Digital Tools to Measure Blood Sugar & Metabolic Health with Dr Casey Means

Dr. Casey Means is changing the face of metabolic health with her company, Levels. After growing weary of treating the symptoms of chronic conditions, Dr. Means decided to tackle the root cause instead. During this interview with functional nutritionist Dr. Jockers, Dr. Means delves into how glucose causes inflammation and disease. Sher explains why there is no one-size-fits-all approach to diet, how personalized choices are the key to health, and why tracking glucose is the best way to make the right choices for your body.

• Check out Levels
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• Connect with Dr. Casey Means on LinkedIn or Twitter
• Check out Dr. Jockers Functional Nutrition
• Connect with Dr. Jockers on LinkedIn or Twitter

5:00 – Stay out of the operating room with personalized health

Environment and lifestyle choices can increase inflammation and risk of disease. Tackling these root causes could minimize the need for medical interventions.

“Chronic inflammation is in many ways, really rooted in our everyday exposures. So what we eat, the toxins we’re exposed to in our food, air and water, how much sleep we get, the stress in our lives, how much or how little exercise we’re getting, our microbiome. All of these things have a direct relationship to chronic inflammation. So treating it with this sort of very reactionary, invasive, more anatomic approach with surgery there was some sort of missing a missing link there. Certainly surgeries are really important and beautiful art, but for some of the conditions really rooted in chronic inflammation it kinda got me thinking there might be a better way to approach this. What could we be doing with sort of really personalized dietary and lifestyle interventions, really foundational help, to really quell that chronic immune response, quell that threat the body is sensing and potentially keep patients out of the operating room?”

8:33 – Creating medical webs instead of silos

With the vast majority of Americans considered unhealthy, focusing on the common cause of disease should prevent the many conditions associated with inflammation.

“We’ve conventionally looked at diseases in conventional medicine as isolated silos. You’ve got depression, you’ve got obesity, you’ve got diabetes, you’ve got prostate cancer, you’ve got IBS and that these are all things that are different. And we treat them separately with totally different medications, with totally different mechanisms. But when you step back and you use sort of more advanced research techniques, like whole genome sequencing and proteomics, how can we actually see what are the molecular links between diseases? And you create a web, a network, a system, and that’s really the root of systems and network biology. And when you start doing that, you see these connections and I think the future of medicine is really treating conditions at that level, at the connections between diseases. Because when you do that, you can hit a lot more birds with one stone.”

11:45 – Inflammation spreads to the whole body

It may present as one specific condition, however metabolic dysfunction will be present in every cell of the body.

“Something like a core root cause of dysfunction in the body, like blood sugar dysregulation and resultant insulin resistance, that doesn’t live in one little part of the body. It doesn’t live in a small box in the body. It lives everywhere. We are a unified system connected by our circulation, by everything. And so things aren’t sequestered to one small area. So that insulin resistance and the fact that the body has to produce more insulin to basically get the signal to the cells, that’s being heard by every cell in the body. And so while in one person that may show up as polycystic ovarian syndrome and another person that might show up as Alzheimer’s. And in another person it might show up as non-alcoholic fatty liver disease, and another person that’s hypertension, in another person it could be a more aggressive cancer. These things, they seem so different. But I think stepping back and really thinking about the body, all parts of the body are hearing this, in some people where that is expressed, where that becomes pathology is going to look a little bit different based on our unique characteristics.”

14:25 – Replace one measurement a year with hundreds per day

An annual physical shows a glimpse of health, but it doesn’t see the detail. A continuous glucose monitor tracks blood sugar throughout the day for a clearer picture of metabolic function.

“So traditionally you’ve had these one-time point measurements for lab testing, like hemoglobin A1C. You get your blood drawn, it tells you about a three-month average of your glucose levels. You get a fasting glucose, that’s just a one-time measurement of what your morning glucose is. And by nature of actually just getting that test one time, it almost leads us to believe that the number is fairly static. When in fact fasting glucose can bounce around a lot day to day. But it kind of primes us to think, oh yeah this is my fasting glucose. This is who I am in terms of my glucose. It’s not true. It bounces around day-to-day based on the choices we’re making every day. And then what’s more after you get that morning fasting glucose, your glucose is going up and down potentially on a roller coaster throughout the entire 24 hours, which has a huge implication on health. And that’s what you can’t pick up with these one-time lab draws. So continuous monitors totally opened up this whole new role of data that can be really useful and really actionable to people.”

16:58 – Monitoring glucose gives a dynamic understanding of health

Tracking glucose shows the links between behaviours and how the body reacts.

“You can see how if you eat a high carbohydrate meal at night, your fasting glucose could be five or 10 points higher the next morning. You can see after a meal in the middle of the day whether your glucose spikes up to a really high level or just stays pretty flat. You can see how exercise impacts your glucose and your response to meals. You can see how something like stress, a stressful phone call, or a stressful conversation with a friend, how that affects your glucose. You can also see how a poor night of sleep or a really good night of sleep affects your fasting glucose. So really dynamically understanding how your behaviors are affecting glucose.”

18:10 – High glucose is wreaking havoc on health

Glucose intake signals insulin production to absorb that glucose into the cells. Too much glucose and this process goes into overdrive, creating insulin resistance and a cycle of ever-increasing levels. This triggers mechanisms like fat storage and cell growth.

“High glucose is going to trigger inflammation. It’s going to trigger oxidative stress. It can trigger the process of glycation, which is where high glucose in the blood causes glucose molecules to stick to different things in the body like proteins and potentially cause dysfunction in how these proteins work. So alone glucose can cause those processes, inflammation, oxidative stress, glycation. But it’s also, of course, going to be stimulating the pancreas to make insulin and to produce more insulin. Like Ben talked about on his episode. And when that happens, that’s a normal process. Your glucose goes up, your pancreas makes insulin, the insulin allows you to take glucose up into the cells. But when that’s happening all the time and you have high-glycemic variability, means you’re spiking over and over and over again, multiple times per day. Maybe cause you’ve been told to have snacks many times throughout the day, which was a common recommendation in the past. Your insulin is constantly going to be peaking and what that’s telling your body, that is molecular information to your body for every single cell that it’s essentially turning on the pathways that insulin turns on, which is a lot of vital pathways, but when they go on overdrive, it can be a problem.”

21:51 – You could be a banana or a cookie person

Each body responds differently to foods, studies have shown. One person could eat a cookie without glucose spiking and a banana surges glucose, or vice versa.

“There has been this paradigm that there’s this standard characteristic of specific food that is like, this is how much this food is going to raise the blood sugar and how quickly in a person and that’s sort of uniform. But what we’re figuring out is that that’s actually not true because our personal response to a specific carbohydrate is going to be very different. And how that carbohydrate translates to glucose in the bloodstream is actually a very complex pathway. A lot of this research came out of this amazing paper that was published in 2015 from the Weizmann Institute in Israel, which was called Personalized Nutrition by Prediction of Glycaemic Responses. And this paper basically put continuous glucose monitors on tons of healthy non-diabetic individuals and then fed them standardized meals. So they all ate the same thing and they looked at their glucose after those meals. And under the glycemic index paradigm, you would think that every single person would respond the exact same way to the same food. That everyone eats a piece of white bread and then their blood glucose all goes up a certain amount and comes down. They’re all healthy. You know, it’ll all be the same. But that’s actually opposite of what happened. Basically what they found is that people could have equal and actually people had a very wide spectrum of their responses to the exact same food.”

28:17 – Stressful modern lives are spiking glucose

Humans adapted so that in times of stress glucose is released to power the body to run away from threats. This is what takes place every time we have a stressful interaction or physical stress like too little sleep.

“Our body developed adaptive responses to help us in times of stress, and unfortunately in our modern society these are becoming maladaptive for us. So you think back, way back in ancestral times when really stress was probably more likely a physical or corporeal threat. We had to run from the lion as the classic example, who knows if that happened very often. But you’re in a physical threat and in that time of stress, your body releases cortisol and catecholamine hormones, and it tells the body you got to run and so your muscles need quick energy. And the quickest form of energy in our body is glucose. And we have little bits of it stored for moments like that when we get stressed, stored in our liver and our muscles, and our body when it’s stressed says, okay, dump this from the liver, get into the bloodstream, get it to the muscles. And so you often with high stress experience, we’ll see even in a fasted state, the glucose rise during that stressful event and that was because our body was trying to help us get the energy it needed to run away from something really. Now our threats are generally not physical. We generally don’t need to activate our muscles when we’re having a stressful conversation or get a stressful email. And so that’s really not necessary anymore. And yet that’s happening all the time.”

37:13 – Getting a grade A for mealtime

Levels gives a score of 1-10 on how glucose fluctuates following a meal, so you understand if it was a grade A or a fail.

“Right now if you just walk into the doctor, they’ll say you’re fasting glucose is 98 or your fasting glucose is 115. It’s hard to know exactly what that means and what does it mean if your glucose goes to 130 after a meal? Well, the beauty is the literature, the scientific literature tells us a lot about the implications of these fluctuations. But that’s thousands of pages of papers that we’re not going to be thinking about every time we take a bite. And so our goal is really to condense it into a 1 to 10 score that when you eat, sit down and eat a meal, two hours later you have a grade essentially for that. Was it an A, was it a B? And that’s taking into account a number of aspects of what happened to your glucose curve after the meal that we know are associated with better or worse health outcomes. So there’s a lot of different things you can learn from just that little curve that happens after a meal.”

42:35 – Is that two pound weight gain water weight or that cake you ate?

Instead of guessing which actions have impacted your health, a CGM creates that awareness.

“Nutrition has been notorious for having open loop feedback and high variability and complexity and understanding the relationship between the choice you’re making and what’s happening. Traditionally, what we’ve had is one, stepping on the scale the next morning. And you’re like, okay, well I’m two pounds heavier. Is this water weight? Is this my hormones? Is this the cake I had at 2:00 PM yesterday? What is this? So that’s very challenging to look back and say what can I do differently. It’s sort of like, well, do everything differently, but you just don’t know. The second one we’ve had is that yearly fasting glucose test at the doctor’s office with your annual physical. And so last year fasting glucose was 87, this year it’s 89. What does that mean? It really means nothing. And so it doesn’t help you actually change things.”

45:38 – Tune in to what the body is saying

Greater understanding of what’s going on in the body can reduce disease. By combining an action with data and the feelings in the body, it’s possible to learn what that feeling means.

“I think we all intuitively know this, but in our current modern world it is so much harder to hear our internal body signals. We’ve got a lot of distractions, we’re very screen facing, we’re on the go, we’re tired, we’re staying up late. We’re also exposed to these crazy hyper palatable foods that are basically frankenfoods, they’re not real and they hijack our normal rewards circuitry. So we don’t really know how we’re feeling because we feel we’re getting essentially a drug surge when we get sugar and processed and refined foods. So the idea of really true body awareness is challenging. And when you pair a tool like a biofeedback tool, whether it’s heart rate or glucose, you can actually improve your interoception capabilities.”

47:00 – Once you know, it’s like having food poisoning

With data showing clearly how the body reacts to certain foods, when a negative reaction happens it’s impossible to ignore.

“When you can create that trifecta of awareness of action, metric, biofeedback, and subjective experience, it also becomes much less painful to part with things in your life. If you love oatmeal, once you see that it’s so clear. It’s so obvious that it’s not upsetting to say I’m not gonna eat this anymore. I’m gonna eat differently to have a better outcome because you have understanding. And it’s so much that I think the difficulty with dieting and with adopting ‘healthy diets’ or other behaviors, is that we don’t actually know if they’re working or doing something. There’s such a lag time between whether we actually have the outcome we want on the scale or a cholesterol test or our fasting glucose test that it’s ultimately very challenging to adopt these behaviors. But when you can just see the instant response, it’s a lot easier to part. I liken this to food poisoning.”

Dr. David Jockers [00:00]                         Hello and welcome to the Dr. Jockers Functional Nutrition podcast, the show designed to give you science-based solutions to improve your health and life. I’m Dr. David Jockers, doctor of natural medicine, chiropractor and functional nutrition practitioner. And I’m the host of this podcast. I’m here to tell you that your body was created to heal itself. And on this show we focus on strategies you can apply today to heal and function at your best. I’m excited about today’s podcast. But before we jump in, I wanted to remind you to download this month’s Special Gift at drjockersgift.com. From keto meal plans, smoothie recipes, to fasting quick start guides. We have a new complimentary gift every single month. To get your gift, simply visit drjockersgift.com. That’s D R J O C K E R S G I F T .com. Thanks for spending time with me, and let’s go into the show.

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Well, hey everybody. Welcome back to the Dr. Jockers Functional Nutrition podcast. And you guys know that one of my favorite topics to talk about is blood sugar, insulin, and metabolic health. And we had a great interview recently with Dr. Ben Bikman where we went in depth on that. And this is almost like a follow-up to it because we’re going to talk about really the personalized approach to really looking at your blood sugar and how it’s responding to the foods that you’re consuming. And so my guest is Dr. Casey Means. She is the chief medical officer at Levels. And she is a Stanford trained physician. Again, chief medical officer and co-founder of the metabolic health company Levels. And she’s the associate editor of the International Journal of Disease Reversal and Prevention. And you can find more information about her at levelshealth.com. And we’re going to talk about what the best foods are for blood sugar management, for metabolic health and how that could be variable, depending on how your body’s responding to the foods that you consume. We’re going to talk about personalized medicine. So Dr. Casey, thanks for joining us here.

Casey Means [04:25]     Thank you so much for having me, Dr. Jockers. So happy to be here.

Dr. David Jockers [04:29]                         Well, yes, for sure. And I’ve heard several of your interviews on other podcasts and you really do a great job of explaining how important blood sugar stability is. And you know, this new technology that we have now, continuous blood glucose monitoring. And so what I’d love to do is start with your story and you know, how you went from Stanford and trained in medicine to now kind of branching out into functional nutrition, integrative medicine approach.

Casey Means [04:56]     Yeah, absolutely. So, like you mentioned, I trained as a medical doctor, conventional medicine. I trained at Stanford, did my undergrad and medical school there. And then I went on to become a head and neck surgeon. So I was deep in the surgical world for about five years. And in my role as a head and neck surgeon, which is really treating the conditions of the ear, nose, and throat. So an ENT surgeon. Something I noticed was sort of hitting me head on, you know, after about five years. Like, “Wow, pretty much all of the conditions that I’m treating are inflammatory in nature, they’re all related in some way to chronic inflammation.” So some of the things you think about are like sinusitis, which is inflammation of the sinuses, and chronic ear disease, which is inflammation of the eustachian tube, the tube that connects the nose to the ear, and you get inflammation in that tube and you get pus building up in the ear. You’ve got Hashimoto’s thyroiditis, which is the inflammation of the thyroid. You’ve got things like vocal cord granulomas, which are inflammatory mass to the vocal cords. And then lots of head and neck cancer, of course, which we know cancer has very much relationship between chronic inflammation. So it was really interesting to me to sort of step back and say, “Wow, this is sort of a very common theme between a lot of the conditions that I’m treating.” And in some way, it didn’t make total sense to me that we would be treating those conditions with surgery because chronic inflammation is fundamentally an issue with how our immune system is responding to perceived or real threats in the environment, in our bodies. And you know, more and more, we’re learning about how chronic inflammation is in many ways really rooted in our everyday exposures. So what we eat, the toxins we’re exposed to in our food, air and water, you know, how much sleep we get, the stress in our lives, how much, or how little exercise we’re getting, our microbiome. All of these things have a direct relationship to chronic inflammation. So treating it with this sort of very reactionary, invasive, more anatomic approach with surgery, you know, there was some sort of a missing link there. And certainly surgeries are really important and beautiful art. But for some of the conditions really rooted in chronic inflammation, it kind of got me thinking there might be a better way to approach this. What could we be doing with sort of really personalized dietary and lifestyle interventions, really foundational help, to really quell that chronic immune response? Quell that threat the body is sensing, and potentially keep patients out of the operating room. You’re not going to prevent all surgeries, but I certainly think there’s some low-hanging fruit we could do to help people minimize the severity of their diseases and hopefully never have to get, have them get to that really end of the line where they see me in the OR going under the knife, which is a really serious, serious thing. So that really got me on this journey of trying to understand the root causes of disease. And that led me to functional medicine. And so I actually stepped away from the operating room, got training with the Institute for Functional Medicine, and really started thinking of disease a lot differently. I started seeing things much more as symptoms and diseases often being the branches on a very similar tree. And that tree that we, that sort of root that connects a lot of seemingly desperate diseases often comes down to things like inflammation. And even deeper than inflammation, metabolic dysfunction. This was talked about so beautifully in your episode recently with Dr. Ben Bikman, who is talking about metabolic dysfunction, insulin resistance. But what’s so interesting is that in our country, it’s thought that about 88% of Americans have met, or have signs of metabolic dysfunction, that was shown in a study a couple of years ago from UNC. That 88% of adult Americans have at least one biomarker of metabolic dysfunction. And metabolic dysfunction and insulin resistance, which are kind of two sides of the same coin, really can directly feed into inflammation. So it’s all really related. And what’s sort of hopeful about this is that those are things that are readily modifiable with smart choices, in how we live and what we expose ourselves to. So, became really interested in that and really this systems and network biology movement, which is really stepping back and saying, you know, we’ve conventionally looked at diseases in conventional medicine as isolated silos. You’ve got depression, you’ve got obesity, you’ve got diabetes, you’ve got prostate cancer, you’ve got IBS. And these are all things that are different. And we treat them separately with totally different, with medications, with totally different mechanisms. But when you step back, and you use sort of more advanced research techniques, like whole genome sequencing and proteomics, how can we actually see what are the molecular links between diseases? And you create a web, a network, a system, and that’s really the root of systems and network biology. And when you start doing that, you see these connections. And I think the future of medicine is really treating conditions at that level, at the connections between diseases, because when you do that, you can hit a lot more birds with one stone. That’s sort of a negative metaphor, but you know what I mean? It got, instead of playing whack-a-mole, you’re really, you can have multiple various effects with some single interventions that affect that root cause physiology. So my career really moved in that direction. “How can we help people understand what ties their symptoms and conditions together on a root cause? And then how can we help inspire people and enable people to make the choices day in, day out?” The personalized choices for their body that actually moved the needle on that sort of fundamental molecular biology. And that comes down to a lot of the principles that we all know. We, you know, how we eat, how we sleep, how we exercise, how we stress, what we expose ourselves to in the environment. These translate in our bodies and the molecular information that guides our physiology. And so I’m really passionate about creating tools, like what we’re doing with my company Levels, to help people understand their body and make those decisions day in and day out, that moves the needle on core physiology.

Dr. David Jockers [10:56]                         Yeah, it’s so good. And it’s amazing to think 88%. So it’s nine out of 10 people are dealing with some sort of metabolic dysfunction that’s going on. And the way that we react to stress, I mean, really, we all kind of react, our physiology reacts to stress the same. However, we can have a unique genetic expressions. It’s kind of like you’re saying, there might be the same underlying factors behind why somebody might have Hashimoto’s thyroiditis and somebody else might have eczema. And so, you know, it doesn’t mean that those diseases are totally different. There’s a lot of similarity and overlap and some of the same factors, like blood sugar instability might be at the core there. And so that’s kind of what you’re talking about, tying that together and going upstream and finding root cause factors.

Casey Means [11:45]     Exactly, yeah. And again, I think Ben described this really well on the podcast. You know, something like a core root cause dysfunction in the body, like blood sugar dysregulation and resultant insulin resistance. That doesn’t live in one little part of the body. It doesn’t live in a small box in the body. It lives everywhere. We are a unified system, you know, connected by our circulation, by everything. And so, you know, things aren’t sequestered to one small area. So that’s insulin resistance. And the fact that the body has to produce more insulin to basically get the signal to the cells, that’s being heard by every cell in the body. And so while in one person that may show up as polycystic ovarian syndrome and another person that might show up as Alzheimer’s, and in another person it might show up as non-alcoholic fatty liver disease, and in another person that’s hypertension, in another person it could be a more aggressive cancer. Like these things are, they seem so so different, but I think stepping back and really thinking about the body, you know, all parts of the body hearing this, but some, in some people where that is expressed, where that becomes pathology is going to look a little bit different based on our unique characteristics. And if it’s the ovaries that happen to be more sensitive to that insulin resistance, PCOS, you know, if it’s the brain, brain insulin resistance, neurogeneration. So I think it’s a really, yeah, it’s a whole new way of kind of looking at things. And I think there’s certainly a lot of movement and books like, you know, Why We Get Sick, and others are really helping to reframe our perspective about why we have to think about some of these things. Like, you know, blood sugar, even if we’re not diabetic. You know, well before we get to that advanced disease state, because even in those earlier stages, even when we’re ”normal” with our fasting blood sugar, there’s still probably a lot of optimization we could do to just sort of help our entire bodies thrive a bit more.

Dr. David Jockers [13:40]                         Right. Right. Absolutely. So, you know, my health coaches and I, when we’re looking at blood work, right? Somebody goes in, they do a fasting blood work in the morning and typically major markers we’re looking at, our fasting glucose, fasting insulin levels, hemoglobin A1C, fructosamine,  right? And they kind of give us an idea of what’s happening in a point of time. However, you know, with what you guys are using with the continuous blood glucose, it’s really looking at what’s happening all the time. Like you continuously can monitor it, how your body’s responding to momentary stress, food that you’re consuming, things like that. Can you talk more about that and how that compares to testing on just a standard blood lab, like we talked about?

Casey Means [14:26]     Yeah. Well, first of all, I’d say the labs you’re ordering are amazing and definitely more thorough than what the average doctor, or average patient is going to get when they walk into the doctor’s office. I mean, nearly adding a fasting insulin is giving you 10X the information that just a fasting glucose is doing. And so I think that can be extremely helpful to start painting the picture of how people, where people really stand on the metabolic health spectrum. And, but I think, yeah, there’s this really exciting new wave of diagnostics and monitoring tools that are continuous in nature. So traditionally you’ve had these one time point measurements for lab testing, like hemoglobin A1C. You get your blood drawn, it tells you about a three-month average of your glucose levels. You get a fasting glucose, that’s just a one-time measurement of what your morning glucose is. And by nature of actually just getting that test one time, it almost leads us to believe that that number is fairly static, when in fact fasting glucose can bounce around a lot, day to day. And so, but it kind of primes us to think, “Oh yeah, this is my fasting glucose. This is who I am in terms of my glucose.” It’s not true. It bounces around day-to-day based on the choices we’re making every day. And then what’s more, after you get that morning fasting glucose, your glucose is going up and down potentially on a roller coaster throughout the entire 24 hours, which has a huge implication on health. And that’s what you can’t pick up with these one-time lab draws. So continuous monitors, like a continuous glucose monitor, totally opened up this whole new role of data that can be really useful and really actionable to people. So just to step back on what a continuous glucose monitor is, so it’s a wearable sensor, you know, in the same vein as something like a Fitbit or a Whoop. You wear it on your body 24 hours a day, and it’s giving you a continuous data stream of your glucose levels, 24 hours a day. And it’s doing that. You wear this on the back of the arm. It’s about the size of a quarter. It sticks with an adhesive and there’s a small four millimeter probe that’s like a piece of almost like dental floss, just four millimeters that goes under the skin painlessly. And it’s sensing glucose in the background every 15 minutes. And then sending that information to your smartphone. And with that, as opposed to one glucose measurement a year, you’re getting like a hundred, you can get up to a hundred or more time points of glucose per day and see a real curve of what’s happening. And why that’s important is because, first of all for a metric like fasting glucose, you can see how it changes day to day. You can see how if you eat a high carbohydrate meal at night, your fasting glucose could be five or 10 points higher the next morning. You can see after a meal in the middle of the day, whether your glucose spikes up to a really high level or just stays pretty flat. You can see how exercise impacts your glucose and your response to meals. You can see how something like stress, a stressful phone call, or you know, a stressful conversation with a friend, how that affects your glucose. You can also see how a poor night of sleep or a really good night of sleep affects your fasting glucose. So really dynamically understanding how your behaviors are affecting glucose. And then the other reason it’s quite important is because it measures glycemic variability. So glycemic variability is essentially how spiky your glucose is throughout the day. Really for optimal health, we want to probably have flat and low glucose levels. You know, maybe gentle, rolling hills, up and down as the glucose rises a little bit after a meal and comes down, but we do not want sharp peaks and valleys, you know, stalagmites and stalactites. We don’t want that. That’s bad for health. When that’s happening, when you have high-glycemic variability, you know that a few things are happening. One, high glucose is going to trigger inflammation. It’s going to trigger oxidative stress. It can trigger the process of glycation, which is where high glucose in the blood causes glucose molecules to stick to different things in the body, like proteins, and potentially cause dysfunction in how these proteins work. So alone, glucose can cause those processes, inflammation, oxidative stress, glycation, but it’s also, of course, going to be stimulating the pancreas to make insulin and to produce more insulin, like Ben talked about in his episode. And when that happens, that’s a normal process. Your glucose goes up, your pancreas makes insulin, the insulin allows you to take glucose up into the cells. But when that’s happening all the time, when you have high-glycemic variability, means you’re spiking over and over and over again, multiple times per day, maybe because you’ve been told to have snacks many times throughout the day, which was common recommendations in the past, you know? Your insulin is constantly going to be peaking. And what that’s telling to your body, that is molecular information to your body for every single cell that it’s essentially turning on the pathways that insulin turns on, which is, you know, a lot of vital pathways. But when they go on overdrive, it can be a problem. It’s a pro-growth signal, and you just don’t want it to be on all the time. It’s a fat storage signal. It tells your cells to take excess glucose and put it into fat in the cells. It stops you from burning fat. It also makes your cells insulin resistant. And so when that signal of insulin is being constantly triggered, our cells get a little confused. They’re like, “Why is there so much insulin around?” And they actually kind of put on the brake and they say, “This is too much. We can’t take in all these substrates. Let’s slow down the signal.” And they become less responsive to insulin, which means that you have to make more of it. And then, you know,  your insulin levels are going to rise, become hyperinsulinemic. And as you know, you guys talked about on the episode a few weeks ago, that has lots of implications for health. So really, by using continuous monitoring for the first time ever, right, we have the ability to understand glycemic variability, which is a metric that is hugely important to health. It’s an independent predictor of poor health outcomes down the road, separate from just a high fasting glucose. And it gives you a lot more granularity into how specific behaviors are affecting glucose in real time that you can then potentially modify.

Dr. David Jockers [20:29]                         Yeah, and this is really changing the way that we understand nutritional science too, because we’ve been looking at things like the glycemic index and the glycemic load for a while to help us understand how certain foods are going to impact our blood sugar. For example, something that’s high, has a high glycemic index is going to spike your blood sugar quickly, but then typically it drops pretty quick. And if it has a high-glycemic load, you know, it may not spike it quickly. Something like oatmeal, for example. You know, classic kind of higher glycemic load where it’s not a quick spike, but it’s going to keep your blood sugar elevated for a longer period of time, and your insulin elevated for a longer period of time. However, we’re realizing here with the continuous blood glucose management, or this tool, is that certain foods are going to react in different ways, right? So it’s not really textbook style. We can’t just say, “Okay, you know this banana’s high-glycemic so it’s going to spike your blood sugar.”  Everybody, people are responding differently. And there may be foods that normally we would think, “This is very blood sugar stabilizing,” but for you, it’s not, right? And your body’s going to respond to stress and it’s going to cause a higher amount of blood sugar release and possibly hypoglycemia, reactive hypoglycemia, where your blood sugar drops too low, maybe two hours later. So can you explain more about that?

Casey Means [21:51]     Yeah, absolutely. I think you nailed that. You know, it really- So we are rapidly shifting in terms of our conception of what glycemic index means. Like you mentioned, there has been this paradigm that there’s this standard characteristic of specific food that is like, “This is how much this food is going to raise the blood sugar and how quickly in a person.” And that’s, you know, sort of uniform. But what we’re figuring out is that that’s actually not true because our personal response to a specific carbohydrate is going to be very different. And how that carbohydrate translates to glucose in the bloodstream is actually a very complex pathway. And a lot of this research came out of this amazing paper that was published in 2015 in cell from the Weisman Institute in Israel, which was called Personalized Nutrition by Prediction of Glycemic Responses. And this paper basically put continuous glucose monitors on tons of healthy non-diabetic individuals and then fed them standardized meals. So they all ate the same thing and they looked at their glucose after those meals. And under the glycemic index paradigm, you would think that every single person would respond the exact same way to the same food, that everyone eats a piece of white bread and their blood glucose all goes up a certain amount and comes down. They’re all healthy, you know, it’ll all be the same. But that’s the opposite of what happened. Basically what they found is that people could have equal and they could actually-  People had a very wide spectrum of their responses to the exact same food. And when you give two people two different foods, they can have equal and opposite reactions to those foods. So you could give someone a banana and a cookie, me and you, you know. You get a banana and cookie, I get up a banana and cookie, and I could spike on a cookie and not spike on a banana and you could do the exact opposite.

Dr. David Jockers [23:37]                         Right.

Casey Means [23:37]     And what’s super cool is that they then went further and they said, “Well, what is the thing that predicts how people are going to respond to these different foods?” And some of the key factors were microbiome composition. So they stool sampled everyone multiple times during the study. And they found that composition of microbiome was a predictor of how people would respond. Also things like anthropomorphic features. So, really like body type, which makes a lot of sense because we know that certain body types are more associated with insulin resistance. Visceral adiposity and waist to hip ratio can have a, is well correlated with level of insulin resistance. So that one makes quite a bit of sense, basically that your, how insulin sensitive you are would have an impact on how you respond. And other things like activity and sleep, like you mentioned, those were also factors as well. So really what’s more likely is that each of us have our own personal glycemic index for every single food based on our own unique physiology, but even upping the complexity a little bit, probably that glycemic index changes day to day, based on other factors that are affecting glucose. And it’s very sort of modifiable, based on other aspects of our health and our behaviors that do impact glucose, because it’s not  just about food. It’s not just about what we put in our mouth. It’s also the broader metabolic context and some of the big factors that we’ve already touched on- our sleep quality, how much stress we have, and then what physical activity we’re doing. Those things just translate directly into how we process glucose. So one day you might dip a banana, and poor sleep, no exercise, high stress and have an 80 point glucose spike. The next day, you might have eight hours of sleep, you’ve done your meditation, you’ve done your Peloton workout and you go up 15 points. So that’s a different glycemic index for each day. So it’s pretty fascinating. And what’s awesome is that by wearing a monitor and testing out your favorite foods and then testing out different permutations of that food, so pairing it with exercise, pairing it with, you know, a meditation session, you can actually start to really build your intuition about what works for you. And then, you know, more broadly, and we can talk about this too, but like how you even, what you even do with the food and the context of the food. It’s very rare that we eat a food in isolation, which is how the glycemic index works. It’s like, you know, 50 grams of whole wheat pasta, this is what happens. It’s all based on a 50 gram- They basically looked at what happened to glucose levels after intake of 50 grams of carbohydrates at a very specific food. So when we pair foods, it also changes our reaction to them. So mixing carbs with protein and fat can change the glycemic index. Usually actually adding protein and fat diminishes and blends our glucose spike to a food. But again, that’s individual. And then the timing of when we eat. So something we eat in the morning will probably cause a bigger glucose, I’m sorry, a smaller glucose spike than something we eat late at night. And so it’s just, you know, long story short, it’s highly complex. There’s very, there’s a lot of variables impacting our personal glycemic index. And it’s really interesting to figure, we now can figure it out for ourselves with continuous monitoring and know what’s actually, really answer for the first time ever. Like, this food is healthy for me. This food is the right food for my body and this is how I should eat it, which is something we really had to do trial and error on for the rest of history. So, yeah. it’s an exciting-

Dr. David Jockers [27:13]                         Yeah. Absolutely. Well, it’s such a great, great explanation there. What I found, with my wife and I who have both worn these, is that it can really, our blood sugar was really impacted by sleep quality by a, because we also wear Oura rings to track our sleep. Stress levels were a huge factor. And you know, I have kind of this guided meditation device called the Brain Tap. When I put that on, it would significantly drop my blood sugar, you know, and I’d feel great, right? Coming out of that, a lot more refreshed and relaxed. So some simple things like that. I mean those are bigger players than I thought. Just stress, even though I didn’t feel stressed. Just kind of working intensely was causing a higher blood sugar levels. So yeah, it’s really great to get that instant feedback and see those types of things and then be able to make some different modifications, right? Like taking some time to just take some deep breaths, you know, to help get things back under control and reduce the stress hormones. It just plays a really big role.

Casey Means [26:17]     Absolutely. I think it’s such a great, great point, the sleep and the stress and their impact on glucose, and realizing that just like really simple behaviors, like getting a better night’s sleep or doing some breathing can have such an impact on it. And it’s quite interesting because really these are, you know, with the stress, for instance, like our body developed adaptive responses to help us in times of stress. And unfortunately in our modern society we’re almost, these are becoming maladaptive for us. So you think way back when, you know, ancestral times when really stress was probably more likely a physical or corporeal threat. You know, we had to run from the lion, you know, is the classic example. Who knows if that happened very often, but you know, you’re in a physical threat and in that time of stress, your body releases cortisol and catecholamine hormones, and it tells the body you got to run. And so your muscles need quick energy. And the quickest form of energy in our body is glucose. And we have little bits of it stored for moments like that when we get stored in our liver and our muscles. And our body, when it’s stressed, says, “Okay, dump this from the liver, get into the bloodstream, get it to the muscles.” And so you often, with high stress experience, will see, even in a fasted state, the glucose rise during that stressful event. And that was because our body was trying to help us get the energy it needed to run away from something really- Now, our threats are generally not physical. We generally don’t need to activate our muscles and we’re having a stressful conversation or get a stressful email. And so that’s really not necessary anymore. And yet that’s happening all the time. We have so many low grade stressors that are just constantly that, the pings of the phone, the honking of the car, is the emails coming in. You know, the digital stuff that’s just constantly sort of getting our cortisol on alert and we don’t need that glucose. So what’s happening is that we’re kind of chronically elevating our glucose more than it needs to be and exposing ourselves to all that glucose load just unnecessarily. And it’s yeah, it’s pretty interesting how that’s, you know, with many things like our modern world is kind of co-opting our evolutionary advantages and turning them against us. And we have to sort of rise above that to get, you know, on top of it.

Dr. David Jockers [30:37]                         I just wanted to interrupt this podcast and tell you about these keto cookies that taste incredible. I mean, it took this company over a year to formulate this product to ensure that it did not cause your blood sugar to spike, your ketones to drop, your insulin to spike and promote inflammation in the body, which most products, most, you know, sweet treats, even low carb treats actually do. I know I’ve tried it, so many low carb cookies and they threw me out of ketosis. And so these keto cookies are actually formulated with ingredients that are not going to impact your blood sugar in the same way. You got things like grass fed butter, almond flour, coconut flour, coconut oil, egg. It’s got acacia gum, which is actually a great prebiotic fiber. It’s got grass fed collagen, which is incredible for your skin, your hair, your nails, your gut lining, and your joints. So if you’re looking for a great keto dessert, you know, these are things that you probably could get away with eating every day for a lot of you guys and do well. But if you’re just looking for something as like an occasional treat and you know, you’re tired of trying to make these things, these different keto dessert recipes on your own, then pick these up. They are the perfect keto. Keto cookies. So simply go to perfectketo.com/drjockers and use the coupon code drjockers, all one word. So just D R J O C K E R S to save 15% off of these today. Again, that’s perfectketo.com/drjockers, use the coupon code, drjockers to save 15% off. You guys are going to love these cookies. I’m telling you what, Might as well get a few cases because you’re going to love them. Your family’s going to love them, and you might as well stock up. All right. Back to the podcast.

Yeah. Yeah, absolutely. And I’m really interested in what you guys are doing with Levels Health because you guys have created a metabolic score. Right? Can you explain more about that? Because it’s one thing like, you know- So the continuous blood glucose monitor you can get from Freestyle Libre, like that’s probably the most popular brand, I would imagine. They’ve got an app that you can watch your blood sugar and how it’s going, but it’s another thing, the more in-depth analysis that you guys are doing really helps somebody understand how they’re responding to the foods and the environment that they’re in. Can you explain more about that?

Casey Means [33:15]     Yeah, absolutely. So, there are continuous glucose monitors on the market, and these have been around for over a decade. They’re FDA approved devices that are for the management of type one and type two diabetes. So these have been a game changer for the diabetic population because instead of having to prick your finger three, four or five times a day, you can see your glucose all day long. And so these devices, you know, they eliminate the finger pricks and they’re amazing. But as we know more and more about metabolic health and how it is so important for us to really stay on top of this earlier, rather than later. These are, you know, diabetes, type two diabetes, is largely preventable condition. So having insight into our metabolic health far earlier is really the time to get on top of it, like stay low and flat with your glucose throughout your life. And, you know, never have to walk into the doctor’s office and say like, you know, “Here’s a surprise.” Like, you know where you’re at on that metabolic spectrum and can continuously work to improve. But these devices were really never meant to be behavior change tools. They weren’t meant to guide us to really what the right behaviors are. And as we’ve talked about, there’s a lot of complexity to it. There’s many input variables that can affect glucose from, you know, the nature of our meals, to what we’re pairing them with, when we’re timing them, and then all the other lifestyle factors. And so just having the raw glucose data stream isn’t necessarily going to push us to really intuit what we need to do to make changes. And so that’s where the company that I’ve co-founded, Levels, that’s where we’re really trying to fill that need- to make understanding this glucose data stream super intuitive, and to help people develop their metabolic intuition and get excited about how to move the needle on a lot of these different modifiable aspects of glucose control. And so that’s the software that we’ve developed, and really trying to get this mainstream, and people to think about it similar to how they think about their other health tracking tools. You known we all are, these days we’re in the Oura, the Fitbit, the Whoop. People have their smart beds, you know, the Eight Sleep. You know, we’re tracking HRV with Oura and Heartmath and Leaf Therapeutics. These companies are amazing because what they’re doing is they’re tapping into a continuous data stream within an overlay to motivate you, to make it social, to give you insight into the variables of how you can change. You know, Whoop and Oura tell you what to do to get your sleep better, to get your HRV better. And this is just where there’s a huge, there’s a vacuum and a void around glucose. We don’t have that. So that’s what we’ve created. And we really, we know that to- You know, we’re dealing with a metabolic health epidemic in our country. Like I mentioned, 88% of people with a sign of metabolic dysfunction and 128 million Americans with diabetes, or pre-diabetes, that’s like a third of the country. And 74% of Americans are overweight or obese. So this is monumental and, you know, to really move the needle on those crises, it’s coming down to consistent day in and day out personalized behaviors that are right for your body that move the needle on health. And so that’s where I think digital health and software is really going, is to help people understand their body, make the choices, and then do them consistently. And that’s, so that’s what we’re doing for glucose. So that’s what the Level software is.

Dr. David Jockers [36:34]                         Yeah, absolutely. And, basically you guys have an analysis system, like an algorithm that based on what the person ate and how their blood sugar responded to that, that scores it from zero to 10 as well.

Casey Means [36:47]     Yeah.

Dr. David Jockers [36:47]                         Which makes it really easy for the user, because user doesn’t really understand, necessarily. You know, it’s like, you got to really micromanage how that blood sugar responded and it can be tough to analyze. But when you get a score, I think all of us understand kind of that gamification. We all understand scoring, right, from school and just our upbringing. So I think that really helps us understand how we’re responding to the foods that we’re eating and the environment that we’re into.

Casey Means [37:13]     Yeah, exactly. And that’s really what our goal has been, is to make this as simple as possible for people. And so that really has driven some of our new metrics that we’re adding. So, right now, like you, if you just walk into the doctor, they’ll say your fasting glucose is 98 or your fasting glucose is 115. No one, it’s hard to know exactly what that means. And what does it mean if your glucose goes to 130 after a meal? Well the beauty is, the literature, the scientific literature, tells us a lot about the implications of these fluctuations. But that’s, you know, thousands of pages of papers that we’re not going to be thinking about, that every time we take a bite. And so our goal is really to condense it into a one to 10 score that when you eat, sit down and eat a meal, like two hours later, you have a grade essentially for that. Was it an A, was it a B? And that’s taking into account a number of aspects of what happened to your glucose curve after the meal that we know are associated with better or worse health outcomes. So there’s a lot of different things you can learn from just that little curve that happens after a meal. So some of the things that you can look at that actually make, tell us something about metabolic health is how high the spike went. So like the peak and the Delta from baseline. Where did you start? Where did you go? The second thing is, how long did it take to come down? Did you go straight up and straight down or did you go up and you stayed elevated for a while? How spiky were you coming down? Was it kind of like, you know, you were jumping like a yo-yo as you were coming down or was it just sort of a very smooth curve? Even how long it takes you to get to the peak after a meal makes a difference. All of these things have been sort of looked at as proxies of our overall metabolic health. So in creating our scoring systems, we take into account those things and really do analytics on that curve to give people just this very simple grade. And so, you know, 10 is an A+, essentially. Zero is not good. And we really want to encourage people to stick with sevens, eights, nines and tens. That would be sort of like the passing grade and what, you know, sort of the green zone. And I’ve been fascinated by seeing our users, you know, it’s- These simple scoring also really lends to people being able to share this information and be excited about it. Like I got a 10. I had a day of straight tens and people love sharing that on social and seeing that. So it is very cool to see sort of this community element arise around a biomarker that never has really been one that we’ve seen tracked before. People love to share about steps and their sleep data. But now there’s this new biomarker that we can really rally around and support each other and have community around. So that’s the meal score and that’s really, that’s the zero to 10. And then you also mentioned the metabolic fitness score. This is a more, a longer-term metric that like grades your day. “So how are you doing overall?” And so, when you look at the full 24 hour period, we can capture a lot of additional sort of interesting data points from the curve. So what is your baseline glucose? I.e., when you  go up and come down after a meal, where do you sort of rest during the day, your basal level? And then what is your glucose first thing in the morning, more of your fasting glucose? How much does your glucose rise first in the morning, right when you wake up? There’s a phenomenon called the dawn effect, which is where, when we wake up from rest, we get a cortisol surge to help us get out of bed. And that’s tradition, it’s a sort of a stress signal, but it, really what it’s doing, it’s helping our body mobilize to get up out of bed. And that can cause a little bit of a glucose rise. So we can look at that and how much you’re rising in the morning from cortisol, “What is your overnight levels?” So  you can take all of that into account and kind of give a more composite picture of the whole day and sort of, so where you’re at on that spectrum and that’s the metabolic fitness score. So those are two things that we’ve developed to just help make it easier for people to understand what’s happening with their choices, and hopefully move to make choices that they get their scores up.

Dr. David Jockers [41:16]                         Yeah. And I think it really does too, because I think we’re naturally wired to want some level of reward and food gives us an instant reward. We eat food we enjoy, we get a dopamine spike, we feel great, right? It just, you know, it’s good. We don’t really realize the impact it might be having on our body, but when we’re able to look at this and kind of be able to see what our score is, like our meals score and whatnot, now it gives us extra incentive because we’re going to get another dopamine hit when we have a good score, right? And so we have that sort of accountability and instant feedback that we’re able to get that is going to make us, it’s going to give us more reward, more instant reward for making good choices. Like, you know, you don’t think about weight gain in one meal, right? Or weight loss through one meal, you know? Those are things that happen over time. Same with your energy, same with, you know, all of these other elements of how we feel. We typically, these are more long, you know, they’re more consistent lifestyle habits over time, but by being able to get an immediate impact score like that, I think that’s going to really help incentivize people. So I know certainly for myself on that, I’m wired like that, where I like to have some level of immediate score to let me know. “Okay, I did good here.” You know what I mean?

Casey Means [42:34]     Absolutely. And I think this comes down to the concept of closed loop biofeedback, which is extremely effective for behavior change. And that’s really the founding principle of this company, is that when there is a lag time between what you do and what the result is, it is much harder to then change that behavior because it is very easy to misattribute the action to the reaction. You misattribute the reaction to the action if there’s a longer time period, a lot more variables come into play. So the tighter you can make that, the better in terms of behavior change. And nutrition has been notorious for having open loop feedback and highly, high variability and complexity and understanding the relationship between the choice you’re making and what’s happening. Traditionally, what we’ve had is one, stepping on the scale the next morning. You get on the scale and you’re like, “Okay, well I’m two pounds heavier. Is this water weight? Is this my hormones? Is this the cake I had at 2:00 PM yesterday? Like what is this?” You know? So that’s very challenging to look back and say, like, “What can I do differently?” It’s sort of like, “Well, do everything differently,” but you just don’t know. The second one we’ve had is that yearly fasting glucose test at the doctor’s office with your annual physical. And so last year, fasting glucose was 87, this year it’s 89. What does that mean? You know, it really means nothing. And so it doesn’t help you actually change things. Your doctor might say, “Oh, your fasting glucose has gone up a little bit. Like, I’d watch your diet and I’d try and exercise more.” But that is essentially ineffective. And so, you know, and then of course we also have our subjective feeling. So you can have a meal and you could really tap into how you’re feeling after a meal. And I think that’s wonderful. That’s essentially somatic awareness. And I’m a huge proponent of that in terms of, you know, knowing how something is affecting us. But that is also a tough one because do we really know if our glucose is spiking after a meal? I think you can get to the point where you do actually have a sense of that, but I think the biofeedback with actual CGM helps you gain that type of somatic awareness. So this is a term that I think, there’s a term called interoception, which I think is really relevant to continuous glucose monitoring. And interoception is similar to the concept of somatic awareness, but it’s basically an understanding of something that’s going on inside of your body, like a quantifiable metric, and being able to have an awareness of it. So you can think about heartbeat. People who have good heartbeat interoception or people who can sit quietly and just say, “This is how fast my heart is beating,” and they can even pump it on the table. There’s other people who have no awareness of how fast their heart is beating. And interestingly, people who do have more interoception about something like heart rate have lower rates of anxiety and depression, they have better cardiovascular outcomes. There’s something about being able to hear what’s happening inside your body that is good for health. I think we all intuitively know this, but in our current modern world, it is so much harder to hear our internal body signals. We’ve got a lot of distractions, you know, we’re very screen facing, we’re on the go, we’re tired, we’re staying up late. We’re also exposed to these crazy hyper palatable foods that are basically frankenfoods- they’re not real. And they hijack our normal reward circuitry. So we don’t really know how we’re feeling because we feel, you know, we’re getting essentially a drug surge when we get sugar, you know, and processed and refined foods. So, the idea really of true body awareness is challenging. And when you pair a tool, like a biofeedback tool, whether it’s heart rate, or glucose, you can actually improve your intraception capabilities. So when they put heart rate training on people, they take people and they give them a heart rate tracker and they help them see it and understand their heart rate, they become better at their interoception. And I think that that actually happens as well with glucose. As I’ve tracked my own glucose, I’ve been wearing a continuous glucose monitor for a year now, I am very sensitive now to what is happening inside my body, even if I don’t look at my glucose. I know when my glucose is going up, I know when it’s going down and I can just feel it. But that’s because I’ve had so many instances of this trifecta of an action, seeing the data and feeling the subjective experience. And now I can just triangulate those three things naturally. And our CEO, Sam, his biggest experience with this was he put on a CGM and he had his normal breakfast, which was oatmeal. And he didn’t check his glucose for a while, but he had a big bowl of oatmeal, which he’s always been told is like a heart healthy food. It’s a whole grains dadada. And later in the morning. And he also had some coffee. And later in the morning, he felt his normal, you know, early afternoon, like late morning, early afternoon kind of energy slump, kind of felt tired, kind of felt a little moody. And he checked his glucose and he looked back at his data and it turns out he’d spiked to 200, which is super high. And then it crashed down to like 60. So he had a huge hyperglycemic spike and then a hypoglycemic episode. And the reason that happens is because when you have a big glucose spike like that, your body throws the insulin on that and you soak up so much glucose that you end up overshooting and dipping, and that can lead to anxiety, low energy. So he’s like, “Oh my God, like, I’ve been always attributing this morning slump to sleep quality or maybe my caffeine, but like, I’m going on glucose rollercoaster.” And so basically the past year Sam’s been eating like avocado and scrambled eggs for breakfast has zero glucose spike with that. And like it’s totally revolutionized his mornings. And he, this misattribution that we so often do when we don’t have closed loop with biofeedback is instantly gone. And what’s also interesting about that is that when you can create that trifecta of awareness of action, metric biofeedback, and subjective experience, it also becomes much less painful to part with things in your life. Like if you loved oatmeal, once you see that, it’s so clear, it’s so obvious, that it’s not upsetting to like, say, “I’m not going to eat this anymore. I’m going to eat it differently to have a better outcome,” because you have understanding. And it’s so much that I think the difficulty with dieting and with adopting “healthy diets” or other behaviors, is that we don’t actually know if they’re working or doing something. There’s such a lag time between whether we actually have the outcome we want on, you know, the scale or our cholesterol test or our fasting glucose test that it’s ultimately very challenging to adopt these behaviors. But when you can just see the instant response, it’s a lot easier to sort of part. And I kind of like it. I liken this to  food poisoning. Like when you eat clams and you have food poisoning, like you never want to eat a clam again. It’s not like you’re sad to give up clams, you just go, “Oh, of course I would never eat them again because I don’t want this to happen again.” It’s a similar unemotional feeling, I think, when you have the glucose data. So.

Dr. David Jockers [49:49:]                       Yeah, immediate feedback, closed loop biofeedback, like you talked about. Yeah. So important. So how close are we to being able to make these continuous blood glucose monitors affordable for people to be utilizing all the time? Because I know, you know, really up until very recent, the only way to get it is a medical prescription. I believe that’s still the case, right? And then on top of that, they’re very expensive, especially if you don’t have insurance. And I believe insurance is only going to cover it if you have diabetes or type one or type two, is that correct?

Casey Means [50:21]     That’s correct. Yeah. So these devices are still prescription only in the United States. Most of them are actually over the counter in almost every other country in the world, which makes a lot of sense because we also walk into the pharmacy and buy a finger’s glucose monitor. So kind of create your own continuous glucose monitor by just pricking your finger, you know, 50 times a day.

Dr. David Jockers [50:40]                         Did you say only in the United States, their prescription? [crosstalk]

Casey Means [50:44]     Or maybe other, some other countries, but in the majority of other countries, they’re over the counter.

Dr. David Jockers [50:49]                         Oh, wow. Yeah.

Casey Means [50:50]     Very interesting. Yeah. So here, like with our company, we have the software, but we also have a telemedicine network that’s evaluating people for these prescription devices. And then we fulfill them through a partner pharmacy, because it is difficult to go into your primary care doctor’s office and say, “Hey, I want this device.” A lot of people aren’t primed yet to really be thinking about glucose for the non-diabetic use case because we’re so trained to think about glucose only in the context of diabetes, of this really late stage manifestation. So that’s one of the things that we wanted to help with, was access. But you’re right, they are very expensive. And I think that that price point is going to come down rapidly over the next few years for a couple of reasons. One, there’s a lot more interest in this non-diabetic market and I think the demand is going to grow, and that’s going to change the economics of it. There’s also many, many hardware companies coming down the pipeline creating new types of glucose sensing technologies. There’s some really, really cool things. And so the hardware is rapidly advancing and I think we’re going to see a lot more FDA approved players on the market and that’s going to bring the price point down too. And so yeah, I think it’s going to be a very exciting next couple of years in terms of glucose monitoring.

Dr. David Jockers [52:13]                         Yeah. So, what is the typical price range now for continuous blood glucose monitor?

Casey Means [52:19]     Yeah. So out of- So like you mentioned, they are currently only covered for people with type one or type two diabetes by insurance. And even in that world,  I’ve heard from many diabetic individuals that even getting access to the sensors is somewhat difficult through insurance, which is always a surprise to me because from a cost saving standpoint of helping people manage their disease and manage their medications more effectively, these are proven to have, you know, just superior efficacy to finger sticks. So I’m hoping that will change, you know, just general coverage and access for the diabetic population. And if you’re just buying it out of pocket, they range from about 60 to a hundred dollars per device. And each device lasts on the arm for 14 days. I’m talking specifically about the Abbott Freestyle Libre, which is one of the most commonly prescribed versions. So it’s just a little quarter, that’s disposable that it sticks on the back of your arm and you throw it away after 14 days. And those range from about 60 to a hundred. And the reason I say it ranges is because every pharmacy you walk into to get these, it’s going to have a slightly different price, which again is just a strange function of our healthcare economics in this country. But I think that price point is going to get down quite a bit in the coming years.

Dr. David Jockers [53:41]                         Yeah. I think you guys are really leading the way in that, making it a lot easier for people to access. And people can go to levelshealth.com. And are you guys still in beta testing or are you now working with the general public?

Casey Means [53:54]     Yeah, we are in beta testing right now. So we have had about a thousand people go through our program and we are planning for a full launch at the end of 2020 where you can just come to the website and sign up.

Dr. David Jockers [54:06]                         Great. So is there like a waiting list right now that people can get on?

Casey Means [54:11]     There is, yeah, there’s a waiting list. So what I would recommend is if people are interested, to come to www.levelshealth.com, and you can sign up for the waitlist, which will keep you in the loop of when we have access available. And then it’ll also get you on the newsletter. And me and a team of other  physicians and PhD experts are writing voraciously on the Levels blog about these topics, and about glucose really targeted towards the non-diabetic individual, how glucose relates to athletic performance, fitness, endurance, general health now, you know, prevention of future disease. Just some really, really interesting topics there, personalized nutrition. So yeah, definitely recommend that if people want to learn more.

Dr. David Jockers [54:59]                         Yeah, I would definitely recommend it for our listeners. I mean, it’s pretty easy to go out and spend a few hundred dollars to get a lab test done. You know, most really good lab tests are going to cost you a few hundred dollars. So you can use that same money and do a month on the Freestyle Libre, utilizing your guys’ system to really be able to check your metabolic score and get that feedback. So you really learn a lot about how your body’s responding to things. And then if you did that, like for one month out of a year, and then started practicing that throughout the year, I think it would be just a great way to improve your health and give you that feedback that you want that really can’t test, you know, with standard blood work. So, I’ll recommend that.

Casey Means [55:43]     Thank you so much. Yeah, we’d be happy to hear from anyone who wants to learn more, so.

Dr. David Jockers [55:47]                         Yeah, for sure. And then last question, how close do you think we are to getting a continuous insulin measurement? I would love that.

Casey Means [55:56]     Oh, it’s my dream. Yeah. It’s a harder molecule to test. You know, glucose is so simple with the glucose oxidase reaction, and insulin is a large protein and no one’s cracked this code yet. Many people have tried, and I think we are many, many years out from seeing that, although I think it would be absolutely game changing for help. The good thing is that glucose is a close proxy to insulin in most people. And I do think, you know, getting a fasting insulin, continuous insulin monitoring would be amazing, but I think working with a functional medicine doctor, or if you’re, you know, normal primary care doctor is open to doing it, like I would just implore anyone listening to ask for that fasting test and just, you know, and see. That’s just such a great way to understand sort of what the last 10 years of your lifestyle has been kind of doing to your overall metabolic health, because, you know, if I would say, if you’re between less than six, you know, two and five, six, like really awesome, your insulin is low. You’re probably not dealing with much insulin resistance. You know, six to 20 you’re starting to see some movement of your insulin kind of creeping up at that baseline, probably because it’s been, you know, lot of spikes for years and years and years, your cells have been exposed to lots of insulin and it had to kind of get the baseline up there. And then above that, you know above 20 or more, probably dealing with some more severe potentially insulin resistance. So those are sort of generalities. And I think everyone has a different range because these have not been, these ranges for insulin have not been standardized yet, but it kind of gives you a sense of like the long-term view. But what’s cool is that with using a sensor, like a continuous glucose monitor, basically the way you can think about how it affects your insulin is that if you can keep those spikes minimized day after day, essentially like you’re going to the gym, instead of going to the gym and working your regular fitness, you’re working your metabolic fitness. And the thing we’re doing there is keeping glucose spikes lower. You can imagine you’re keeping your insulin lower each day and every day you’re keeping your insulin lower, your cells because they wake up again to that insulin signal and become more insulin sensitive. And then your pancreas can turn down its, you know, faucet of insulin. And so, basically each day you’re using that CGM to keep the spikes down, you can assume that you’re keeping that insulin exposure lower, letting yourselves wake up, become more insulin responsive, giving your pancreas a break. And over time, what could you expect is that the next time you get your fasting insulin checked, it’d be a lot lower. So that’s kind of the big picture I know. I know you know, but just to kind of paint the picture for everyone.

Dr. David Jockers [58:39]                         Yeah, but that is so important because I’ve seen a lot of people with hemoglobin A1C who are very healthy, yet they had weight loss resistance. They couldn’t lose weight, inflammation in their body. And then when we test fasting insulin, fasting insulin is 12, but their hemoglobin A1C is 5.0. So their blood sugar is staying down, but they’re producing a lot of insulin in order to do that. And they’re most likely having a lot of little spikes in that range. And so continuous blood glucose monitoring can really help with that.

Casey Means [59:13]     Well, in a resilient body, there’s, you know, pancreas can do a whole lot of work to force the glucose to be in a specific level before we sort of, that process breaks. And we start to see that fasting glucose or that A1C going up. So a lot of people say, and I think Ben Bikman says this in his book, or maybe on some podcasts I’ve heard, but that insulin has probably elevated predating glucose elevations by like 10 years. You know, we’re just compensating and forcing that glucose into the cells, keeping the glucose somewhat stable, appearing on our yearly lab tests by just producing more insulin. So, so yeah, so it’s a great test and we can move that whole ship in the right direction by improving our insulin sensitivity by keeping our glucose lower. So, it’s an exciting time that we’re able to kind of put some of these pieces together, even though the technology and the tests aren’t, you know, there’s still going to be a lot of progress on the road. Like you said, continuous insulin monitors, continuous inflammation monitors, all this stuff, but we can certainly triangulate the issue pretty much better now than we could, you know, five years ago. So.

Dr. David Jockers [01:00:22]                 Well, it’s been such a fascinating conversation, and I just want to really acknowledge you guys for all the great work that you’re doing. And Dr. Casey, you’re a great spokesperson for the company. You really have a great way, great, elegant and sophisticated way of explaining all these topics. And I know I learned a lot listening to this, and I know our listeners have gotten a lot of value out of it as well. So thanks again for your time. And you guys can check out levelshealth.com. We’ll have a link of course in the show notes. But check that out. And I know Dr. Casey has been doing a lot of podcast interviews. So anytime you see her out there, make sure you download and listen to her podcasts and interviews because she’s on the ball with this and really is a pioneer in leading the way to get this testing out to more people. So thanks again, Dr. Casey.

Casey Means [01:01:06]                Thank you so much.

Dr. David Jockers [01:01:08]                 All right. And so for those of you listeners, definitely leave us a review and any sort of feedback you have on this. And we’ll see you guys in our future podcast.

Well, that’s all for this show, and I want to thank you again for spending your valuable time with me today. And if there was something you’ve heard in this interview that you have questions on, or you want to dive into deeper, then drjockers.com is the best place to go. If you enjoyed this episode, please consider taking just a quick moment and giving us a great review. Your reviews help us influence more people and transform more lives. And if you took something valuable away from this episode, and please share it with someone in your life you know it can help. We’ll see you soon on a future podcast. Be blessed everybody.