness and some of people who have self-reported that’s what they’ve been like, 20 years of being obsessed with nutrition, put on a continuous glucose monitor and in a month, they figure out, “Oh, these foods work for me and these foods don’t seem to work for me. These combinations work for me and walking after meals for 20 minutes really works for me.”

Dr. Casey Means:

And then all of a sudden it’s like, “I don’t have to think about this as much anymore. I’ve actually as opposed to taking everyone’s advice and reading everything possible and trying to just muddle through all this information, I’ve figured out these 10 new things that work well for me.” That can actually be quite liberating. And I would say for me personally, I think a lot less about food now than I did previously before wearing this. And the reason for that is because I have in my mind the algorithm of what works and what keeps my glucose stable.

Dr. Casey Means:

So in terms of things like weight or whatever, it’s not a mystery. I know what’s going serve the goals and what’s not. And so there’s two sides to the coin. One which can be, I think, freeing and create efficiency in our nutrition journey and one that can unfortunately lead to a bit more focus and obsession on it. And so we have to just be really careful about I think spreading that message, sharing that information and making sure that the product itself, the software that create really tries to guide people towards a really healthy experience with the food.

Max Lugavere:

And I think it does. As I’ve said, I used Levels and I really enjoyed that two week period that I was using it for. I think what you’re talking about really speaks to the fact that all new technologies really have an aspect to them that’s like a double edged sword, it’s just like fire. Fire can either cook your food or it can burn you. So I think it’s about establishing a healthy relationship with these things, but at the end of the day, I love this notion of the quantified self. What you can measure, you can manage and less improve and the more data the better.

Dr. Casey Means:

Yeah, I would agree. I think we are a black box and it’s really hard to control something that you don’t understand. And unfortunately, the labs we get the single time point measurements make it very difficult to actually have understanding because they’re not a story, they’re just a snapshot. Stories help us with understanding and continuous variables like glucose creates a narrative and a story out of what’s happening. And that allows us to have more understanding of our own bodies, be able to see within a little bit and make better decisions.

Dr. Casey Means:

And so that’s what I’m hoping for people, and really the core mission of Levels is to help people understand how food’s affecting their body and to empower individuals with their own information so they can make better decisions and have agency. And especially in the face of a lot of industries that really want us to eat their packaged, processed foods and really benefit off us being sick, independent on the system. I am really eager to empower people with their own information so that they can make their own independent better decisions.

Max Lugavere:

I love it. And I love the word that you keep using agency. I think it’s a really great word. Agency over one’s health I think is something that people just don’t feel this sense of agency, they feel like they’re disempowered. They feel like they’re victims, but really all takes a little bit of knowledge and to really turn that sentiment around. So grateful for what you guys are doing.

Max Lugavere:

What about like biohacker bro? That puts on a level, a level of CGM and they eat an apple, they see their blood sugar spike, they eat a piece of bacon, doesn’t spike. They like, “Okay, bacon’s got to be better for me than the apple.” Would that be a misunderstanding of the data? A misconstruing of the data from that?

Dr. Casey Means:

Yeah, that is a situation that frankly, it’s a fear you know I have that people are going to look at this and just say, “Oh my God, I’m going to …” Because if you think about it, you could literally drink a gallon of canola oil and your glucose won’t spike. And so is that the new optimal diet?

Max Lugavere:

Right, yeah. That’s a very interesting question. Our glucose spikes. So yeah, glucose spikes we know are not the end all be all metric arbiter measure of a food’s healthiness. But just going back to the person who doesn’t fully understand the implications of what this data is telling them, they’ll eat a delicious just honeycrisp apple, and I’m not making a qualitative judgment against bacon, I love bacon. But is that a switch that you might endorse based on the data to come from CGM?

Dr. Casey Means:

Well, there’s two things here that I think are important. The first is that this is why education is such a key part of our program. We talk a lot about the goal is not necessarily to rig the game, win the game by just having a flat and stable glucose line. The goal winning the game is having a body that is metabolically healthy. And that has the cellular machinery that process energy effectively. And so what while minimizing glucose spikes is a part of that, it’s not at all costs type of thing.

Dr. Casey Means:

So we educate tons like in our app about the microbiome and about micronutrients and about environmental toxins and about oxidative stress and all these things that people can understand the full picture of these things, sure that was a flat glucose spike because you chugged the canola oil, but the oxidative stress is going to over the long-term damage the mitochondria and lead to metabolic dysfunction in the long run. It’s the same with micronutrients.

Dr. Casey Means:

You need all these little tiny vitamins and minerals, manganese and magnesium and zinc and Vitamin C, they literal really serve as lock and key co-factors for the proteins that process glucose in our cells. It’s so cool, but you might not necessarily realize on the glucose monitor, I need to be optimizing for micronutrients because you don’t see it show up immediately. It’s over the weeks and months and years that it matters, and so that’s an education piece. But the second cool thing is that this is where the future of biosensors is going.

Dr. Casey Means:

The future of biosensors is going to be multi-molecule biosensors. Right now the only molecule we can measure on the body is glucose. It’s the only one that exists to actually you have a sensor on your body and it’s giving you that data and it’s a great step forward. But diet is not just about glucose, it’s about all these other things. And so multi-molecule sensors which are certainly right around the corner are going to be able to disambiguate some of these things that we’re talking about.

Dr. Casey Means:

So let’s say you do eat the canola oil, maybe it doesn’t show up on the glucose test, but what if we had that test for oxidative stress? What if we had the test for cytokines that are showing our acute inflammatory risk stress response? What if we had some molecule that we could test that shows like about leaky gut or something in that realm? Then you could start to say, “Okay, it didn’t spike my glucose, but it caused all these other problems.” An example of this is that fructose straight fructose which is causing huge, huge amounts of problems in America, primarily hurting our livers because fructose drives fatty liver disease and makes our livers insulin resistant through a glucose independent pathway, fructose doesn’t actually stimulate.

Dr. Casey Means:

It will not increase glucose or insulin on your glucose monitor. Now almost all the foods we eat with fructose also have glucose in them like high fructose corn syrup is usually half glucose. So you will see a glucose spike, but fructose itself isolated will not spike glucose or insulin. So you could potentially be going, eating straight fructose, going down the pathway of metabolic dysfunction that wouldn’t show up on a CGM, but-

Max Lugavere:

It will jack your triglycerides.

Dr. Casey Means:

Yeah, you could jack your triglycerides or uric acid is actually downstream of fructose as fructose gets processed in its pathway in the cell, it generates uric acid which is actually something we can measure on a finger prick now or in a lab, not continuous yet. But you can imagine if you had a uric acid monitor a lot on with your glucose monitor on the same little sensor, you’d be able to now see, disambiguate those types of foods.

Dr. Casey Means:

And so that’s where I really see things going where you have a dashboard where it’s like, “Okay, this food had this type of impact on my body and it’s not just about glucose.” So that’s what I’m really excited it to see and I think what Levels will emerge as is really the software layer to put that type of stuff together. But I think we’re going to see some really exciting stuff in the next two to five years with multi-molecule sensors that help essentially answer that question about bacon and the apple. Maybe the bacon didn’t cause a glucose spike, but maybe it caused your free fatty acids to go to a really unhealthy level or something like that.

Max Lugavere:

Yeah. Oh my God, I’m just thinking about drinking canola oil and it makes me queasy. It’s so gross. And just to underscore what you said earlier in the episode which I think is so important, it’s that metabolic dysfunction, it’s blood sugar specifically, fasting blood sugar, it’s a lagging indicator of what would be 13 years you said? Of just doing things wrong. Eating the wrong diet, living the wrong way and at that point, think about all the damage that potentially has already been done on your organs, but also on your skin, on your brain.

Dr. Casey Means:

Blood vessels.

Max Lugavere:

Blood vessels.

Dr. Casey Means:

Yeah. Yeah, exactly. So we got to start catching these things early and I think it’s going to … Really got to get doctors on board with thinking this way from like that pre-disease root cause approach and not just focused on feeling like success criteria is diagnosing and treating. Like that’s not success criteria in treating, success criteria is preventing and reversing and we’ve got to shift gears for more doctors to be focusing that way.

Max Lugavere:

Love it. Well, thank you for democratizing these biosensors so that people can have a better sense of what their blood sugar is doing. Being able to look under the hood, something that you used to have to go into a doctor’s office to be able to do, and now you can do it from home which I think is an amazing thing. So thanks for doing that. I’ve got one last question to ask you before I get to that, where can listeners connect with you on social media and where can they learn more about Levels?

Dr. Casey Means:

Yeah, so they can connect with me personally at Dr. Casey’s Kitchen, Dr. Casey’s kitchen on Instagram and Twitter. We’re at Levels on Instagram and Twitter for the company. And it’s really fun to follow Levels on Instagram because we’re always reposting what our members are doing and the experiments they’re running. And you learn a lot from what these other people are doing which I love. And then you can find out more about Levels at levelshealth.com and that’s where you can sign up for our wait list and our newsletter, we’re producing really amazing high quality content with the top researchers in the field about metabolic health. And so definitely sign up for our newsletter and levelshealth.com/blog is where a lot of the educational information is.

Max Lugavere:

Dope. The last question that gets asked everybody on the show. Dr. Casey Means, what does it mean to you to live a genius life?

Dr. Casey Means:

Hmm. For me to live a genius life, it means I would really say managing, this is an audiencer, but I would say managing my nervous system.

Max Lugavere:

I thought you were going to say managing your glucose levels.

Dr. Casey Means:

That would’ve been too easy. No, I think I learned that I got an older that really a key priority for me is keeping my nervous system in check whether that’s through meditation, through mindfulness practice, through therapy, through whatever it is because the energy that I have inside of me is really once that’s managed, I can give my best light to the world. And so figuring out ways to do that and kind of doing the daily practices that keep me in that parasynthetic state and keep me really channeling good energy, I think is like a core focus that’s emerged in my life, and then for people who bring out the best energy in me. So that’s one of the key things I’ve been focusing on to live my my genius life and to live aligned with my values.

Max Lugavere:

I love that, and I feel like I aspire to do the same. Thanks for your time. To all you guys, we’re going to put bonus content from Dr. Means in our locals VIP, Genius Life VIP program on locals. You can go to maxlugavere.locals.com to watch that and text me to let me know what you thought about this episode of the show. Would love any feedback that you have 310-299-9401 and I’ll catch you on the next episode. Peace.

Max Lugavere:

Hey guys, you know how there’s always like a tease at the end of Avengers movies or any movie for that matter in the Marvel universe about like upcoming movies? Well, this is a way less fun version of that. Before we fully exit out this episode, I just wanted to share that Levels has set up an exclusive code for The Genius Life family. If you’re looking to try out a continuous glucose monitor, now’s your chance.

Max Lugavere:

Levels is currently running a closed beta program with a wait list of over 145,000 people. But if you’d like to skip that line and participate in their early access program, all you got to do is head over to levels.link. Yeah, it’s levels.link, you heard that correctly /geniuslife, levels.link/geniuslife, you’ll get to the head of the line of their wait list again, which has over 145,000 people. And you’ll get to try a CGM for yourself. So yeah, keep that in mind. Peace.