Podcast

Metabolic Heath and Better Living for Everyone on The Inc. Tank

Episode introduction

Dr. Casey Means was a Stanford-educated ENT surgeon when she realized that the healthcare system was due for an upgrade. Her patients were suffering from chronic inflammation, but doctors were treating symptoms instead of finding root causes or prevention methods. Her search for answers led her to co-found Levels Health, a continuous glucose monitoring device and analytics platform. By tracking user’s food intakes and resulting glucose levels, Dr. Means hopes Levels can provide actionable insights into individual diet and health needs. Levels also aims to help doctors provide preventative care for healthy patients by identifying early signs and data-driven actions to avoid metabolic dysfunction diseases. In this episode of The Inc.Tank with Christina Elson, Dr. Means talks about the harmful link between COVID & metabolic diseases, the how and why of inflammation, and why your healthy breakfast might be tiring you out.

the inc tank podcast

Show Notes

Show Links

Key Takeaways

1:18 – Chronic diseases & COVID outcomes

When COVID combines with a metabolic-linked disease, the immune system response is pushed into dangerous overdrive.

“When you have diabetes or obesity or heart disease or even dementia, we know that there’s actually this unregulated immune response. The body thinks there’s some sort of threat there. These diseases, obviously, aren’t a normal state for the body and we tend to have circulating molecules in the body called cytokines that tell the body, ‘You’re in threat. We need to really activate the immune system’. And why this was super relevant for COVID is because it’s not actually the COVID virus that kills people. It’s our immune response to COVID – that overwhelming immune response – that causes disastrous health outcomes, like acute respiratory distress syndrome. That’s the body dumping all this fluid and all these immune factors into that tissue and causing the problems. And so when people have an underlying pro-inflammatory state with chronic disease, and then you add on the insult of a virus, you kind of get this extreme magnitude of response to the virus that actually worsens outcomes.”

6:40 – The dangerous rise of ‘Frankenfoods’

Why is America struggling with metabolic dysfunction? Dr. Means points a finger at the increase in highly processed, highly refined food products.

“What we see when we walk into the grocery store are food-like substances that are not actually real food. By and large, these are highly processed, highly refined, nutrient-depleted imitations of food. And that’s the majority of what we’re seeing in grocery stores. But because it’s so pervasive and it’s so widely marketed, I think many of us have actually come to believe that this is actually food. This is actually going to somehow build a body that works, but that’s actually not true. These food-like substances, Frankenfoods that I like to sometimes call them, basically anything you’re finding in a box that was made in a factory that’s like stripped of its real nutrient density – this is not the types of products that’s going to go in and build a body that’s highly functional.”

9:08 – Getting to know your health up-close

No more doctor’s office surprises: biowearable can help users pinpoint and correct potential health issues pre-diagnosis.

“It’s not like one day we’re non-diabetic and the next we are. These are conditions that develop over years, if not decades, these days actually starting in childhood. And because of the way we’ve organized diagnostics, it almost leads people to believe that they’re fine until the day that they’re not. And I think if we really expanded the way we think about diagnostics, and understood our bodies on a deeper level and on a spectrum, we’d actually come to realize that we have so much time to actually intervene far before that day when you walk into the doctor’s office and get a big surprise. And that’s actually one of the reasons I’m so excited about so much of the direct-to-consumer lab testing and the biowearable movement, because for the first time ever people have access to data that they own that can tell them where they fall on the spectrum of health or disease, and let them take action.”

11:18 – Following the healthcare money

A fee-for-service healthcare system encourages a focus on treatment and intervention – at the cost of preventative care.

“Our traditional healthcare economic system has actually really struggled with this concept of the value of prevention, because we have largely been for many years a fee-for-service healthcare system. Which means that a doctor in a hospital is going to get paid by an insurance company or a patient if they do something. You get paid for action. And you don’t need to take a lot of action with a healthy person necessarily. And so there is sort of a bias towards if I need to do action to get paid, I’m going to probably focus on the people who need more actual intervention, which is the people who have already gotten sick. It doesn’t actually pay to just do nutritional counseling or having a long health maintenance conversation with a patient. So it hasn’t traditionally been where we focused our energy.”

15:12 – Taking health ownership home

Levels’ CGM tool empowers users to make independent health decisions by providing accessible insights and glucose biofeedback.

“We are leveraging continuous glucose monitoring technology, which has traditionally been a tool used as a monitoring tool for diabetic individuals, so that they can track their glucose 24 hours a day at home for management of their disease. And we’re making this technology mainstream to everyone as a wearable that can be used to give you real-time biofeedback about nutrition. So for the first time, you can actually eat a meal and say, instantly, ‘Was this meal good or bad for me? Should I eat this or should I not?’ And that’s very exciting…So the whole wearable movement is just a huge step forward and letting people be empowered with their own health information to make the decisions that ultimately generate health. We’re moving things out of ‘health happens in the doctor’s office’ and we’re moving it towards health actually happening in the home with the choices that you make every day.”

19:30 – Diet and energy levels are intimately linked

Levels’ CGM technology tracks both diet and corresponding glucose levels – showing users exactly how their food choices impact their day.

***“*What we want for our glucose levels in our body is to be fairly flat and stable throughout the day. And without that data, it’s really hard to know when people see what’s happening after they eat something and what their glucose response is. It can be a profoundly interesting experience for people. And it does get into what you said, is it actually loops into people better understanding their subjective experience of their health and their day. So here’s an example. People might eat some oatmeal in the morning. They might have oatmeal every morning with some berries or maybe brown sugar. And they might always be the type of person who mid-morning has a little bit of a mid-morning slump, needs an extra cup of coffee and was feeling a little lethargic by around 11:00 AM or getting really hungry for lunch by then. And so then you put a continuous glucose monitor on and that person might see that their glucose started at 80 milligrams per deciliter, a normal, and then shot up to 200 milligrams per deciliter, which was like a huge spike, and then came crashing down. And then that’s exactly when they felt tired in the morning. All of a sudden there’s so much power that’s unlocked there. First, you realize, Oh, this tiredness I’m feeling is not a mystery. It’s not because I didn’t get great sleep. It’s not because I’m stressed. It’s not because I didn’t have coffee. It’s because of the oatmeal.”

22:50 – Pursue treatment, not bandaids

As an ENT surgeon, Dr. Means realized doctors were only treating symptoms of inflammatory illness – and ignoring the triggers of the disease itself.

“Almost every condition that I’m treating as an ear nose and throat surgeon is chronic inflammatory in nature. So it’s chronic sinusitis, chronic ear disease, chronic thyroiditis cancers, vocal cord granulomas, which are inflammatory masses of the vocal cords. All of these things are essentially the immune system rubbing up in these tissues causing blockages and then like pasta building up, for sinusitis and ear disease and whatnot, or chronic inflammation creating inflammatory masses. With cancer, we know there’s a lot of overlap with sort of immune dysregulation and how cancers become unchecked and grow. And so I started thinking, really why is everyone so chronically inflamed? Why are people getting these heavy doses of steroids, which we were prescribing for everyone….And it’s like, these are all medications that tamped down the immune system. And that can be helpful for a little while, but it doesn’t actually fundamentally change what’s generating the chronic inflammation. It quells it, but it doesn’t actually change what the triggers are. And same with surgery.”

25:45 – Choices are greater than prescriptions

Sugar shows up as a driving force behind chronic illness – and reducing consumption may be as good a treatment as meds.

“It comes right back to those environmental exposures: the toxins we’re exposed to, the things we’re eating, how little or how much we’re moving, our sleep quality, how much stress we have in our lives. These things can trigger inflammation. And a big piece of that, in terms of what we’re eating, is that sugar is a huge driver of inflammation in the body. And these chronic conditions like we talked about earlier can generate a pro-inflammatory state in the body. So actually on the Venn diagram of just these ENT conditions, if you draw the Venn diagram with all these other chronic conditions we’re seeing – like diabetes, obesity, dementia, heart disease – the same immune chemicals, the cytokines are unregulated in all these diseases. So there’s something going on underneath all of this that’s sort of driving this state that we’re in. I think a lot has to do with the metabolic system and the blood sugar and a lot of these other things I mentioned. And so that just really was a profound realization for me. Why are we reaching for our prescription pad, reaching for our scalpel when we’re really not addressing potentially some of this low hanging fruit of the choices we’re making and the exposures our bodies are seeing?”

28:50 – Getting personal with glucose levels

Studies show that healthy food choices aren’t one-size-fits-all, and glucose responses are custom-fit.

“Every single person responds to food differently in terms of how much it spikes their glucose levels. We are such complex systems and a carbohydrate in the mouth doesn’t necessarily mean glucose in the bloodstream. Typically we think like carbs are essentially glucose, but actually, there’s a lot of processing that happens between the mouth and the bloodstream that is different between people. And so there’s a really interesting study that came out about five years ago from the Weizmann Institute in Israel, it was published, called Personalized Nutrition by Prediction of Glycaemic Responses. And they put continuous glucose monitors on a bunch of healthy people, gave them all standardized meals, the exact same meals. And then they looked at their glucose and they found that you would expect everyone to have the exact same glucose response. They’re eating the same food, but it turned out that it was all across the board.”

30:31 – New me, new glucose levels

Daily changes in sleep, stress, and movement can change the way your body responds to glucose.

“The second crazy thing is that it actually probably changes day to day for our own bodies. So a banana for me on Monday could actually have a different response than a banana on Tuesday, based on other factors that affect metabolic health.  I’m under more stress and I’ve had poor sleep and I haven’t exercised, that food might significantly spike my glucose more than it would the day prior. So it’s really all about learning what these different levers are for your own body to keep glucose stable, whether it’s the food choices or the other mitigating factors like sleep and exercise and stress management, and then just really building this comprehensive holistic metabolic awareness. So, what is actually right for you?”

31:53 – Eyes on a (system-wide) change

Dr. Means has a clear vision for a changing future: lowered metabolic disease rates, increased preventative care, and at-home tools to optimize your own health.

“If there’s one thing I would like to see change, it is a massive reversal of our metabolic disease epidemic. And I think it’s possible. We should not have 72% of people in our country suffering from obesity or being overweight. When many of these people are going on diets every year to try to mitigate this and to improve this, and it’s not working well. We should not have 34% of our country with diabetes or pre-diabetes. And I think we’re gonna start to see a movement in this area because people want to live healthy lives. And currently though, we don’t have the time with our doctors to really dive into the root causes of these conditions because of the way the system is set up. And we don’t have access to measurement tools that can actually help us track and optimize these conditions. But both of those things ideally will be changing as we move towards a system where people do have more access to their own personal data and optimization tools, and more of a value-based system where we invest more in prevention.”


Episode Transcript

Dr. Casey Means: [00:00:00] Health actually happens in the home with the choices that you make every day.

Female Speaker: [00:00:05] Welcome to The Inc. Tank, where we explore the impacts of leading edge technology on business and society.

Christina Elson: [00:00:13] Welcome to The Inc. Tank. I’m your host, Christina Elson, and I’m joined today by Dr. Casey Means. She’s the Co-founder and Chief Medical Officer of Levels Health.

Today, we’re going to talk about the role that metabolic health plays in warding off chronic diseases and we’re going to talk about Casey’s role transitioning from a traditional medical doctor into functional health and working to bring this product, Levels, to consumers to help them think about managing their metabolic health.

So Casey, thanks so much for joining me today in The Inc. Tank.

Dr. Casey Means: [00:00:52] Thank you so much for having me, Christina.

Christina Elson: [00:00:55] Let’s start off with the idea of why the lack of overall health among Americans might be contributing to a higher COVID impact. So first of all, what is the health issues that we’re already struggling with going into this pandemic and how could they be contributing to what’s happening with us and with this disease?

Dr. Casey Means: [00:01:19] It’s a great question and it’s such an important one. We’re dealing with a major chronic disease epidemic in our country. We are seeing rates that are just astronomical of lifestyle related chronic diseases. So in our country right now, we have 72% of Americans who are overweight or obese. We have 128 million Americans with pre-diabetes or diabetes. So right now 13% of the US population has Type 2 diabetes and there are 84 million Americans with pre-diabetes, and of the people with pre-diabetes, of those 84 million Americans, 90% don’t know they have it. So we’re just walking around with these chronic illnesses that are affecting every aspect of our health and many of us aren’t quite aware of it and it has a huge impact on all aspects of our health, including our propensity to develop infectious diseases. So diabetes, obesity are big ones. Other, big hitters in our country would be obviously cancer, heart disease, dementia and so how this relates to COVID is quite profound.

We knew from very early on in the disease back, even in March, that diseases like cardiovascular disease, heart disease, diabetes, and obesity, all significantly increased our risk of having a worst course or death from COVID and I actually published a paper back in April in the journal Metabolism talking about some of the mechanisms that linked diabetes to worst COVID outcomes, and even that early in the condition, we understood quite a bit about this physiology and just to  outline a few of those things, diabetes, which is a state of high blood sugar – that blood sugar can actually directly impair our immune cells to function properly. So that blood sugar almost stuns our white blood cells, our immune cells to do what they’re supposed to do. White blood cells have to move through the body and they have to engulf other cells that are infected and they actually can’t do that properly when blood sugar is extremely high. And so that’s, a direct mechanism.

There’s also really interesting, more nuanced stuff where people with diabetes actually have increased receptors on their cells called ACE2 receptors. And we found out early in the disease that COVID viruses actually bind to the ACE2 receptor to get into cells. So people who had this, upregulation of this receptor on their cells potentially had more likelihood of those viruses being able to actually infect their cells.

We also know that people with diabetes have higher blood sugar in their lung fluid. Some of that sugar actually goes into the lung fluid and that seemed to be associated with the virus having an easier time replicating in the respiratory tissue.

And then the last one that’s interesting and very relevant to a lot of chronic diseases is that many chronic diseases are actually known to be associated with chronic inflammatory state. So people have upregulation of our immune threat signal. When you have diabetes or obesity or heart disease or even dementia, we know that there’s actually this unregulated immune response. The body thinks there’s some sort of threat there. These diseases, obviously, aren’t a normal state for the body and we tend to have circulating molecules in the body called cytokines that tell the body you’re in threat. We need to really activate the immune system. And why this was super relevant for COVID is because it’s not actually the COVID virus that kills people. It’s our immune response to COVID, that overwhelming immune response that causes disastrous health outcomes, like acute respiratory distress syndrome. That’s the body dumping all this fluid and all these immune factors into that tissue and causing the problems. And so when people have an underlying pro-inflammatory state with chronic disease, and then you add on the insult of a virus, you get this extreme magnitude of response to the virus that actually worsens outcomes.

So those are just going through four mechanisms of why this happens, but it’s very real and anything that we can do to improve our underlying health and our underlying disease status is likely going to help us with our immunity and our resilience if we actually are infected with this virus or really any virus.

COVID is not the first virus to discriminate against people with chronic disease. Even in the standard flu, people with underlying conditions have between four and five times increased rate of being hospitalized for something like the flu. So this is not a new thing. These conditions have a wide effect on immunity and that can impact lots of different viruses.

Christina Elson: [00:05:47] That’s such a great point and our diet in many times does have so much sugar. And then also people can get into health states where they feel like this is the normal state for them, so maybe they stopped noticing the inflammatory aspect, maybe they don’t feel as good as they could. But do you see that it’s hard sometimes for people to see or understand how food is affecting them or how the current state that they’re in is not really the optimal state? And why is it hard for people to self-diagnose or get this information or be able to understand what they’re really feeling and what’s going on with them physically?

Dr. Casey Means: [00:06:26] One factor is very much the food and nutrition culture. What we are told is normal, what we see when we walk into the grocery store are food-like substances that are not actually real food by and large. These are highly processed, highly refined, nutrient depleted imitations of food and that’s the majority of what we’re seeing in grocery stores. But because it’s so pervasive and it’s so widely marketed, I think many of us have actually come to believe that this is actually food, this is actually going to somehow build a body that works. But that’s actually not true. These food-like substances, frankenefoods, that I like to sometimes call them, basically anything you’re finding in a box that was made in a factory that’s stripped of its real nutrient density. This is not the types of products that’s going to go in and build a body that’s highly functional. We need the food that’s in its whole form, that’s nutrient rich to really be both the substrate that builds the body that functions properly, but also that serves as the signaling molecule that tells the body what to do properly.

So one, I think we just have a food culture that makes it very challenging to know what is healthy and what we should be eating. I think the second piece you talked about was why do people not know? Why are they unaware of these conditions that are happening? A lot of that has to do with the way we actually diagnose illness in our country and really is a systems issue. We tend to diagnose diseases only when you’ve reached a critical threshold and meet diagnostic criteria. So for something like diabetes, until you walk into the doctor’s office and have a fasting glucose of 126 or above, you are told you are essentially okay and don’t really need to be thinking about this. Maybe if you’re in the pre-diabetic range, which is a glucose of 100 to 125, your doctor might mention it and say, “Hey, you should probably work on your diet.” But by and large, if you’re below the diagnostic threshold, you actually are told that you’re in the clear and you’re fine. And that’s really a fallacy. That’s not actually what’s happening on a biologic level. It’s not like one day we’re non-diabetic and the next we are. These are conditions that develop over years, if not decades. These days actually, starting in childhood. And because of the way we’ve organized diagnostics, it almost leads people to believe that they’re fine until the day that they’re not. And I think if we really expanded the way we think about diagnostics and understood our bodies on a deeper level and on a spectrum, we’d actually come to realize that we have so much time to actually intervene far before that day when you walk into the doctor’s office and get a big surprise.

And that’s actually one of the reasons I’m so excited about so much of the direct to consumer lab testing and the bio wearable movement, because for the first time ever people have access to data that they own that can tell them where they fall on the spectrum of health or disease and let them take action a lot earlier.

Christina Elson: [00:09:26] Yeah. I noticed with kids, that just giving them sugar, you see how radically different some of them respond to it, right? Just the way that one person responds to something is different than the other and that change is probably over time as well. But you’re mentioning how doctors have approached solving these problems. Help us understand a little bit about that. How has this happened?

Dr. Casey Means: [00:09:50] I think that a lot of this has to do with efficiency. We have a huge population and we have to risk-stratify people and we do have to categorize people in order to channel our resources effectively in healthcare. And so that has been the pervasive thought. We need to – of course for people who meet diagnostic criteria for diabetes, be able to put them into the system in a way that we can actually put them into a treatment plan and make sure that we’re focusing our resources to help that group. That’s the group that’s going to be most severely affected compared to the pre-diabetic or the non-diabetic individuals. However, What I think is really worth noting and I think what we’re realizing more and more is that a lot of these diseases are largely preventable and the costs, once you develop disease both to the person, but also to the healthcare system, are astronomical. It is very inexpensive to take care of a healthy person and it’s very expensive to take care of someone who’s developed disease. And so, it really makes you have to step back and start thinking about this model a little bit more carefully. What if we put our resources up front towards these healthy people, help them actually stay in the healthy range? That’s going to cost some money and take some investment, but what could we actually get in the longterm? And our traditional healthcare economic system has actually really struggled with this concept of the value of prevention, because we have largely been for many years a fee-for-service healthcare system, which means that a doctor in a hospital are going to get paid by an insurance company or a patient if they do something. You get paid for action and you don’t need to take a lot of action with a healthy person necessarily. And so there is a bias towards, “Okay, if I need to do action to get paid, I’m going to probably focus on the people who need more actual intervention, which is the people who have already gotten sick.” it doesn’t actually pay to just do nutritional counseling or having a long health maintenance conversation with a patient. So it hasn’t traditionally been where we focused our energy.

I think we’re actually moving in a great direction in that regard, because we are moving towards a value-based care system. You want a high value equation, which means great outcomes for the lowest cost. So you can’t just have low costs. That’s not going to work. You need the outcomes to be there. And fortunately, prevention is our highest value intervention we can do. Prevention like nutritional strategies, exercise, etc. You end up getting really good outcomes for a fairly low cost in the long-term. So that’s really positive. It’s a shift away from the fee-for-service system that we’ve traditionally had. I think another systemic issue here is the way that we have also built in terms of coding. So our system for 60, 70 years has been focused on a medical coding system where a doctor will talk to a patient, do a history and an exam, and then label the patient with various codes, which is how they actually bill. Because of that, we actually have a bias towards labeling and we only label things really that are problems. And so we can label someone who’s diabetic, but we don’t actually have a label for metabolically healthy. So it also biases towards really lumping people into these diagnostic categories.

I think all of these things together, the economics of it, the coding of it. It’s led us the system where we really focus a lot of energy on people who have disease and not as much on people who haven’t developed the disease.

Christina Elson: [00:13:15] Casey, it sounds like part of what we’re talking about is changing incentives for medical providers. Let’s talk about incentives for business to be involved in solving these problems that you’re talking about and you’ve chosen to work with your team of founders to approach this problem of helping us get to a better state of metabolic health. So tell us about that.

Dr. Casey Means: [00:13:44] So I think there’s a really exciting opportunity for business in healthcare right now and we’re seeing just a massive explosion of digital health companies and physicians, I think, partnering with entrepreneurs to really move the ball forward in healthcare. So right now, for the first time ever, we actually have the ability for individuals at home to understand their personal health data in a way that they’ve never been able to do before. We were talking about the wearables. That’s one part of it. We now have the ability to know our heart rate, our activity count, our sleep data and even objective measures of stress at home 24 hours a day. What’s interesting is that sleep, stress and movement are three of, I would say, the four foundational pillars that are involved with our ability to be healthy or to ultimately develop disease.

But the fourth pillar that we really haven’t been able to nail thus far, is at-home information about our nutrition. How is the food that we’re eating actually affecting us and closing the loop on that. We’ve been able to close the loop on every other one of those pillars except for nutrition. But now there actually are really neat opportunities to do that at home.

So my company, in particular Levels, we are leveraging continuous glucose monitoring technology, which has traditionally been a monitoring tool for diabetic individuals so that they can track their glucose 24 hours a day at home for management of their disease. We’re making this technology mainstream to everyone as a wearable that can be used to give you real time biofeedback about nutrition. So for the first time you can actually eat a meal and say, instantly, “Was this meal good or bad for me? Should I eat this or should I not?” And so that’s very exciting. And there’s a lot of other really interesting companies doing this type of thing with direct to consumer information in the nutrition space. There’s GenoPalate, which is looking at genotyping people for understanding their nutrition and just a lot of really interesting things like that.

So the whole wearable movement is just a huge step forward and letting people be empowered with their own health information to make the decisions that ultimately generate health. We’re moving things out of ‘health happens in the doctor’s office’ and we’re moving it towards ‘health actually happens in the home’ with the choices that you make every day. And I think that’s a huge paradigm shift.

And so something I think about a lot as a physician in now the digital health world, is that doctors are privileged to have gotten a lot of education, a lot of training and a very specialized skillset, but fundamentally right now, doctors, what we do, it’s very unscalable. We spend all this time one-on-one with individuals and we usually have about 15 minutes with people and are seeing 30 to 40 patients a day. That’s not enough time to dig into really the root causes of chronic health conditions, which do relate to diet and lifestyle. These are long conversations and complex psychosocial dynamics that have to do with these things and doctors don’t have the time and we’re also not really equipped to be great coaches on these things. In a lot of ways, we are not doing a great job of scaling our abilities to help patients with the actual drivers of chronic disease these days.

And so I think there’s just this amazing opportunity for doctors to work with entrepreneurs and engineers and device manufacturers and people in industry to figure out how to actually scale what we know and what we know can help people into tools that can do this in a much bigger way. We need to think bigger about how to creatively scale solutions to help people take ownership over their health and to make the choices that are ultimately going to lead to better health and reduce risk of disease.

Christina Elson: [00:17:34] So ideally, what you would like to see is that somebody could eat something and then they could immediately see how that’s affecting their blood sugar and other indicators of how their body is dealing with that food and over time, come to an understanding of what it is that makes them feel good what it is that makes them feel tired or overly energized or whatever the case may be, but also have some real data to discuss with a healthcare professional and work out a plan that would be beneficial for them in terms of understanding what they need to do long-term. Is that what you’re going for?

Dr. Casey Means: [00:18:19] That’s exactly right. So Levels, what we’re doing is, we’re the first metabolic fitness company. So what we focus on is helping people improve their metabolic fitness, meaning their ability to have an efficient and highly functional metabolism and the beauty about this program is that we have this technology, the continuous glucose monitoring technology, that people haven’t had access to before.

This is a wearable sensor that is tailing your glucose 24 hours a day and sending it to your smartphone. And a lot of people understand that glucose is important, but don’t really understand how critical managing your glucose is for all aspects of health and performance. And so what our software does is it takes that glucose data stream that you’re generating from the wearable and interprets it for you and helps you understand how to move this glucose curve into the right direction. What we want for our glucose levels in our body is it to be fairly flat and stable throughout the day and without that data, it’s really hard to know. When people see what’s happening after they eat something and what their glucose response is, it can be a profoundly interesting experience for people and it does get into what you said. It actually loops into people, better understanding their subjective experience of their health and their day.

So here’s an example. People might eat some oatmeal in the morning. They might have oatmeal every morning with some berries or maybe some brown sugar and they might always be the type of person who mid morning has a little bit of a mid-morning slump, needs an extra cup of coffee and was feeling a little lethargic by around 11:00 AM or getting really hungry for lunch by then. And so then you put a continuous glucose monitor on him. That person might see that their glucose, say it started at 80 mg/dL, at normal, and then shot up to 200 mg/dL, which was a huge spike and then came crashing down and then that’s exactly when they felt tired in the morning. All of a sudden there’s so much power that’s unlocked there. First you realize, “Oh, this tiredness I’m feeling is not a mystery. It’s not because I didn’t get great sleep. It’s not because I’m stressed. It’s not because I didn’t have coffee. It’s because of the oatmeal. I went straight up with my glucose and then it crashed and then I felt fatigued.” And then what our software helps people do is figure out how to modulate that breakfast, to ideally move towards choices that aren’t going to have that type of spike and crash and going to keep things much more stable. So maybe that means adding protein and fiber and fat to their oatmeal. Maybe it means taking a 30 minute walk after they eat oatmeal to bring their glucose down. Maybe it means switching the oatmeal altogether to something like a really nut and seed rich muesli or eggs with avocado or something else that just has much less glucose in it. And so we really start to understand what these rollercoaster rides of glucose are doing to our everyday life. And with athletes, so often find that they see what’s happening with their food and their sports drinks and these foods they’re eating that they think are helping give them energy, but they’re actually realizing that it’s spiking their glucose and it’s just going up and down and that’s actually contributing to worse endurance and to less stable energy during their workouts.

So it’s really all about awareness and then optimization. But I really love that point you brought up about really understanding our bodies because one of my big goals with this product is to help people have better body awareness and to get back into their body and start linking how they’re feeling with objective data and then linking that to the choices they’re making. And I think that trifecta between choices, objective data and then keying into the subjective experience of how people are feeling is a powerful behavior change feedback loop. So that’s really a goal of mine is that body awareness.

Christina Elson: [00:21:57] So Casey, I think your story about the oatmeal eater just completely described me and maybe I need to rethink this whole oatmeal thing. But tell me about the path that led you to levels.

Dr. Casey Means: [00:22:10] So I started out my career – I was at Stanford for undergrad and medical school and it was there that I actually really studied personalized genomics. So I was at Stanford right after the Human Genome Project wrapped up. I worked at 23andMe, which was just coming online and it was just a really exciting time for personalized medicine. And that was really the ecosystem in which I entered the biomedical sciences. It’s a really empowering perspective, thinking about the personalization of health because what we really come to realize and understand is that we are these biochemical blueprints. We have this genetic code that was passed down to us. But that’s only part of the picture. The other part of the picture is that environmental exposures are what can change and modify expression of that genome. And when I say environmental exposures, that means what you’re eating, when you’re eating, how much stress you’re under, how much or how little you’re moving, how much or how little sleep you’re getting, toxins you’re exposed to in your food, water, and air. All of these go into the body, are translated as molecular information through our hormones, through the nutrients in our food, etc., and tell our bodies and our genes, essentially, how to be expressed. So that’s really empowering because we have a lot of agency over modifying those environmental factors and getting essentially the best expression of our potential. I just love that about the personalized genomics revolution.

So after medical school, I went into head and neck surgery, ear, nose and throat and I was trained at OHSU up in Oregon. I was there for about four and a half years when I stepped back and I had this realization, I’d been so busy for those four years just operating and learning and I stepped back and I said, “Wow! This is really interesting. Almost every condition that I’m treating as an ear nose and throat surgeon is chronic inflammatory in nature. So it’s chronic sinusitis, chronic ear disease, chronic thyroiditis, cancers, vocal cord granulomas, which are inflammatory masses of the vocal cords. All of these things are essentially the immune system rubbing up in these tissues causing blockages and then pus building up for sinusitis and ear disease and whatnot, or chronic inflammation creating inflammatory masses or with cancer, we know there’s a lot of overlap with immune dysregulation and how cancers become unchecked and grow. And so I started thinking, really why is everyone so chronically inflamed? Why are people getting these heavy doses of steroids, which we were prescribing for everyone. You either get nasal steroids, Flonase. You get oral steroids, like a Medrol dosepak or you get inhaled steroids like Fluticasone or you get IV steroids. These are all medications that tamp down the immune system and that can be helpful for a little while, but it doesn’t actually fundamentally change what’s generating the chronic inflammation. It quells it, but it doesn’t actually change what the triggers are.

And same with surgery. Surgery is an anatomic exercise, right? It’s changing the anatomy, but you actually can’t operate on the immune system. So that started making less sense to me and I thought let’s really examine what’s causing people to be inflamed. And again, it comes right back to those environmental exposures, the toxins we’re exposed to, the things we’re eating, how little or how much we’re moving, our sleep quality, how much stress we have in our lives. These things can trigger inflammation and a big piece of that in terms of what we’re eating is the sugar. Sugar is a huge driver of inflammation in the body. And these chronic conditions like we talked about earlier can generate a proinflammatory state in the body. So actually on the Venn diagram of just these ENT conditions – If you draw the Venn diagram with all these other chronic conditions we’re seeing like diabetes, obesity, dementia, heart disease, the same immune chemicals, the cytokines are up regulated in all these diseases. So there’s something going on underneath all of this that’s driving the state that we’re in and I think a lot has to do with the metabolic system and the blood sugar and a lot of these other things I mentioned. And so that just really was a profound realization for me. Why are we reaching for our prescription pad, reaching for our scalpel when we’re really not addressing potentially some of this low hanging fruit of the choices we’re making and the exposures our bodies are seeing.

And so I just became laser focused on – One, how do we keep people out of the operating room by focusing on these aspects, these modifiable aspects of health? Two, how do we build a system that actually gives doctors the time and the incentives to focus on these things upfront? And then three, how can we build tools, digital health tools or other products that help people feel empowered to understand this about their own health. And that’s really, for me, where Levels arose because I said, “Hey! We have a measuring tool for glucose, our key metabolic substrate. People don’t have access to it and we don’t have software that makes that data useful and interpretable. Let’s build it.”

Christina Elson: [00:27:00] Levels has a beta product now that’s in active use. Can you share some stories about people participating?

Dr. Casey Means: [00:27:07] Oh man! There are so many. I think one of my absolute favorites is this young woman who had lost about – I think she’d lost about 60 pounds on a ketogenic diet and ketogenic diets are low carb very low carb diets – and she had been really strictly adhering to this keto diet and actually has an Instagram platform where she posts about it. She’s under @a.keto.girl on Instagram and she found out about Levels and she got into our beta program and she put on the sensor and what she actually realized was that a lot of the foods that she had been restricting for years to help with this monumental weight loss journey actually were not spiking her glucose levels. And so it actually allowed her to liberalize her diet. So she had been told, on keto, you need to avoid the more sugary vegetables like carrots because they’re going to spike your glucose. But it turns out that carrots didn’t spike her glucose at all. So she was able to stop picking out carrots out of her salad and actually liberalize that. And there are lots of examples like that for her and I think it was a wonderful experience to free her up because she’d just been so latched onto this rigid eating plan and was able to expand things.

And I think it really highlights an important point about metabolic health, which is that every single person responds to food differently in terms of how much it spikes their glucose levels. We are such complex systems and a carbohydrate in the mouth doesn’t necessarily mean glucose in the bloodstream. Typically we think carbs are essentially glucose, but actually there’s a lot of processing that happens between the mouth and the bloodstream that is different between people. And so there’s a really interesting study that came out about five years ago from the Weitzman Institute in Israel. It was published in Cell called “Personalized Nutrition by Prediction of Glycemic Responses.” And they put continuous glucose monitors on a bunch of healthy people, gave them all standardized meals, the exact same meals and then they looked at their glucose. And they found that you would expect everyone to have the exact same glucose response. They’re eating the same food. But it turned out that it was all across the board and so what might

be metabolically unfriendly for one person is actually potentially fine for another person. And one of their examples was a banana. A banana could cause a huge spike in a certain person and virtually no spike in another.

Then they looked at what the factors that were predictive of this were and they were things like microbiome. So microbiome composition actually could predict how you would respond to a particular food. And then there were other factors like recent exercise and sleep and body type. So it was just very interesting because I think we’ve adopted this belief in the Glycemic Index. You just can choose foods that are low-glycemic and they won’t spike your glucose. But it actually turns out that it’s more likely that we each have an individual glycemic index for each food for our own body and we really have to test it to know.

And the second crazy thing is that it actually probably changes day to day for our own bodies. So a banana for me on Monday could actually have a different response than a banana on Tuesday, based on other factors that affect metabolic health. Like if I’m under more stress and I’ve had poor sleep and I haven’t exercised, that food might significantly spike my glucose more than it would the day prior.

So it’s really all about learning what these different levers are for your own body to keep glucose stable. Whether it’s the food choices or the other mitigating factors like sleep and exercise and stress management, and then just really building this comprehensive holistic metabolic awareness  so you know what is actually right for you?

And that’s just been really beautiful to see in our customers like @a.keto.girl, who I mentioned, and just many others who now just have this whole toolbox of things they can reach for to keep their glucose levels more stable, whether it’s getting better sleep or being more mindful and practicing deep breathing and keeping their stress under control or just taking walks after their higher carbohydrate meals.

Christina Elson: [00:30:59] So as we’re coming to a close I’d like you to share with me one major change you’d like to see happen in healthcare in the next decade.

Dr. Casey Means: [00:31:08] If there is one thing I would like to see change, it is a massive reversal of our metabolic disease epidemic and I think it’s possible. We should not have 72% of people in our country suffering from obesity or overweight when many of these people are going on diets every year to try to mitigate this and to improve this and it’s not working well. We should not have 34% of our country with diabetes or pre-diabetes. And I think we’re going to start to see a movement in this area because people want to live healthy lives and currently though, we don’t have the time with our doctors to really dive into the root causes of these conditions because of the way the system is set up and we don’t have access to measurement tools that can actually help us track and optimize these conditions. But both of those things, ideally, will be changing as we move towards a system where people do have more access to their own personal data and optimization tools and more of a value-based system where we invest more in prevention. But that is absolutely what I’d like to see change.

Christina Elson: [00:32:15] Casey, thank you for joining me today in The Inc. Tank. This has been an inspiring conversation. It’s very helpful for us to understand how sleep, stress and moving are related. But actually underlying all of this is this fundamental understanding we should develop around our metabolic health. So thanks so much, Casey, for joining us.

Dr. Casey Means: [00:32:39] Thanks so much for having me on Christina.

Female Speaker: [00:32:41] Subscribe to The Inc. Tank at theinctank.org or wherever you get your podcasts. The Inc. Tank is brought to you by the Wake Forest Center for the Study of Capitalism and the Ed Snider Center for Enterprise and Markets.