How to Use Glucose as a Continuous Health Marker for Metabolic Health With Dr. Casey Means of Levels
Dr. Casey Means know’s the body inside and out. Now, she’s attempting to bring that sense of holistic understanding to everyone. Truly knowing your body involves more than being aware of what food you put into it, and how often you exercise. It’s about knowing how those foods and choices impact you personally, and the other lifestyle triggers that might be holding you back from optimum health. As a guest on The Wellness Mama Podcast, host Katie Wells got the lowdown from Dr. Means on how glucose impacts the body, why exercise-driven glucose spikes are good for you, and how to actually train your body to burn fat without resorting to questionable diet hacks.
09:56 – Why is everyone so chronically inflamed?
Most chronic diseases are a form of chronic inflammation. Instead of treating them with surgery and steroids, we need to step back and ask ourselves why. It comes back to our daily lifestyle choices around food, sleep, exercise.
“It was about four and a half years into my surgical training when I had this fairly major realization that almost all of the conditions I was treating were, in some way, chronic inflammatory in nature. It was sinusitis, thyroiditis, inflammatory masses of the airway, chronic ear infections, and so much of these conditions were fundamentally rooted in some way that the immune system was getting revved up and causing inflammation that ultimately led to the pus build-up of sinusitis or the auto-immunity of Hashimoto’s thyroiditis. And then we treat with medications or steroids. And I really sort of stepped back and asked myself, why is everyone so chronically inflamed? And why am I reaching for my prescription pad to constantly prescribe steroids?…so much of this threat that our immune system is sensing is really caused by our exposures and our choices that we make every day, like the foods we’re exposed to, how much sugar we eat, how much chronic stress we have, whether we’re sedentary, how much sleep we’re getting, how’s the quality of that sleep, and the environmental toxins we’re exposed to and micronutrient deficiencies, all of these things are really the exposures that lead to this chronic inflammation.”
12:02 – The lowest hanging fruit
Controlling blood sugar through diet is the easiest way to massively improve the health of our population at large. This cannot be done with a single doctor’s visit in a year; the intervention has to be embedded in daily life.
“It’s not that a 15-minute conversation with the doctor is necessarily going to really be the thing that can transform a lot of these behaviors. I really do think it has to be something that is embedded in someone’s daily life. And all of this got me really focused intensely on metabolic health because when our metabolism and specifically our blood sugar is out of control, it can directly drive inflammation and impair all aspects of health. And then on the flip side, controlling our blood sugar is like a superpower. It can improve energy, it can improve memory, endurance, sleep, mood. It can also, of course, ward off future metabolic diseases that range from diabetes to obesity, to cancer, to dementia, to infertility, to erectile dysfunction, to fibromyalgia, to chronic liver disease. All of these things are related to metabolism and blood sugar dysregulation. And if we could just control it upfront, we could really make a big dent here. So to me, getting blood sugar under control just seemed like the lowest hanging fruit intervention we could do to massively improve the health of individuals and the population at large.”
14:40 – We are getting the medicine but not the support
The five factors of optimal metabolic health are blood glucose, triglycerides, cholesterol, blood pressure, and waist circumference. When any of these are off, we get medication. But what we need is better support.
“In this particular study that was done out of UNC, they were looking at defining optimal metabolic health as having optimal levels of five factors. So those were blood glucose, triglycerides, high density lipoprotein cholesterol, blood pressure, and waist circumference without the need for medications. So if people had all of these things in the optimal range, they were considered metabolically healthy. And only one in eight Americans met that criteria. These are simple tests to do, right? It’s just measuring your waist circumference, blood pressure, getting your cholesterol checked, and making sure you’re getting your glucose checked. And those are all things that are simple and important to do. But then the question is, if one of these is off, how do we move it in the right direction? And I think that’s where we really struggle. We often are prescribed either a statin for the cholesterol or medication for the glucose or an antihypertensive medication for the blood sugar. But we’re not really getting the support we necessarily need to actually change these things from the inside out.”
16:45 – We should test for health instead of testing for disease
We can test glucose levels and have a wide range of criteria for what indicates diabetes. But we don’t have a standard for what is “healthy,” because we are not testing healthy individuals.
“So standard criteria by the American Diabetes Association is that to be a normal, non-diabetic individual, you need to have fasting glucose that’s less than 100 milligrams per deciliter. The second criteria are what’s called an oral glucose tolerance test. And this is a test where you drink 75 grams of glucose, a standardized drink, and then they check your glucose over the course of two hours after that drink to see what happens for your glucose. And if your glucose goes up after that drink, but at two hours, you’re less than 140 milligrams per deciliter, you’re considered to be normal. If your glucose is 140-200 two hours after that drink, you’re considered pre-diabetic. And if you’re above 200 two hours after that drink, it’s considered diabetic. And then there’s the third test. That is the hemoglobin A1C, which is a marker of basically three month average of glucose in the blood. It’s a blood test and it’s basically, what they’re looking at is your red blood cells and how much sugar is actually stuck to your red blood cells. That’s called glycated hemoglobin. If the percentage is less than 5.7% of glycated hemoglobin, it’s considered a normal A1C. If it’s between 5.7-6.4%, it indicates prediabetes, and 6.5% or more indicates diabetes. So these are kind of like the standard criteria. The question is what should we actually be shooting for if we want to be as healthy as possible? And that I think is actually very different ranges, but we don’t have a standardized opinion in healthcare on this. And I think that’s largely because non-diabetic individuals haven’t really been testing their glucose very much in the past.”
23:11 – The dawn effect
When we wake up, our body releases cortisol to wake us up, which tells our liver to release stored glucose. This is the dawn effect. It’s much more pronounced in people with high cortisol or insulin resistance.
“When we wake up, our body actually releases a surge of cortisol, traditionally known as our stress hormone. And the purpose of this is to get us to open our eyes and get out of bed. And it tells our body it’s ready to go. It pushes our body to get started. But what cortisol also does in the body is it actually tells the liver to mobilize glucose. We have been evolutionarily wired to respond to stress hormones, like cortisol and other catecholamines, by dumping some of our stored glucose from the liver into the bloodstream. Because traditionally, if we were having a stressful event, you can think way back to old times, that example of like we were probably being chased by a lion, we needed glucose to feed our muscles, to escape whatever stressful threat was happening. So we are wired to respond to stress hormones by releasing glucose to basically fuel us, to get us to move. So that’s actually a fairly normal response. The dawn effect, we see it much more pronounced in diabetic individuals who are very insulin resistant. So because their cells are extremely resistant to insulin, that effect of glucose in the blood is going to look a lot larger, because they’re not going to be able to take it into the cells as easily since they’re insulin resistant. So you see a much smaller dawn effect in non-diabetic individuals and there’s some evidence that the bigger the dawn effect, the more we’re either dealing with problems of too high cortisol or maybe some underlying insulin resistance.”
26:24 – The different spikes in glucose
Muscles have an insulin-independent way of soaking up glucose. Your body releases stored glucose during high intensity workouts, which causes spikes in blood sugar. This is different from the spikes from eating high-carb meals, which need insulin to be broken down.
“Even as our favorite Peleton or lifting workout, that is still actually going to generate a stress signal in the body. The body will release cortisol and it will release other catecholamine hormones to drive the body to be able to respond to that stimulus. And so that is going to tell the liver, okay, there’s a stressor, it’s an exercise, get that glycogen broken down into glucose, get it into the bloodstream. And so that actually can be a sign that you’re having a high-intensity workout. And to some extent, I actually now look at my spikes during workouts as a measure of how intense I’m going. It’s almost like biofeedback about whether I’m pushing myself hard and there’s evidence that those spikes are not actually maladaptive. So glucose spikes after food are going to create one pathway of physiology where you eat the high carbohydrate meal, glucose is broken down and is in the bloodstream. That’s going to cause the body to release insulin to help the body essentially take up this glucose into the cells. And that’s one process. But with exercise, it’s very different. The body’s mobilizing stored glucose for an actual need. And the muscles, interestingly, actually have an insulin-independent way of taking up glucose just by the sheer movement of the muscle fibers contracting. These cells can actually take up glucose, independent of insulin. So it’s a very different physiologic pathway and high-intensity workouts are pretty universally shown to improve insulin sensitivity over time and improve our metabolic health over time.”
29:20 – Why you shouldn’t carbo-load during a workout
In a fasted workout, the body starts burning fat to produce energy. If you eat carbs during the workout, the body continues to burn the carbs and stops burning fat.
“Let’s say you’re working out in a fasted state. You’re doing an early morning workout. You haven’t eaten any carbohydrates and you get this glucose spike with a high-intensity workout that’s coming from within your body because you haven’t eaten anything. So you’re actually clearing out that stored glycogen and moving towards that point when you’re not going to have glucose in the body to really be able to mobilize for your activity, and you’re going to have to transfer into fat burning. So when we run out of that glycogen, as we empty that tank, we start to increase our fat burning percentage. And the more we do that and get into that place where we actually have to tap into that fat for energy, the more we’re going to build that metabolic flexibility. That is so good for health, that ability to flip-flop between glucose and fat. And you can imagine if you’re eating glucose during a workout, you’re eating Gatorade or gels or whatever, and you’re replenishing that glucose, you’re not going to empty the tank. You’re going to keep providing your body with this glucose energy and not going to need to tap into that. And so I would say it’s great to be able to see that on a monitor when you’re working out to really know like I am working through this glucose. And that means that I am going to start burning more fat, and that we know is great for health.”
33:58 – How to burn fat without working out
When we keep our blood sugar spikes low consistently, our body becomes highly insulin sensitive, burning more glucose. Since insulin blocks fat-burning, low insulin will help us keep burning fat.
“I like to think of it almost like working out. Like we go to the gym and we lift weights so that we can become stronger. We do the reps to build muscle and we have to do the reps with our metabolism to get a stronger, more insulin sensitivity. And the way that we do the reps with our metabolism, as we keep our spikes low day after day, week after week, our cells perk up again. And they start hearing that insulin signal more robustly. And you need to basically then produce less insulin to get the same amount of glucose. And then that glucose can start falling again. The added benefit of that is that another function of insulin other than taking glucose up into the cells is that it also blocks fat burning. When insulin is high, it actually tells our body to not burn and break down fat for energy, because it’s a signal that the body has tons of glucose on board. So it doesn’t actually need to use the fat. So as we get more insulin sensitive, we build our metabolic fitness. We bring our insulin down, we can allow our bodies to tap into those fat-burning pathways more and we can start to lower our glucose levels.”
41:25 – Carb in the mouth is not necessarily glucose in the bloodstream
The study conducted at Weissman has proven that everyone responds to carbohydrates differently depending on a variety of factors. Key factors in metabolic health include microbiome composition, body type, sleep, and movement, among others.
“This was laid out in this fabulous paper that was published in cell a few years ago by the Weissman Institute of Science called Personalized Nutrition by Prediction of Glycaemic Responses, where they put continuous glucose monitors on a bunch of healthy non-diabetic individuals, and then gave them standardized meals and saw what happened. And based on the more glycaemic index philosophy, you’d think everyone responds the same, but it was just all across the board. So what might be a very metabolically healthy choice for one person was not for another person. And then they looked at what were the factors that actually went into predicting how someone responds to a particular carbohydrate. And some of the key factors were things like microbiome composition and body types, anthropomorphic features like how much visceral adiposity people had, how much visceral fat, which is a signal of how insulin sensitive someone is. And even some things like sleep and movement had an impact. And so really how I like to think about it is like a carb in the mouth is not necessarily glucose in the bloodstream. There’s a lot that has to happen between when it goes in the mouth and what actually happens to the blood that can really be very, very different.”
45:02 – Ways to modulate the carbohydrates for metabolic health
Food sequencing, food pairing, food timing, exercising after a meal – all of these affect how we process the food we eat.
“Food that’s eaten earlier in the day during daylight hours tends to have a lower glucose response than food eaten after dark. And you alluded to this with the late-night eating and this really comes down to melatonin. We release melatonin at night to help us prepare for bed from the pineal gland. And this hormone actually tells the pancreas to produce less insulin. So, for the same amount of carbohydrates, after dark late at night we’re going to probably see a bigger glucose bump, because we have less insulin circulating and so it has less ability to get that glucose up into the cells. So there are just so many ways to modulate the carbohydrates, to make them more amenable to our particular metabolism. And it really comes down to food sequencing, food pairing, food timing, and then there’s just a number of other adjuncts that you can try as well. You can exercise or walk after a meal. Just a 20-minute walk after a meal can lower glucose responses. Making sure you’re eating in a mindful way and not when you’re stressed, that can actually have a really big impact on how we process the food.”
58:54 – The micronutrient aspect of metabolic health
The nutrient density of our diet has a big impact on long-term metabolic health. Micronutrients like vitamins and minerals help mitochondrial function and insulin signaling, impacting long-term metabolic health.
“When we think about metabolic health, we think about fat. We think about carbohydrates. We think about protein. But there’s actually this whole other story that is fascinating to me, which is the micronutrient aspect of metabolic health. And this is looking at nutritional co-factors, vitamins, minerals that are actually involved in our mitochondrial function and our insulin signaling. All of these metabolic pathways in the body are really just chemical reactions that are happening inside the cell where different substrates are converted to downstream products by enzymes. All of these enzymes require nutrient cofactors to function properly. Some of the key ones for metabolic health are things like zinc, magnesium, manganese, B vitamins, vitamin D, and omega-3 fats. These are required for proper metabolism. And actually, when you get into these biochemistry cycles, like the Krebs cycle that converts glucose to energy and fat to energy, you actually can see why these enzymes require these things. And so I think it’s not actually talked about enough that really the nutrient density of our diet actually also has a big impact on long-term metabolic health and making sure that all these molecular engines are running smoothly.”
1:07:27 – Revolutionary books about health
Dr. Means shares some of her favorite books about health, each of which has influenced her journey and the way she thinks about holistic medicine.
“So many books have really moved the needle in my life. And I would say particularly on the topic of metabolic health, there have been some authors that have totally changed the trajectory of my medical career. So the ones I would shout out would be Mark Hyman’s The Blood Sugar Solution, an amazing book that looks at all the different factors that go into our metabolic health really holistically. I would say Dr. Sara Gottfried’s The Hormone Cure, Ben Bikman’s Why We Get Sick, an incredible book about how insulin resistance is really at the root of the majority of the chronic health conditions we’re seeing today. I would shout out Jason Fung’s The Obesity Code and The Diabetes Code, both of which talk about why the ‘calories in calories out’ model that we’ve thought about with weight loss just really doesn’t make sense. There’s much more hormonal nuance to it with insulin, and we have to get our insulin down if we want to actually tap into fat burning and weight loss. I would say Joel Fuhrman’s Eat To Live, which is really about plant-based nutrition and a high nutrient density diet. Cyrus Khambatta’s Mastering Diabetes, David Sinclair’s Lifespan. And I have to throw in Michael Greger’s How Not To Die and his second book, How Not To Diet. When I was in my medical training, my surgical training, I would be listening to a lot of these books that are just really revolutionary in terms of thinking about health.”
Katie Wells: [01:12:47] I love it. This has been so information packed and so helpful. I will make sure that all the links, I know you guys have articles on a lot of these things, and of course the link to find out more and keep learning from you guys. But this was really, really fun, I enjoyed it, I’ve learned so much from Levels and so much from this interview. And Dr. Means, thank you so much for your time.
Dr. Casey Means: [01:13:05] Thank you so much for having me, I hope you have a great day.
Katie Wells: [01:13:08] And thank you guys, as always, for listening, for sharing your most valuable resource, your time with both of us today. We’re so grateful that you did, and I hope that you will join me again on the next episode of the Wellness Mama podcast.
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