Dr Casey Means | Continuous Glucose Monitoring (CGM), Optimal Glucose Numbers, The Dawn Effect, Why Cortisol Raises Glucose KKP: 180
Small choices add up, for better or for worse. This is what Dr. Casey Means realized during her study of health. Every single tiny choice we make throughout the day, from the food we eat to the sleep we get, can impact our health. In America, as a country we are consistently moving toward the danger zone. That’s why Dr. Means co-founded the metabolic health company Levels. She and the Levels team are on a mission to fight the epidemic of chronic diseases in the United States. In this interview of Keto Kamp with Ben Azadi, Dr. Means explains how diet and lifestyle choices directly impact health, the role of glucose in metabolic dysfunction, and the small changes everyone can make to prevent disease.
11:29 – Eat to beat chronic disease
Millions of Americans are suffering from the effects of metabolic dysfunction with conditions like obesity and diabetes. Diet and lifestyle choices are the key to reversing this trend.
“Now in our country we’re dealing with this chronic disease epidemic. We’re dealing with 88% of Americans having insulin resistance or metabolic dysfunction, 74% of Americans being overweight or obese, 128 million Americans having pre-diabetes or diabetes. These are just a couple of the massive amount of chronic disease that we’re seeing and that are touching almost every American. We know that these diseases are rooted directly in dietary and lifestyle choices over the years and yet not necessarily something that’s really factoring into our day-to-day practice or the nuances of our practice. The average medical student only gets about four hours of nutrition training in their entire medical school career, even though nutrition is arguably the highest value, lowest hanging fruit intervention for really reversing disease.”
13:02 – Everything is inflammatory
As an ENT surgeon, Dr. Means found that all the diseases being treated were caused by inflammation in the body.
“Almost every condition treated in the operating room here as an ear nose and throat doctor is fundamentally an inflammatory condition. So sinusitis is inflammation of the sinuses. When the nasal tissue gets inflamed, it kind of closes the hole that drains the sinuses and then pus builds up. I was treating tons of chronic ear disease, like middle ear infections that kids are always getting. And that fundamentally is the tube that drains the ear into the nose, the nasal tube, gets inflammation, clogs up. You get pus build-up in the ear and then you punch a hole in the eardrum and you put an ear tube in and you suck the pus out and that’s fixing it. And I was seeing a lot of Hashimoto’s thyroiditis, which is really rising and rates, especially in women in our country, and this is inflammation of the thyroid. It’s an autoimmune attack of the thyroid. And then I was also seeing a lot of cancer, which we’re more and more understanding as an inflammatory disease…Inflammation fundamentally is the immune system saying there is a threat and we have to activate in order to fight that threat. So it became very imperative to me to think, what is this threat and why is everyone inflamed? And this was just in my little ENT world, but looking more broadly across chronic disease. A lot of chronic diseases we’re facing are fundamentally inflammatory in nature: obesity, heart disease, stroke, Alzheimer’s, etc.”
15:30 – Health comes from choices
Inflammation can be caused or cured by the lifestyle choices we make. Food, movement, stress, and sleep all play a part.
“The choices we’re making in terms of what we put in our body, what we expose ourselves to day to day ultimately are I think triggering a lot of the chronic inflammation that we’re seeing. Our bodies are exposed to whole new breeds of foods that our bodies throughout history were really never meant to be exposed to. Refined and processed grains, refined and processed sugars, processed vegetable oils that are highly oxidized. All these things that you can imagine go into the body, your body hasn’t seen these things in these quantities ever throughout human history. And so the immune system’s like, whoa, threat. This is not good. Same is true of environmental chemicals, environmental toxins, and pollutants…Then we’ve got chronic sleep deprivation. We’re sleeping way less than we used to, which is to the body registered as a threat that the body’s like, why are you not sleeping? Something must be wrong. And so it activates. And then you’ve got sedentary behavior which triggers the immune system. And we’ve got chronic low-grade stressors. every time you get an email or a ping on your phone, the body’s like, Ooh, what’s happening?”
18:20 – The key to health is sitting in our pockets
To create true change and results, we need to take health into our own hands. With digital health tools there is greater accountability for choices and behaviors.
“People really have to be every single day making consistent choices that improve their health. They have to be making good choices in relation to food, exercise, sleep, stress exposures. And so really this comes down to inspiring people to make good choices and make behavior change choices every single day. And to me, that really lends well to digital health solutions because we have our phones on us every single day. We don’t have our doctors with us every single day. And so in order to make sustainable choices, and we make hundreds, if not thousands of choices every day about all these different things. To have a tool with you that can help you make those choices in a smart way for your body, I thought was really where we needed to go. And doctors really need to be adopting and engaging with technology so that patients can make those sustainable choices that ultimately lead to the expression of health and essentially functional physiology.”
25:57 – Diseases take decades to develop – so start monitoring now
Diabetes doesn’t come on overnight. It takes years of lifestyle choices to slowly cause metabolic dysfunction. A continuous glucose monitor shows glucose response in real time so you can see how each decision impacts your body.
“What’s really cool about glucose is that it changes rapidly after an input. So you eat and your glucose, if it’s going to change, it’s likely going to change within 30 minutes to an hour. So you’re getting this really closed loop, one-to-one feedback between what you’re eating and what’s happening to your blood glucose. So this is a technology that has been around for actually a while, over a decade. And it’s FDA approved for management of type one and type two diabetes. So right now it’s got a clinical use for these populations and has been a game-changer because formerly these individuals were pricking their fingers three to five times a day after meals to see what’s happening and mostly from medication management and this tool allowed them to stop having to put their fingers and is just a lot more comfortable. It’s completely painless. And it’s just such a more robust data stream. But what’s interesting about metabolic diseases, insulin resistance and metabolic diseases, these are diseases that don’t just turn on like a light switch when you get a diagnosis of diabetes. These are diseases that start decades before the actual diagnosis and are essentially the result of repeated regular insults to your metabolic system, through these hundreds of daily choices that we make every single day. So it became how can we use this incredible technology that gives us a data stream to help people far before their diagnosis, refine their diets and lifestyles so that they never get to that stage.”
27:55 – Everybody is unique, so their diet should be too
The mainstream belief is that there is a standard response to carbs. This is classified as the glycemic index. However new studies are showing that everyone responds to foods differently.
“No two people respond to carbs exactly the same. So there’s tons of variability between how you or I would respond to the exact same carb load. We can both eat a banana and I could go to a glucose level of 150 milligrams per deciliter and you could go to 90 milligrams per deciliter. And so a banana is probably a much better choice for you and a much worse choice for me. I’m almost certainly going to secrete more insulin from my pancreas when I eat that banana, that insulin is going to be floating through my bloodstream. And if that happens repeatedly is ultimately going to lead to myself becoming possibly insulin resistant and lead me down the path towards something like type two diabetes or pre-diabetes.”
35:41 – There’s a glucose surge when you think you’re being chased by a lion
The body is designed to release stored glucose during times of stress, like working out. This response helps to fuel the muscles to prepare to run away from the threat. After stress, the muscles are better adapted to absorb glucose.
“Essentially the body’s fairly simple. When the body thinks that there is a threat or we are under stress and need energy to essentially run from something, like in the old days the example of being chased by a lion. You think that you need to essentially run from a lion. Your muscles are going to need very quick sugar to work. And so the body has this mechanism where if you think you’re about to be chased by something and you need energy for your muscles, you’re going to dump your stored glucose from your liver, which was stored as chains of glucose called glycogen. You’re going to dump it out really fast and flood the bloodstream with that to feed your muscles…So you start lifting weights or you start a high intensity interval training workout, and that sends to your body to signal, Oh man, we need sugar. We’re about to run from a lion. This is a stressful situation. And your liver immediately basically dumps out a bunch of sugar. The muscles don’t tend to need as much as what the liver dumps out, it overcompensates. And so that’s why you see a rise.”
38:17 – Become aware of stress for better health
Modern lives are full of stressors which raise glucose and impact health. Many are unaware of how stressed they are throughout the day. Using a CGM and combining with a heart rate monitor could help build awareness and mediate stressful times.
“Our perception of stress in our day-to-day lives has a huge impact on our glucose levels. So you can just have a stressful conversation or respond to a stressful email or anything like that. And it can actually raise your glucose on its own. And we’ve seen this a lot actually just in our customers and I’ve seen it in myself. I remember the first podcast I recorded ever, my glucose totally went up fast recording it. And it was just like, Oh, this is so interesting, this must have been a cortisol response. And I think it’s really good to be aware of that. And I think that’s a really interesting part of this biofeedback aspect of CGM, because sometimes it’s very difficult to know actually whether we’re stressed or not. And I think a lot of us deny stress, but our bodies, you cannot hide stress from your body. Even if your brain thinks that you’re not stressed. And I have so many patients who say, Oh, I’m never stressed. But stress from a physiological level, it’s there in almost all of us. And so I think it’s really neat to be able to actually almost have this accountability check of something going on.”
43:07 – As the sun rises, so does glucose
First thing in the morning glucose will rise slightly as the body wakes. This will be a sharper rise for people with metabolic dysfunction.
“So the dawn effect is this phenomenon that you can see where basically first thing in the morning, glucose just rises on its own totally in a fasted state. And it can rise like 5 points, 20 points. And in people with metabolic diseases like type one or type two diabetes, that’s going to be very high, can go up 50 points. So the physiology behind this is that in order to wake up from sleep, our body releases cortisol and other hormones to essentially rouse us, to get us to wake up. And those are going to have an impact on the things we just talked about, on the liver and mobilizing glucose. Your body is preparing to need to be alert, stand up, use your muscles again. And so that’s what’s happening with the dawn effect. It’s more pronounced in someone who has diabetes or insulin resistance, because if you are insulin resistant, then you’re going to have more of this inability to get that glucose quickly into the cells. And so you’re going to see more of that rise.”
51:55 – The constant highs lead to terrible lows
Glucose spikes cause insulin to be released. The more often this happens, the less responsive the body becomes to insulin and the more it pumps out. When there’s too much insulin in the system, blood glucose can drop too low and cause symptoms like fatigue and low mood.
“So high glucose leads to inflammation. It leads to oxidative stress – so too many free radicals in the body. And it leads to glycation, which is glucose sticking to proteins and fats and other things in the body and causing dysfunction. So you want to avoid inflammation, oxidative stress, and glycation, and you want to avoid hyperinsulinemia. And so for all those reasons, I think really shooting for much more rolling hills on the glucose and not peaks and valleys. And then two other small things I will say is that when you do spike your glucose very, very high and have this big insulin surge, the body essentially is sucking all that glucose up really fast. Cause you have all this insulin and you often see this sharp spike and a big drop, and sometimes you can overshoot on the drop and you’ll actually go lower than what you started at. And that’s called reactive hypoglycemia. It’s an overcompensation of insulin to a high spike. And that state, that reactive hypoglycemia is often associated with brain fog, fatigue, anxiety, and that post-meal like energy slump that a lot of people feel.”
53:30 – Small lifestyle changes can balance glucose levels
It’s possible to alter the glucose response in the body with small alterations, like timing food, pairing it, and reducing stress.
“There’s so much that we can do in terms of modulating our diet and lifestyle to achieve more gentle rises and fall. It doesn’t necessarily mean eliminating all your favorite foods. It means pairing foods, appropriately timing foods, appropriately pairing foods with exercise in the right way, making sure we’re not eating in a super stressed out state, and making sure we’re getting really good sleep. All those things feed into our glucose response. So we can really artfully modulate the diet to get lower spikes. And that’s essentially what my company and the software we’ve developed helps people do is learn how to do that.”
54:21 – Levels is making glucose monitors accessible for everybody
Continuous glucose monitors are currently only available for diabetics through physicians. Levels is bringing this technology to anyone who wants to improve their health through a network of online physicians.
“A lot of primary care doctors aren’t really familiar with this use case of health optimization and performance optimization and dietary personalization with a CGM. And so if an average person who does not have diabetes walks in and talks to their doctor, their doctor might just be like, no, this is not for you. This is for people with diabetes. And so something that we did early on in our company was we set up a telemedicine physician network of partner physicians. When you essentially become a Levels customer, you get a telemedicine consultation with a physician in your state, which is all done over the internet and they evaluate you to make sure that you are safe to use a CGM. And if they do, they write a prescription for a continuous glucose monitor, that’s sent to our partner pharmacy, which fulfills the prescription for these sensors and sends them to our customer’s house. So they end up getting a box with two 14-day continuous glucose monitors. So the two sensors together make up a 28 day program we call our metabolic awareness program and then onboarding instructions of how to get access to the app.”
57:35 – The impact of alcohol
Alcohol can lower blood glucose, which people who are fasting should be extra cautious of.
“There’s a couple other interesting scenarios. One is with alcohol. So alcohol often makes people’s glucose levels lower as well, and that’s independent of insulin. So people will often find if they have a glass of red wine with a dinner that usually causes the blood glucose rise. It will actually cause less of a blood glucose rise, but that’s from a totally different mechanism. And that happens because alcohol inhibits the part of the liver that essentially makes new glucose…So let’s say you eat a totally no carb meal and you have alcohol. You could very well see your glucose drop because of this little faucet that’s always going to replace some glucose in the bloodstream has been impaired. So it’s something that actually people who are on a keto diet or who are fasting really need to be careful of. You do not want to be drinking alcohol when you’re on an extended fast, or super in ketosis, because you may block one of the only pathways you have at that point towards replenishing glucose in the blood. So there have been reports of people having comas and things like that because of drinking in a fasted state.”
1:01:47 – Flexing your fat burning muscles
By keeping blood sugar stable, insulin remains low. This triggers the body to use fat for energy when glucose is unavailable. This is what Dr. Means calls metabolic flexibility and a way of keeping the body healthy.
“For fat to be used as fuel in the body and for us to use fat as an energy source and be metabolically flexible, insulin has to be low. And as you use those fat burning pathways more and more, they get stronger and you become more efficient at using them. And so I really like to think of this as by having good days on CGM, it’s just like working out. You are getting reps in to build your metabolic fitness. And when you are building your metabolic fitness, it means that you’re keeping your insulin stable and you are tapping into fat burning pathways more effectively. And then in different times of energy substrate availability, like a fasted state, or you’re exercising in a low glucose environment, or you are doing keto, you know that you’re going to be able to flip flop back and forth between burning glucose and burning fat. The average person walking around in the United States, I don’t think has the capability of doing that very efficiently because we have been so exposed to such readily accessible food sources that spike glucose.“
[00:00:00] Ben Azadi: Coming up on the keto Kamp podcast, we welcome Dr. Casey Means.
[00:00:20] Dr. Casey Means: In terms of all of us trying to check our glucose and become really metabolically healthy, all we’ve got really is – Okay, if I’m below a 100 in the morning, I’m okay. And if I’m, after a huge carb rich meal, under 140 after 2 hours, I’m fine. I would argue that these are drastically too lenient. And if that’s what we’re focusing on and orienting around, people will not achieve optimal health.
[00:00:49] Ben Azadi: I’m a certified functional health practitioner who’s on a mission to educate 1 billion people. I’ve been obese for most of my life. From rock bottom to the top of the mountain, I am passionate about studying ancient healing strategies, like fasting and the ketogenic diet and curating this information on the Keto Kamp podcast. My goal is to bring you the thought leaders in this space.
My name is Ben Azadi, and I want to thank you for spending part of your day with me. Hey Keto Kamper, hope you are doing incredible today. Hope this episode finds you in gratitude and in love. And when I say love, loving yourself and loving the world, I cannot wait to, share with you, Dr. Casey Means. Who’s a Stanford trained physician and co-founder of Levels Health, which is a startup focusing on maximizing diet and exercise through continuous blood glucose monitoring. And that’s what today’s episode is all about – the CGM. You might’ve heard of a continuous glucose monitor, we’re going to break down everything you want to learn about it. I have been using one for the last 3 weeks and I share my experience with it on this episode.
And I get some coaching from Casey. Cause I saw some interesting things, looking at my blood glucose, the last 3 weeks, every few hours or so, I became a little obsessed with it. It’s such a cool little device, such a great biohacking device. I asked Dr. Casey questions, like, why did my glucose go up almost 15 points midway through a workout and then drop those 15 points towards the end and my workout. I asked her about my glucose dropping to the low 60s after having, just protein from sheep yogurt and bone broth powder, and she gives me coaching on that. We discussed the benefits of wearing the CGM. How can you get a CGM. How CGMs fit into the keto lifestyle. I asked her about the Dawn effect, which is having higher blood sugar levels first thing in the morning. Is this normal is this healthy? She’ll break that all down for you.
Then we get into the normal glucose ranges, the optimal ranges that we want to hit. She has a great perspective in research on specific numbers and ranges we want to get into with our blood glucose. So if you’re hitting those numbers know that you’re aging gracefully and the foods you’re eating is doing you well. So this is a great discussion, because we talk about insulin. We talk about glucose. We talk about Levels Health, which you’ll hear more about. And foods that work with your physiology. How do you know? Even if it’s keto foods, if it works for your physiology? So we get into all of that. You’re going to love Dr. Casey’s energy, I sure did, and our energies fed off of each other for a fantastic discussion. So grab a pen and paper. You’re going to love this interview.
Just to give you a heads-up, Levels Health is doing a pre-launch right now, and they have a 26,000 person wait list to access their Levels software and service. For the listeners to the Keto Kamp podcast, we worked out a skip the line link. So yes, you might still need to wait 8-12 weeks for shipment due to high demand to this early access program, however, you skipped a line of 26,000 people. For being a listener to the Keto Kamp podcast we wanted to reward you. So you could find that link in the notes of this podcast. It’s also levels.link/ketoKamp. Just go to the link if you want to see that and click that, it could be found in the notes of this podcast.
I want to take a minute here to get to the Apple podcast review of the day. This is a five-star review from LRMI20, titled, “Fabulous. I’ve been fasting for a couple of years, and I’m always looking for helpful, updated information to help me on my journey. This podcast is fabulous. Great information and guests.” Well, LR, kudos to you for practicing fasting for a couple of years and still getting information that helps you along the way. We are releasing cutting edge research with amazing guests, I’m glad you’re listening. Thank you so much for taking that time to leave the show a rating and review it. It really helps to show grow, it is the oxygen, the lifeline for podcasts. So thank you so much.
If you haven’t left the Keto Kamp podcast a rating and review, as of yet, please do so by going to Apple podcast and leaving that honest rating and review. And when you do, take a screenshot and send that screenshot to [email protected] with your shipping address in the United States. And when I see it, I will sign a paperback copy of my bestselling fasting book and send it out to you as a thank you. So please, leave the show a rating and review, take that screenshot, send it to [email protected]. If you want to take a screenshot of this episode on your phone and post that on Instagram, I love it when new Keto Kampers do that. Send me a tag when you do that @thebenazadi and shoot Dr. Casey a tag @drcaseyskitchen.
If you’re struggling to find the right foods on your ketogenic lifestyle, I highly recommend you check out Kettle and Fire’s new lineup of keto soups. They are delicious. They live up to my high standards of quality ingredients and they’ll help you accelerate your ketogenic results. Visit kettleandfire.com/ketoKamp and use the coupon code “ketoKamp” at checkout for 15% off. That is kettleandfire.com/ketoKamp. Okay, let’s geek out together on continuous glucose monitoring with Dr. Casey.
All right, Keto Kampers, I am so excited to geek out with you with the brilliant a health practitioner, Dr. Casey Means. A Stanford trained physician turned digital health entrepreneur. She’s the co-founder of Levels Health, which is a startup focusing on maximizing diet and exercise through continuous blood glucose monitoring. And that’s what we’re going to talk a lot about today. How to use a CGM machine, continuous glucose monitor, to see what foods are working for you, which keto foods are working for you or not. So without further ado, let’s bring on Dr. Casey Means.
Hey, Dr. Casey.
[00:07:20] Dr. Casey Means: Ben. Great to see you.
[00:07:22] Ben Azadi: Great to see you too. We were just having an offline discussion and geeking out a little bit. So I’m glad that, I’m grateful to connect with you, thank you for joining me today.
[00:07:28] Dr. Casey Means: You as well, thank you so much for having me on.
[00:07:31] Ben Azadi: So how does a surgeon go from being a surgeon and being in that conventional space, to doing what you’re doing today?
[00:07:40] Dr. Casey Means: Great question. So it was a big transition, out of the operating room to the functional medicine world, and then ultimately the digital health world. And it honestly really started way back when I was a college student, so it was a long journey. I’ll give you the cliff notes version, but basically, I started college at Stanford right after the Human Genome Project had wrapped up. And digital therapeutics and direct-to-consumer genetic testing was really coming online. The personalized health revolution was really starting and it was very exciting. And so that was the ecosystem with which I entered the biomedical sciences and the very beginnings of my healthcare career. And with all this, sort of stuff in the water about the human genome project and 23andme and personalized genetics, there really was this overarching sense, to me, that healthcare is really about humans being this unique biochemically individual blueprint, our genes. But the difference between the expression of health or disease, really has to do with how those genes are actually expressed. And that variable that controls that is really, comes down to exposures and that is diet and lifestyle. So it’s what we’re eating. It’s what we’re thinking, how we’re stressing, how we’re sleeping, how we’re moving, what environmental toxins we’re exposed to. And all those things go into our body as molecular information that tells our genes what to do. So in that sense, it’s really an empowering view of human health.
Because even though we are born with this genome, which is, this written code that we can’t do a whole lot about, the expression of that is, we have a lot of control over that. And then since that time, a lot more has come out about that modifiable aspect of genetics through the whole epigenetics revolution, which is how the genome is folded. And we know that certain genes can, essentially fold on themselves and make it more difficult for them to be expressed. But through epigenetics and in histone modification, and then our behaviors, our diet, our lifestyle, the way we manage stress, all these things have a huge impact on epigenics and the folding of the genome. So it’s really interesting.
So that was what I started in my health career, being embedded in. And I worked at 23andme and I was a teaching assistant for a pharmacogenomics class, and I just really loved that. And so then, flash forward, I go to medical school. And medical school is actually a very different approach than this. The way that conventional medicine is taught and practiced is much more of a pattern recognition process. So the way it works is, you go in and you see a patient and you ask them a bunch of questions and you get lab tests and you do an exam. And those end up becoming this collection of signs and symptoms. Signs being objective findings, like lab tests and exam findings and imaging. And symptoms, being more subjective things that you learned about the patient. And the way medicine works is, you say, “Okay, this patient’s got this collection of signs and this collection of symptoms.” And if it adds up you, basically get to label a diagnosis on it. And a diagnosis is like a label, a term, that encompasses the collection of signs and symptoms. And then, as a doctor, you can turn around and you can look at your book of which medicines and which surgeries, essentially are used to treat that diagnosis. And so in that sense, it’s quite reflexive. It’s very much about pattern recognition and it doesn’t really take into account, on the day-to-day practice, a lot of these modifiable aspects of health and disease. This is very interesting because now, in our country, we’re dealing with this chronic disease epidemic.
We’re dealing with 88% of Americans having insulin resistance or metabolic dysfunction. 74% of Americans being overweight or obese. 128 million Americans having pre-diabetes or diabetes. These are just a couple of the massive amount of chronic disease that we’re seeing, and that are touching almost every American. And we know that these diseases are rooted directly in dietary and lifestyle choices over the years. And yet, not necessarily something that’s really factoring into our day-to-day practice or the nuances of our practice. And the average medical student only gets about 4 hours of nutrition training in their entire medical school career, even though nutrition is, arguably, the highest value, lowest hanging fruit intervention for, really reversing disease.
So that was medical school and some observations I had there. And then moved on and went into the surgical world. And so I trained as, in residency, as a head and neck surgeon, which is an ear, nose, and throat surgeon. And given the realities of the healthcare system that I was seeing, I, as this young spritely, 26 year old, was thinking like, “What is my goal? I want to help people. I want to make people well.” And surgery, seemed to me, to be this, within the confines of the system, like the most efficient way to do that. Because you take someone to the operating room, they have pus in their sinus, and at the end of the day, you’ve punched a hole in the sinus, you’ve sucked the pus out and that you’ve “fixed them”. And so that felt really appealing to me, as someone who wanted to do good for patients. And practicing surgery for 4 or 5 years, and ultimately, I was stepping back and seeing, almost every condition I’m treating in the operating room here, as an ear, nose, and throat doctor, is fundamentally an inflammatory condition. So sinusitis is inflammation of the sinuses. When the nasal tissue gets inflamed, it closes the hole that drains the sinuses and then pus builds up. I was treating tons of chronic ear disease, like middle ear infections that kids are always getting. And that, fundamentally is the tube that drains the ear into the nose. The station tube gets inflammation, clogs up, you get puss build-up in the ear and then you punch a hole in the eardrum and you put an ear tube in and you suck the pus out. And that’s fixing it. And I was seeing a lot of Hashimoto’s thyroiditis, which is really rising in rates, especially in women in our country, and this is inflammation of the thyroid. It’s an autoimmune attack of the thyroid. And then I was also seeing a lot of cancer, which we’re more and more understanding as an inflammatory disease. We’re seeing a lot of therapies come online that actually harness the immune system to, actually fight cancers like cancer vaccines. So it’s fundamentally a problem with how the immune system is responding to these abnormal cells in the body. And then, lastly, I’ve seen tons of like vocal cord granulomas and masses on the vocal chords that lead to hoarseness and breathing problems. And these are ultimately, inflammatory masses. So I’m sitting there saying, “Oh my gosh, this is so interesting.” Everything’s inflammatory, prescribing a lot of steroids, which are anti-inflammatory medications, doing a lot of surgery, but it seems a little illogical that I would use surgery, which is like a mechanical, physical, tool to fix what is, fundamentally a complex physiologic problem. That is ultimately related to how the immune system is sensing threat in the body.
Inflammation, fundamentally, is the immune system saying there is a threat and we have to activate in order to fight that threat. So it became very imperative to me to think, “What is this threat and why is everyone inflamed?” And this was just in my little ENT world, but looking more broadly across chronic disease, a lot of chronic diseases we’re facing are fundamentally inflammatory in nature – Obesity, heart disease, stroke, Alzheimer’s etc… And so it became very important to me to think more about that issue. And when I, that led me, really on a journey, that kind of led directly to diet and lifestyle. These are the things, the choices we’re making in terms of what we put in our body, what we expose ourselves to today, ultimately, are I think, triggering a lot of the chronic inflammation that we’re seeing. Our bodies are exposed to whole new breeds of foods that our bodies, throughout history, were really never meant to be exposed to. Refined and processed grains, refined and processed sugars, processed vegetable oils that are highly oxidized, all these things that, you can imagine, go into the body. Your body hasn’t seen these things in these quantities, ever, throughout human history. And so the immune system’s, “Whoa, threat. This is not good.” Same is true of environmental chemicals, environmental toxins, and pollutants. There is a class of compound called POPs, which are persistent organic pollutants, which are all over our environment and cause metabolic dysfunction and inflammation.
Then we’ve got chronic sleep deprivation. We’re sleeping way less than we used to, which is, to the body is registered as threat. The body’s like, “Why are you not sleeping? Something must be wrong.”, and so it activates. And then you’ve got sedentary behavior which triggers the immune system. And we’ve got chronic low-grade stressors. Every time you get an email or a ping on your phone, the body’s, “Ooh, what’s happening? It may be a little threat.” So our bodies, our poor bodies, our poor mitochondria, are just like, “There is so much going on.” And I think we’re very activated from our immune system.
And I, anyways, ultimately decided, okay, if I really want to get to the root cause of some of these ENT conditions, I really need to be helping patients reverse this inflammation. And kind of really get fundamentally healthy. So ultimately, got additional training in functional medicine through the Institute for Functional Medicine. Learned a lot about this root cause approach to healthcare. And, instead of thinking about things as these separate entities in the body like, Oh, these are ear, nose, and throat conditions, and these are metabolic conditions. And these are heart conditions. And these are GI conditions. Instead thinking about what’s the physiology that actually links a lot of these diseases? And so that really led me down the road of really trying to understand metabolic dysfunction. Because when you look at how diseases are connected in the body, especially our major chronic diseases, it really leads you right back to metabolic dysfunction and insulin resistance, which are also drivers of inflammation.
And so, opened up a private practice, a functional medicine practice, where I was really trying to help people understand these root causes. Really trying to optimize metabolic function for my patients. Started putting continuous glucose monitors on a lot of patients to help them have real-time clarity into how food and lifestyle choices were affecting their glucose levels in real-time. Which I found to be a really interesting and engaging, sort of behavior change tool for people. And then, so did that for a while and realized, okay, so ultimately, for me to make a real impact on patient’s lives, people really have to be, every single day, making consistent choices that improve their health. They have to be making good choices in relation to food, exercise, sleep, stress, exposures. And so really, this comes down to inspiring people to make good choices and make behavior change choices every single day. And to me, that really lends well to digital health solutions. Because we have our phones on us every single day. We don’t have our doctors with us every single day. And so, in order to make sustainable choices, and we make 100s, if not 1000s of choices every day, about all these different things, to have a tool with you that can help you make those choices in a smart way for your body, I thought was really where we needed to go. And doctors really need to be adopting and engaging with technology so that patients can make those sustainable choices, that ultimately lead to the expression of health and, essentially functional physiology. And so that’s how I moved from surgery to, ultimately functional medicine and metabolic focus. And then, really started doing more in the digital health world, realizing that doctors have to engage in this if we want to scale our efforts to help the most people and have the most effective impact on behavior change.
[00:18:58] Ben Azadi: Yeah, what a journey you’ve had so far. I love that you recognize that you were being reactive and then you became, now proactive. And I always give that analogy of the old, the whack-a-mole game at the arcade, where a mole pops up and a symptom, whatever it is. So you perform surgery or you give us a pill or even a supplement and another mole pops up and you do the same thing. And shouldn’t we be asking why are these moles popping up? And that’s what you said, why are these moles popping up? And it’s metabolic dysfunction, it’s inflammation, all roads lead to inflammation. And there’s different roads that stem from inflammation, but inflammation is linked to just about every single disease out there. So I acknowledge you Casey, for seeing that and then also making that pivot, which I imagine, and maybe you could share how difficult was it for you to actually make that pivot. Because you were in this conventional world and now you’re looking and thinking outside of the box and you might’ve had some peers that might’ve not have liked that. So how was that pivot for you?
[00:19:54] Dr. Casey Means: Yeah, by the time I ultimately made the decision to put my scalpel down and leave the operating room, it actually was a really easy decision. Because ultimately, I had taken a lot of time to reflect on what is my North star? What is my purpose here as a physician? And my purpose is to help the most people as I possibly can, achieve true, real foundational health and to thrive. And to maximize their human potential. And when it became clear to me, it honestly comes down to a spreadsheet. It’s like, I could invest my time in a tool, a digital health tool, that has the power to meaningfully impact millions of people through principles that I’ve thought a lot about, and that are well-established in the research. Or I could continue helping 20 to 30 patients a week, in my functional medicine private practice, and, which is very useful, but ultimately, a lot of the principles are very foundational and can be scaled if we merge that clinical insight with digital tools. And for moving away from surgery, the same thing was true, my North star was to help people, foundationally, get healthy and thrive. And I think surgery can absolutely help do that in acute situations, where people have an acute injury, like breaking a bone or getting in a car accident and you need to fix something and get them back on track. But for chronic conditions, that are based in inflammation, I don’t see surgery playing a role like it does today, where it is something we’re very quick to engage in. And so once I had that philosophical shift, it was really not that difficult to shift gears. And a big part of this was really getting involved in the network and systems biology movement and really diving into that research. I don’t think that’s a term that many people are familiar with, but ultimately, I think this really is going to be the future of medicine. And what this is, is exactly what you were talking about with the whack-a-mole.
So right now, we see all diseases as isolated silos. We see depression as it’s unique disease, obesity, benign prostatic hypertrophy and prostate cancer, hypertension, diabetes. There are all separate things that we see as silos. And then, let’s say IBS, irritable bowel syndrome, totally separate, no one would really think they’re the the same thing. And we treat them as such, we have a different medication for each of those diseases. But in network biology, because of the proteomics revolution and whole genome sequencing, we now can understand what are the common core pathways and genetic regulation. And the physiology that actually links all of these into a web, as opposed to silos. It is so much more efficient to treat the links between diseases, where one intervention can have multifarious effects, versus playing whack-a-mole, like you said, with all these different diseases. Which is really a never ending cycle, because you’re not actually reversing physiology, you’re just managing symptoms. And so from an efficiency standpoint, from rational biochemistry perspective, treating those links is where I think the future of medicine needs to go, especially with the huge challenges we’re facing right now.
And I just finished Ben Bikman’s new book, Why We Get Sick, and I think he does, probably the best job of describing this network of diseases, of anyone I’ve ever seen. Because he really talks about how that link between so many of the things we’re seeing today, that seems so disparate, skin tags, infertility, erectile dysfunction, hypertension, heart failure, cancer, seem different, but actually, fundamentally this is a problem of insulin resistance. And so that’s the web that links these things. And so, I think once you’ve wrapped your head around that and really believe it, based on a lot of late nights reading research literature, it’s not that hard to walk away. Because ultimately, you just believe a different, you’re moving in a different direction of how you want to help people. And I certainly don’t regret any of my time there because it led me to understand this problem in a way that gives me, really that fire to want to approach it a little bit differently.
[00:23:57] Ben Azadi: Absolutely. Yeah, it does. So let’s talk about why you decided to go. You just explained it, all roads are leading to inflammation, insulin resistance, and high glucose levels. So you developed a software, you co-founded Levels, and you utilize a CGM, which is a continuous glucose monitor. So for somebody listening or watching here on YouTube, and they have no idea what a CGM is, this is the first time they’ve ever heard about it, could you explain what it is?
[00:24:20] Dr. Casey Means: Absolutely. Yeah, so a continuous glucose monitor is this tiny little quarter sized wearable sensor that you stick to the back of your upper arm. And it’s got a tiny little hair-like filament that goes under the skin. And that little filament is actually checking your glucose every 15 minutes, 24 hours a day. And you wear this sensor just like you would wear a Fitbit that measures your heart rate. And it’s transmitting a glucose value to your phone every 15 minutes without you having to do, really anything. And so what you end up with is this incredible biometric data of what’s going on inside your body and your response to food, continuously. What’s really cool about glucose is that it changes rapidly after an input. So you eat and your glucose, if it’s going to change, it’s likely going to change within 30 minutes to an hour. So you’re getting this really closed-loop, like one-to-one feedback between what you’re eating and what’s happening to your blood glucose. This is a technology that is, has been around for, actually a while, like over a decade. And it’s FDA approved for management of type 1 and type 2 diabetes. So right now it’s got a clinical use for these populations and has been a game changer. Because formerly, these individuals were pricking their fingers 3-5 times a day, after meals, to see what’s happening. And mostly for medication management. And this tool allowed them to stop having to prick their fingers and is just a lot more comfortable, it’s completely painless. And it’s just such a more robust data stream.
But what’s interesting about metabolic diseases is that, these are insulin resistance and metabolic diseases. These are diseases that don’t just turn on like a light switch when you get a diagnosis of diabetes. These are diseases that start decades before the actual diagnosis and are essentially the result of repeated, regular insults to your metabolic system, through these 100s of daily choices that we make every single day. So it became, how can we use this incredible technology that gives us this data stream to help people, far before their diagnosis, refine their diets and lifestyles so that they never get to that stage. They never develop insulin resistance. And you could say, oh, why don’t people just eat low carb? And then they won’t get glucose spikes and then this will never happen. But you know that, unfortunately, we’re at monumental proportions of this epidemic, in terms of metabolic dysfunction. And I think people do really benefit from having tools that give them some accountability and clarity into what’s going on and keep them on track. But what’s most interesting is that no two people respond to carbs exactly the same. So there’s tons of variability between how, like you or I would respond to the exact same carb load. We can both eat a banana and I could go to a glucose level of 150 milligrams per deciliter, and you could go to 90 milligrams per deciliter. And so a banana is probably a much better choice for you and much worse choice for me. I’m almost certainly going to secrete more insulin from my pancreas when I eat that banana, that insulin is going to be floating through my bloodstream. And if that happens repeatedly, is ultimately going to lead to myself becoming, possibly insulin resistant, and lead me down the path towards something like type 2 diabetes or pre-diabetes.
Because of that biochemical individuality, which is relatively a new concept, formerly we thought, like everyone responds the same. And that’s why we have these indices, like the glycemic index chart. Which basically says that if you and I both eat a banana, we’re going to have the same glycemic impact from that food. But more recent research, most notably out of the Weizmann Institute in Israel, which was published in Cell, in 2015. Which was called Personalized Nutrition by Prediction of Glycemic Responses, they put continuous glucose monitors on a huge population of healthy individuals and saw that, basically people are all over the place with how they respond to a standardized carb load. And so, for us to really stay on track in the face of a food culture that has a lot of glucose triggering foods, I think it’s really important to have some more clarity and data into that.
[00:28:23] Ben Azadi: Yeah, it’s super cool. Cause I’ve been using one, you all sent me one a few weeks ago. I think I’ve been using it now for about, almost 3 weeks. And it’s been really awesome to see the data, when it happens. I’ve never used a CGM before. I’ve used finger pricks and I’ve seen what happens. But I was not pricking my finger all day long. With this, I have the CGM, if you’re watching on YouTube, I actually have it right here in the back of my shoulder here, or arm, I should say. And it’s very simple. I just put my phone here and it’ll give me a reading and it’s continuously monitoring. But I found that blackberry’s actually jacked up my blood sugars. And I would think, blackberries, they’re low on the glycemic index, they’re low in sugar for a fruit. But for me, I don’t do well with that. I do much better with blueberries. So just knowing that data, I can understand that I’m going to have more blueberries and less blackberries.
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Okay, let’s go back into this episode of the Keto Kamp podcast.
So I want to actually get some coaching from you Casey, because I had a few different scenarios that I want to get your feedback on when it came to monitoring my glucose via the continuous glucose monitor. And number one was, I remember I was in a fasted state, and typically my fasting glucose is in the 80s, mid-80s or so. And I finished up, doing some work and I was going to go into a meeting and I decided I wanted to break my fast, this is around 1:00 PM or 12:50 PM. And I had about 4 ounces of a sheep’s milk yogurt, and I added some bone broth powder to it. So it was all protein, a little bit of some fat. And then I tested this, I put my phone there and I saw my reading, and it actually dropped my glucose from 88 to the lower 60s. It was like 61. So tell me what happened.
[00:31:47] Dr. Casey Means: That is very interesting. And how quickly did that happen?
[00:31:50] Ben Azadi: 30 minutes, right after.
[00:31:53] Dr. Casey Means: 30 minutes, and you weren’t doing any exercise or anything?
[00:31:56] Ben Azadi: No, I was actually sitting right here at my desk on a call and I just decided to do it in the middle of the call. And I saw it and I was like, that’s interesting.
[00:32:02] Dr. Casey Means: Yeah. That’s fascinating. So, this is a speculation, I’m going to speculate here, I don’t know for sure. But normal physiology, when glucose goes into the bloodstream, the pancreas is gonna release insulin, to basically tell the cells to take up glucose. To get it out of the bloodstream so that it can either be used by the mitochondria to generate cellular energy, ATP, or if there’s excess, for it to be stored. And it will be, can be turned into, either stored chains of glucose, which is called glycogen, which is like short-term energy storage, which goes into the liver or the muscles. Or it can be converted into fat, like triglycerides, and then go into the fat cells to be stored for long-term energy storage. That’s normal.
But other things can stimulate insulin as well, like protein. And so protein, to some extent, does cause an insulin response. It tells your body you’re in a fed state. And so that kind of transmits to the pancreas to release insulin, perhaps because there’s an expectation of glucose coming or something like that. But perhaps, what happened was that you ate this, essentially zero sugar food, the sheep’s milk yogurt. And now, I don’t know how much of residual sugars there were in there, but I imagine very low. And then you added bone broth powder, which gives you extra protein and probably some fat, I would imagine.
[00:33:14] Ben Azadi: Yeah, I had a little bit of some fat, mostly protein. Yep.
[00:33:15] Dr. Casey Means: Yeah, and so you may have had, essentially no glucose come in, but straight protein come in and have a little bit of an insulin surge. So you actually took up some of your circulating glucose, that was already in the blood stream, which is very tightly controlled by the body, and that led to a little bit of a dip. And you didn’t essentially replace it with any exogenous food-based glucose. So that’s a possibility, essentially an insulin response in the absence of glucose.
[00:33:43] Ben Azadi: Yeah, that’s where my line of thinking was too. And I felt totally fine, I didn’t feel hypoglycemic, but it was just interesting data. I wouldn’t have expected that. Second thing that happened was, I went to go workout in the fasted state, which I usually do. I workout, I train in the fasted state. And I started off my workout, glucose was in, before I started my workout I checked my glucose, was like 94, I think it was. And then I did some warming up, I did some strength training, probably about 15 minutes of some weightlifting. And then my glucose went up, it went up to 108, and then halfway through the workout, I finished the strength training, and then I did some sprints on my rooftop here, and then it dropped down to 82. So what will happen there?
[00:34:24] Dr. Casey Means: Yeah, this is so interesting. And I commend you for being in the fasted workout Kamp, because this is heretical to a lot of people who come from the carb loading philosophy of getting the most out of your workouts. But a lot of evidence to support, that actually exercising in a fasted state is really good for the body and for our metabolic pathways. So what likely happened to you there with the weightlifting, is that, essentially the body’s fairly simple, when the body thinks that there is a threat or we are under stress and need energy to, essentially run from something. Like old days, the example of being chased by a lion, you think that you need to, essentially run from a lion. Your muscles are going to need very quick sugar to work. And so the body has this mechanism where if you think you’re about to be chased by something and you need energy for your muscles, you’re going to dump your stored glucose from your liver which was stored as chains of glucose called glycogen. You’re going to dump it out really fast and flood the bloodstream with that to feed your muscles. And so, we often will see a glucose rise, even in a fasted state, because even in a fasted state you still have some stored glycogen in your liver, unless you’ve been fasting for a really long time and which you can fully deplete your glycogen. We store about 2000 calories of sugar, of glucose as glycogen. So you can imagine you could burn through that through an extended fast. But overnight you’re probably not going to burn through all of that. You start lifting weights or you start a high intensity interval training workout, and that sends to your body to signal, “Oh man, we need sugar, we’re about to run from a lion.”, this is a stressful situation. And your liver immediately, basically dumps out a bunch of sugar. The muscles don’t tend to need as much as what the liver dumps out, it overcompensates. And so that’s why you see a rise. Then, you’ll often see a dip after that, because the muscles become very insulin sensitive during a workout. They’re hungry for that glucose. They want it. And so you are essentially going to have maybe an exaggerated response of taking a lot of that up as the workout winds down. And you can see increased insulin sensitivity in the muscles immediately after a workout and in the days following. So that’s what was happening there.
[00:36:37] Ben Azadi: So fascinating. It’s really cool to just see that, in real-time, what’s happening. And the next thing is, what role does cortisol play here? Doesn’t also cortisol has an effect? Because cortisol goes up, glucose tends to follow cortisol. So that also played into the role of exercising in the fasted state, right?
[00:36:53] Dr. Casey Means: That’s exactly what happened. So that’s the language with which the exercise told your liver to do that. So catecholamine release, cortisol release, those things are going to tell your body that it’s time to dump some glucose. And so a couple other, sort of interesting things there. One, is the idea of stress and stress hormones. This is also another very important topic, which is that our perception of stress in our day-to-day lives has a huge impact on our glucose levels. So you can just have a stressful conversation or respond to a stressful email or, anything like that and it can actually raise your glucose on its own. And we’ve seen this a lot actually, just in our customers. And I’ve seen it in myself. I remember like, the first podcast I recorded ever, my glucose totally went up fast as we were recording it. And it was just like, oh, this is so interesting, this is must have been a cortisol response. And I think it’s really good to be aware of that.
And I think that’s a really interesting part of this biofeedback aspect of CGM, because sometimes it’s very difficult to know actually whether we’re stressed or not and I think a lot of us deny stress. But our bodies, you cannot hide stress from your body. Even if your brain thinks that you’re not stressed. And I have so many patients who say, “Oh, I’m never stressed.” But stress, from a physiological level, like it’s there, in almost all of us. And so I think it’s really neat to be able to actually, almost have this accountability check of, no, something was going on. And there are things that we can do. Like what if, you could, quick, insert a little meditation into that part of your day when you know that you’re getting a little glucose surge from stress. Or do other tactics that are going to lower your overall cortisol response. Or something that we’re exploring and are going to be developing is the integration of the CGM data stream with heart rate variability data streams.
So heart rate variability is, essentially looking at the beat-to-beat variability between our heartbeats. So you can check your heart rate, which is how many beats you have per minute, but then you can also look at how much time is in between each heartbeat. And actually, when there’s more variability between the beat-to-beat time, that’s actually associated with a better stress response, more adaptable, more flexible. Flexibility in the body is typically always a good thing. So high HRV is positive. And so it’s going to be very interesting to see how HRV and these stress-related glucose responses correlate. And I think together, could really help move people into more of a sense of somatic awareness. And more body awareness about what’s actually happening, especially for these subjective experiences, like stress, that are sometimes really hard to pin down and to know when they’re happening.
[00:39:23] Ben Azadi: Yeah. Awesome said. It’s super cool to just see this and talk about this.
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Okay. The next thing is this, the Keto Kampers, they’re checking their glucose, their ketones. I get a lot of messages, “Hey, Ben, in the morning when I wake up, my glucose is 105 or 98. Why is it so high in the morning? And then drops an hour later.” And I explained to them, it’s something called the Dawn phenomenon and it’s a natural occurrence. So explain what’s happening there and then we’ll transition to what are the optimal ranges look for?
[00:41:37] Dr. Casey Means: Yeah, absolutely. So the Dawn effect is this phenomenon that you can see, where basically first thing in the morning, glucose just rises on its own, totally in a fasted state. And it can rise, like 5 points, 20 points and in people with metabolic diseases, like type 1 or type 2 diabetes, it’s going to be very high, can go up 50 points. So the physiology behind this is that in order to wake up from sleep our body releases cortisol and other hormones, to essentially rouse us, to get us to wake up. And those are going to have an impact on the things we just talked about, on the liver and mobilizing glucose. Your body is preparing to need to be alert, stand up, use your muscles again. And so that’s what’s happening with the Dawn effect. It’s more pronounced in someone who has diabetes or insulin resistance, because if you are insulin resistant, then you’re going to have more of this inability to get that glucose quickly into the cells. And so you’re going to see more of that rise. The evidence suggests that a very healthy person, with perfect metabolic health should probably not have much of a Dawn effect at all. And the more Dawn effect you have is actually, probably more moving on that metabolic spectrum. In someone who has perfect insulin sensitivity, the cortisol and the stress hormones are going to release that glucose, but you’re immediately going to compensate by taking that up into your cells. And so it’s totally normal to not see a Dawn effect and to just have it completely flat line in the morning, or like a 2 to 3 point raise when you wake up.
[00:43:06] Ben Azadi: Awesome. So let’s talk about what are the normal blood glucose ranges to be in a fasting? And then postprandial? And what are the optimal ranges?
[00:43:15] Dr. Casey Means: Yeah, absolutely. So, to talk about normal, this is really coming from, I’m going to put air quotes around “normal” because this is what the American Diabetic Association and governing bodies, they’ve reviewed the literature and they’ve come up with these criteria for categories of what is normal as a way to categorize people. And as a way to efficiently group who is most likely in certain categories. But I think it’s important to remember if we’re talking about these categories, of like normal pre-diabetic and diabetic, that these are population-based statistics, and they tell you, essentially at a population level, what level of risk you’re at for different things. And so they don’t actually tell us what to shoot for. So in our current system right now, if you have a fasting glucose, first thing in the morning after not having consumed any calories for 8 hours, of below a 100, you’re considered normal metabolic health. If you are between 100 and 125 you’re pre-diabetic, and if you’re 126 milligrams per deciliter or above, you’re considered diabetic. And then there’s other tools that we use to diagnose people for these conditions. And so, one is called an oral glucose tolerance test, where an individual will take either 50 or 75 grams of a glucose drink, usually called glucola. It’s really gross. And you chug it and then…
[00:44:33] Ben Azadi: It sounds nasty.
[00:43:34] Dr. Casey Means: It is nasty, yeah. And you’ll check your finger prick glucose, or your blood glucose from a vein, 1 hour and 2 hours after that. And so, if you go up, your glucose goes up after that glucose drink and if after two hours, you’re below 140 milligrams per deciliter, you’re considered non-diabetic. So that’s the one for that. And then the third test is hemoglobin A1C, which is a blood test that looks at a 3-month average of blood glucose by looking at how much glucose is stuck to red blood cells. And if you’re below 5.7, you’re considered normal. 5.7% of your blood cells having sugar attached to them, glycated hemoglobin. So that’s all we’ve got, in terms of all of us trying to check our glucose and become really metabolically healthy, all we’ve got really is, okay, if I’m below a 100 in the morning, I’m okay. And if I’m, after a huge carb rich meal, under 140 after 2 hours, I’m fine. I would argue that these are drastically too lenient. And if that’s what we’re focusing on and orienting around, people will not achieve optimal health. Those are way, way too lax. And the reason I say that is because if you look at the research literature, even within the normal range, as you go up from, let’s say a fasting glucose in the 70s, up to 99, which is still considered normal, risk of nearly all diseases increase.
So there was one study done in the New England Journal of Medicine, which looked at healthy young men and they were non-diabetic. So all of them had a fasting glucose less than a 100. And they broke them up into core tiles of fasting glucose, the lowest core tile was somewhere between 70 and 78. And then it was like 78 – 85, 85 – 92, 92 – 100. I don’t think those ranges are exactly accurate, but it was like 4 core tiles within normal. And what they saw is that as fasting glucose increased throughout that range, risk of developing type 2 diabetes skyrocket, huge increase in odds ratio. I think it was 8, in the highest core tile compared to the lowest. So you’re much more likely to develop diabetes if you have a higher fasting glucose than a lower fasting glucose. Even if your doctor says you’re totally normal, you’re normal, you’re below 100. The same is true of stroke and heart disease. It’s essentially, that exponential increase in cardiovascular disease that happens with metabolic dysfunction, insulin resistance does not start right at 100. It starts well below 100. So even if you’re at the mid-90s you’re still on that upward curve for developing those diseases.
So I would argue, we need to be achieving the lowest core tile of these things. So I would say, based on my review of the literature, I would suggest a healthy fasting glucose to shoot for between 72 and 85. And that would, based on the data that I’ve looked at, be in the lower risk categories within the normal range for developing future disease. Then, from a post-meal standpoint, and I say 72 as the lower limit for that, and not 70, because there actually is some research that shows that the lower your fasting glucose is, risk for mortality actually goes up. And I think this needs to be studied more. Cause I don’t, I’m not fully convinced of this. Cause I think there are people who are on ketogenic diets who are getting very adequate fuel from other sources to their brain and other parts of their body, who may have a very low fasting glucose. And I’m not confident that’s associated with increased risk. But that needs to be studied. We need to better understand what’s optimal for a non-diabetic person. But because of that research, I would put, for now, the lower limit that I would suggest is maybe 72. Not that you should eat to get, maybe like higher, but just from the research we have now. So there needs to be more research done in this. For post-meal glucose levels, so right now, all we’ve got is that we should shoot for less than 140, 2 hours after a meal, which, to me, is crazy.
There’s about 6 or 7 studies that have taken healthy populations, put CGMs on them and looked at what their 24 hour glucose levels are. So just totally observational studies. In those studies the average healthy person spends 90% of their day between a glucose level of 70 and 120. So the vast majority of our day, we should probably be spending between 70 and 120. And if you look at, even some of the studies that have more lenient, maybe not so healthy populations, but still technically non-diabetic. There’s another study that showed that people spent 93% of the day between 70 and 140. But almost no one really ever goes above 140. So the idea that we should shoot for that after 2 hours of a meal, just seems crazy to me. From my perspective, we should really never be going out of the 70 – 120 range. And I think we should probably be shooting for, pre-meal glucose levels, somewhere in the 80s and 90s, just resting glucose throughout the day. And maybe going up a maximum of 15 milligrams per deciliter after a meal. And the reason for this, really it’s not just about the glucose, but it’s about the insulin. So every time you spike your glucose, if you’re going to release insulin from the pancreas. And when you do that to a high degree, a high glucose spike, high insulin spike, you are exposing all the cells in your body to this big load of insulin. And like you talked about extensively on your episode with Ben Bikman, insulin has 100s, if not 1000s of roles within the body. And when the body is exposed to it over long periods of time it leads to disease. And it makes our body more insulin resistant, which makes our pancreas have to pump out more insulin at baseline. And so we get to this hyper-insulinemic state. So you want to avoid that by avoiding spikes, frequent spikes, and avoiding high spikes.
And the second thing is that, high glucose alone, in its own right, causes problems, independent of insulin. So high glucose leads to inflammation. It leads to oxidative stress, so too many free radicals in the body. And it leads to glycation, which is glucose sticking to proteins and fats and other things in the body and causing dysfunction. So you want to avoid inflammation, oxidative stress, and glycation, and you want to avoid hyperinsulinemia. And so for all those reasons, I think really shooting for, much more rolling hills on the glucose and not peaks and valleys. And then 2 other small things I will say is that, when you do spike your glucose very high and have this big insulin surge, the body essentially is sucking all that glucose up really fast cause you have all this insulin. And you often see this sharp spike and a big drop. And sometimes you can overshoot on the drop and you’ll actually go lower than what you started at. And that’s called reactive hypoglycemia. It’s an overcompensation of insulin to a high spike. And that state, that reactive hypoglycemia, is often associated with brain fog, fatigue, anxiety, and that post-meal, like energy slump, that a lot of people feel. And if you’re experiencing a lot of variability throughout your day, in your mood, your energy, your focus, I think it’d be, really the lowest hanging fruit I would look at is whether you’re spiking and crashing all the time. And you can really avoid that by making these much more gentle rises and falls.
And what’s cool is that there’s so much that we can do, in terms of modulating our diet and lifestyle, to achieve more gentle rises and falls. It doesn’t necessarily mean eliminating all your favorite foods. It means pairing foods appropriately, timing foods appropriately, pairing foods with exercise in the right way, making sure we’re not eating in a super stressed out state, and making sure we’re getting really good sleep. All those things feed into our glucose response. So we can really, like artfully modulate the diet to get lower spikes. And that’s essentially what my company, the software we’ve developed, helps people do, is learn how to do that.
[00:52:12] Ben Azadi: Yeah, the software is awesome. Cause you can put the range of where you want your glucose to be. You want that targeted range, I think you call it. So I actually put that for myself, 70 120. So I’m glad that’s what you recommended because that’s exactly what I put for my range. I want to first ask you, where can we get a CGM? You said right now it’s just for type 1 and type 2 diabetics and it’s not really outside of that. So how can we get our hands on one of these?
[00:52:33] Dr. Casey Means: Yeah. So at this point, a lot of primary care doctors aren’t really familiar with this use case of health optimization, and performance optimization, and dietary personalization with a CGM. And so if an average person who does not have diabetes walks in and talks to their doctor, they might just be like, “No, this is not for you.”, this is for people with diabetes. And so something that we did early on in our company was we set up a telemedicine physician network of partner physicians. Who, when you, essentially become a Levels customer, you get a telemedicine consultation with a physician in your state. Which is all done over the internet and they evaluate you to make sure that you are safe to use a CGM. And if they do, and they do write a prescription for a continuous glucose monitor, that’s sent to our partner pharmacy, which fulfills the prescription for these sensors and sends them to our customer’s house. So they ended up getting a box with two, 14 day continuous glucose monitors. So the 2 sensors together make up a 28 day program, we call our Metabolic Awareness Program, and then, onboarding instructions of how to get access to the app. Which essentially takes this data stream and helps people really parse out all these different drivers of glycaemic function and how to modulate and understand the diet and lifestyle factors to create, really optimal glucose responses. So that’s something that we provide as a company, is this access to a telemedicine network for continuous glucose on our prescriptions.
[00:53:57] Ben Azadi: So now, you have a waiting list right now. So where can they go and apply and get added to that waiting list so they could get one of these eventually?
[00:54:03] Dr. Casey Means: Yeah, so we’re an early company, we’ve been around for about a year. We are pre-full-launch since we’re in closed beta program. Right now, the best thing to do is to go to our website, which is Levelshealth.com and sign up for the wait list. And we’re moving through this group of people, trying to get access as quickly as possible we can, for everyone and anticipate a full launch later this year.
[00:54:26] Ben Azadi: And I was going to say that, if you’re concerned about the method of applying the CGM, from my experience, I wasn’t sure what I was going to feel. I saw some videos, like my friend Mike Mutzel had a video and he said he felt like a pinch when he put it on. So I was expecting a pitch, but honestly, I didn’t feel anything. I didn’t feel anything when I put it on it. I was actually surprised that I was on me. I just pressed it on there, it’s very easy to do, and I didn’t feel anything. And I have it right here. And as you can see, if you’re watching on YouTube, you have this little cool tape, I dunno if you want to call it a tape, but it’s a cool branding thing you have on there. And it really covers it so you don’t rip it off. Like I accidentally did the first time. So I learned from my mistake and it’s been on there, working really well. Tamika Terry wants to know if you’ll be able to purchase this with your FSA card. I don’t know what that is. Do you know what that is Casey?
[00:55:17] Dr. Casey Means: Yeah, it’s like a health savings account. Essentially, pretax money, and those funds are eligible to buy the product.
[00:55:25] Ben Azadi: Awesome. Again, that’s Levelshealth.com. We’re going to put that in the notes of this podcast and the YouTube video down below. Amanda out in the UK says, “So if your blood sugar has dropped after eating or drinking, does that suggest what you consumed raised your insulin?
[00:55:39] Dr. Casey Means: It’s a great question. That is one possibility. There’s a couple of other possibilities that are worth noting. A little bit depends on what you’ve done recently, from a physical activity perspective. Because if you’re eating something low carb and your muscles are particularly sensitized right then to take up glucose, you could just be actually taking up glucose into your muscles and seeing a drop in circulating glucose. And while you’re eating, you’re not necessarily, if you’re eating like a very low carb meal, not actually replacing that glucose. So it could have to do with physical activity. There’s a couple other interesting scenarios. One is with alcohol. So alcohol often makes people’s glucose levels lower as well, and that’s independent of insulin. So people will often find if they have a glass of red wine with a dinner that usually causes the blood glucose rise, it will actually cause less of a blood glucose rise. But that’s from a totally different mechanism. And that happens because alcohol inhibits the part of the liver that, essentially makes new glucose. There’s a process called gluconeogenesis, which is where you make glucose from other substrates in the body. And that’s one mechanism our body has to just make sure that we always have some glucose in the blood. Because we would die if we didn’t have any glucose in the blood. And so your body keeps things really tight and has a lot of redundant pathways. And gluconeogenesis is one of them. And alcohol blocks that. So, let’s say you eat a totally no carb meal and you have alcohol. You could very well see your glucose drop because this, kind of this little faucet that’s always going to replace some glucose in the bloodstream has been impaired. So it’s something that, actually people who are on a keto diet or who are fasting, really need to be careful of. You do not want to be drinking alcohol when you’re on an extended fast, or, super in ketosis because you may block one of the only pathways you have at that point, towards replenishing glucose in the blood. So there have been reports of people having comas and things like that because of drinking in a fasted state. So something important to think about.
So there’s a lot of different variables. And then, I think, one worth mentioning is that this could also just be from sensor error. So these are technologies that do, very accurate technology, it’s used for medication dosing in people with diabetes and it’s a life saving device, and so it’s very accurate. But there are differences between what you pick up on your sensor and what might be in the blood, very small differences, but it could be possible that you’re picking up some of that variability in the sensor. And at lower values, these sensors actually tend to be a little bit less accurate. And that is probably because there’s less concentration of glucose in the blood at lower values. And so the enzyme on the little sensor that’s actually measuring glucose has less to work with. And so the sensors are getting more and more accurate at lower values as time goes on. But just another thing worth mentioning, that it may be physiology, but it may also be the hardware itself. And so if you’re ever worried about low glucose, I think it’s always good to finger prick and just like double-check, if you’re super concerned about that. great
[00:58:34] Ben Azadi: Great answer. When do you think there’s going to be a continuous ketone monitor?
[00:58:40] Dr. Casey Means: Oh man! I’m waiting. I am very excited. There are a lot of really smart groups out there who are working on multi-analyte sensors. And I think that’s really, that is the future. Being able to know your ketones in relation to your glucose and then one day maybe a continuous insulin sensor.
[00:58:56] Ben Azadi: Oh my gosh, I can’t wait.
[00:58:58] Dr. Casey Means: Yeah, I think that a continuous glucose monitor gets us at least 75% of the way there. But having some of those other analytes would be fantastic. Having continuous inflammation monitoring and things like that. But the ketone thing is great because ultimately, one of the big goals of using a technology like this is that, if I can keep my glucose spikes low I can assume that I’m keeping my insulin exposure low. And I am regaining insulin sensitivity. Each day that I put in reps to keep my glucose stable. I am essentially, building insulin sensitivity and I’m also keeping my insulin exposure low, which means that, I know that Keto Kamp people know this. And you talk about this a lot on different podcasts, but for fat to be used as fuel in the body and for us to use fat as an energy source and be metabolically flexible, insulin has to be low. And as you use those fat burning pathways more and more, they get stronger and you become more efficient at using them. And so, I really like to think of this as – by having good days on CGM, you are getting, it’s just like working out. You are getting reps in to build your metabolic fitness. And when you are building your metabolic fitness, it means that you’re keeping your insulin stable and you are tapping into fat burning pathways more effectively. And then, in different times of energy substrate availability, like a fasted state, or you’re exercising in a low glucose environment, or you are doing keto, that you’re going to be able to flip-flop back and forth between burning glucose and burning fat.
And the average person walking around in the United States, I don’t think, has the capability of doing that very efficiently because we have been so exposed to such readily accessible food sources that spike glucose. Refined carbohydrates, refined sugar, at just astronomical levels in our foods that we haven’t really needed to tap into our fat burning sources cause insulin is always there to basically, utilize the glucose for fuel. So it’s a fun way to get your reps in and every day, you get a green circle, on our app, is like a day that you can assume that you have put in a good metabolic flexibility rep.
[01:01:00] Ben Azadi: That’s awesome. Yeah, so if you’re somebody who gets really inspired and motivated by those numbers, this could be something that’s a really cool tool to hold you accountable. So Katherine wants to know if insurance covers the, if you’re not diabetic or pre-diabetic
[01:01:13] Dr. Casey Means: Right now, it doesn’t. Yeah, so insurance does not cover this for off label uses, which is really unfortunate. A big part of our effort, moving forward, is clinical research that’s going to hopefully show the efficacy of this for a non-diabetic population. And also, that this is a really cost-effective tool for keeping people healthy. So our mission is to reverse the trend of metabolic dysfunction in the United States. And part of that is going to be producing the research that shows that this is effective. And ultimately, as we move towards more of a value-based care in our healthcare system, where we’re trying, where we’re incentivized to keep people healthy, I think this is going to emerge as a really big tool. But it’s going to take research and cost efficacy data showing that, for payers to really understand the value of this. So it’s very much on our roadmap to help move that ball forward so that everyone can have access to this. At the current price point of buying out of the pocket, it’s not accessible to everyone, but it should be. And our goal is to make it get to a price point where it can be.
[01:02:15] Ben Azadi: Yeah, so Katherine, they’re working on it. Right now the answer is no, but that’s subject to change. David, who is in my, he’s an amazing member here, he’s type 1 diabetic. Here’s what he wrote, “After becoming fat adapted I no longer have convulsions associated with extreme lows. I now find that my blood sugar of 45 – 60 seems okay. Is it better for ketosis and A1C to operate at these levels or would be lowering basal basil insuin be better? Is there an optimal blood sugar and/or basal rate?
[01:02:42] Dr. Casey Means: Ooh, great question, David. And also, congratulations on your journey and gaining fat adaptation capabilities. And, I am going to defer on this one because I think this is getting very much into the realm of medical and it would probably be a better question for chatting offline with your doctor. But I will say, it is not well known whether living in a blood glucose of 45 – 60 is optimal for health. I don’t have an answer to that question. And that’s a question that I want answered because we see a lot of people, including myself, going into the 50s and 60s. Not infrequently. And I don’t have a clear answer on whether that is safe or healthy, but we do know from large population studies that many healthy individuals, wearing CGM, will drop into the 50s and 60s during a 24-hour period. That’s actually, totally normal on CGM. But what the health outcomes of that are, it is not known. And I think it makes sense because non-diabetic individuals or lower glucose values have not been studied as much, cause they’re not necessarily considered pathologic and we’ve been dealing more with the issue of high glucose. And yeah, ultimately don’t have a clear answer for that.
[01:03:57] Ben Azadi: Okay, yeah, I align with your answer by the way. So Dr. Casey, this has been such a fun, fascinating interview and I can’t wait to do it again and geek out some more because more things are going to arise and more questions will come from me. So we’ll do this again. Where is the best place, besides Levelshealth.com, if you want to get added to the wait list, where else can they go check out some of your work?
[01:04:18] Dr. Casey Means: Yeah, check out @unlocklevels on Instagram and Twitter. And especially for the keto folks, check out Levelshealth.com/blog. Cause we’ve had some people use CGM who we’ve interviewed for the blog and showing how to use CGM to enhance keto, and what I would call Keto2.0, which is glucose informed keto diets. There’s some really interesting stories on there of people following a strict keto diet who actually really liberalized their keto diet from using CGM and learning that certain foods, that were off limits, actually didn’t spike their glucose or kick them out of ketosis. So check that out. Levelshealth.com/blog, @unlocklevels for Twitter and Instagram.
And for me personally, you can find me @Drcaseyskitchen on Twitter and Instagram. So D R Casey’s kitchen. And I’m actually vegan and fairly high carb in my diet. So I write a lot about, basically metabolic awareness and CGM results on a very personalized plant-based diet and how I’ve used CGM to craft a plant-based high carb diet that essentially, keeps my glucose completely flat. All the time. And I think that’s a whole area of the plant-based world and veganism that’s going to be exciting. So Vegan2.0. Really shaping a plant-based diet that doesn’t have the collateral damage of huge glucose spikes that probably a lot of plant-based people are dealing with right now. So @drcaseyskitchen, check it out and I would love to hear from you.
[01:05:40] Ben Azadi: Yeah, so we’ll put all of the links and the resources that Dr. Casey just mentioned in the notes of the podcast and the down below in the YouTube video. I love that, you said that you’re fairly high carb, you’re about 100, you said a 100 or 200 grams of carbs per day. That’s, in the American standard, American diet, considered a low car, but to us, the keto folks, is considered high carbs. So let’s put that in perspective. And you’re doing it in a way that’s very unique because you’re testing. And you’ve tested which plant-based foods work with your physiology, like you said offline, versus which plant-based foods do not. Most vegans are not doing this. So you would have, if you could get on the Rich Roll podcast, that would be such a fascinating topic because you could definitely educate a lot of his listeners on how to do this the right way. I want to acknowledge you and say, I love your energy. You’ve got great energy. Your story’s amazing because you went from the medical world, the conventional medical world, to thinking outside the box. And you’re impacting a lot of lives. And I’ve been really fascinated with my CGM and thank you so, so, much for sending it my way. And I look forward to doing this again, the Keto Kampers are saying, “Excellent. We live in an extraordinary time. I just signed up for your list. Thank you to both of you.”, they’re showing some hearts. So I’m grateful for your research and your energy and I can’t wait to do this again. And thank you so much for coming on the show.
[01:06:53] Dr. Casey Means: Thank you so much. It was so fun to chat with you. And I am so grateful for the work you’re doing to help people become healthy. And creating such culture around it that’s so positive and inspiring, and I just really enjoyed this conversation. Thanks so much for having me on.
[01:07:12] Ben Azadi: I hope you enjoyed that interview with Dr. Casey. If you want to watch the video version of this interview, head to youtube.com/ketokamp, and you can check out the interview. I show my CGM that I’m wearing during that interview as well. Be sure to check out the links and the resources down below in the podcast notes. Again, if you want to skip the line of 26,000 people currently on that waiting list, to be added to the front of that line as a Keto Kamp podcast listener, you can do so. We worked out a special deal for you. Head to levels.link/ketoKamp, that’s camp with a K. We also put a link for that down below in the notes of this podcast. Please leave the show a rating and review if you didn’t do so already. When you do, take a screenshot, email it to [email protected] and I will sign and send you a paperback copy of my bestselling book. That is [email protected], United States only.
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