The Key Signs You're Not Healthy & How To Fix It w/Casey Means, MD EP 1252

It's not working. We're getting sicker. Every single year we're getting sicker, we're getting fatter, and we're getting more depressed as a country. And I think the key problem with this is that...

Welcome to the School of Greatness. My name is Lewis Howes, a former pro athlete turned lifestyle entrepreneur. And each week we bring you an inspiring person or message to help you discover how to unlock your inner greatness. Thanks for spending some time with me today. Now let the class begin. You went from, I guess, being a doctor to saying, well, how can I help people in a holistic approach to preventing chronic illness and disease? And I'm hearing you say that it starts with metabolic health, is that correct? Yes. So what is metabolic health then for people, and how can they optimize this?

Yeah, so, well, first of all, I think you hit the nail on the head. There is a movement and a tribe of doctors who are sort of waking up and realizing that we are missing the elephant in the room of modern American health care. And the elephant in the room is that, first of all, the vast majority of things that are killing Americans today are conditions based in our dietary and lifestyle choices over the course of our lifetime, which means that we have huge amount of agency in changing our fate in terms of these diseases.

How many diseases would you say are caused by food and nutrition alone or our diet.

Nine of the 10 leading causes of death in the United States are either not only just caused by food and lifestyle, but are directly attributable to dysfunctional blood sugar or are worsened by elevated blood sugar. Nine of the 10.

What's the 10th one?

Well, to go through the ones that were like what we're talking about. So we're looking at things like Alzheimer's dementia, which is now being called type 3 diabetes because it's so related to blood sugar, heart disease, type 2 diabetes, cancer is very much driven by blood sugar, chronic kidney disease, which is very much a problem of the small vessels in the kidney becoming narrowed in part because of metabolic dysfunction and erratic blood sugar control, chronic lower respiratory infections of one of the leading causes of death. And we know that people with unstable elevated blood sugar have much higher mortality, even with something like influenza or pneumonia, having high blood sugar actually can get into the fluid of the lung and feed the bacteria that leads to some of these issues. And of course with COVID we've known now since the very beginning of the pandemic that having metabolic dysfunction, diabetes, is a key accelerator and driver of mortality and morbidity. There's some odd ones on there too. For instance, suicide is actually on the top 10 list of killers in the United States and people with with diabetes or metabolic dysfunction actually have higher risk of suicidality.

Really?

So it's all across the board. And so what's really fascinating is the way in which these dietary and lifestyle factors are essentially linking so many of the conditions that are killing Americans today. And the way we've approached it is we've looked at these as all isolated silos. We think of them as all different things, like, huh, we wouldn't treat diabetes the same way we treat cancer or kidney disease the same way we treat Alzheimer's. But when we look at these through the root cause approach that you talked about, and sort of the fancy term for this in medicine is systems and network of biology. What is the network between diseases rather than how are they all different? When we treat at that level, It's so much more efficient and we can actually generate good health in the body as opposed to just reacting to symptoms and managing conditions. So I think that's what a lot of doctors are waking up to. They're sick and tired of being reactive, practicing sick care, practicing this end of the line medicine and they want to help generate health in people's bodies. Interesting. different way of practicing.

Right, yeah. That's inspiring. And so what I'm hearing you say is blood sugar management or control is one of the key factors of either being healthy or potentially linking to one of these other, I guess, diseases, is that right?

That's right, yeah. And what it really comes down to, which kind of gets at your question of what is metabolism, metabolism is fundamentally the way that we make energy in the body. So we eat food and food has fat and glucose in it. And either fat or glucose, glucose is sugar, can be used to convert into a type of energy that our cells can use, which is called ATP. So we take in this substrate, but we have to convert it through our mitochondria in our cells to a form of energy we can use, a currency that our body understands and can use. That process of conversion is metabolism. And this is happening in every single one of the 37 trillion cells in our body. And it has to work properly.

So break it down for me then. Fat or glucose or I guess carbohydrates enters the body through the foods we're eating, right? What happens after that? How is it processed in the body through the cells, through the mitochondria? How is it processed?

Yeah, so looking at carbohydrates for instance, They go into our digestive tract, they're broken down and absorbed into the bloodstream, broken down into simple sugars like glucose and fructose. These go into the bloodstream and let's say we're talking about glucose, which is blood sugar. This signals to the body, particularly an organ called the pancreas, to release insulin, which is a hormone. That hormone allows you to take that sugar out of the bloodstream through the cell membrane into the cell. Once it's inside the cell, it's broken down even further and then goes into the mitochondria to go through a chemical processing that then creates ATP, which is this molecule that can be then used to essentially power all the millions of cellular processes that are happening every second.

So ATP is the power. Is the fuel?

It's the fuel. It's the battery in our body.

Okay, so the way it's processed, Is it based on the foods we eat, whether it be fat or sugar that comes through? Does that determine how the quality of the energy or what does that mean? Is it all equally the same when it converts an ATP or?

Well, I think the way to think about it is to really focus on the mitochondria. This is the energy factory of the cell. This is the powerhouse of the cell. And the thing that people really need to understand is that our diet and our lifestyle in the modern Western world, so past 50 to 100 years, So much of it is actually damaging the mitochondria of our cell and creating problems in that conversion process. So for instance, when we eat too much sugar, okay, and these days the average American- Is eating a lot of sugar. Like 100 times more than we were like 100 years ago into the rest of human history. It's like this massive overload of this substrate. What that does is it causes stress on the mitochondria and creates damage. One analogy I sometimes use is, imagine you had a factory that was making something like cheese, and all of a sudden you get 100 times more of the raw product, like milk, delivered to the factory. The workers would be like, we don't know where to put this. We can't work. They go on strike. There's nowhere to store it. There's no refrigerators. It would all go bad. All of a sudden, you actually produce less cheese, even though you have more substrate. Interesting. And so it's like, we are giving so much of the substrate to the body that it's gumming up the system. It's breaking down the factory and creating problems. And the molecular way this is happening is that each time you have these glucose spikes from eating these refined products or added sugars, your body's releasing more of that insulin. It's saying, okay, more glucose in the bloodstream, so we have to produce more insulin to get it out of the bloodstream. And over time, the body sees all this insulin circulating and it's like, We can't bring more of this into the cell. There's too much. And so it actually puts up a block, which is called insulin resistance, which is that cellular process that leads you towards problems like diabetes. And so what's happening now is the.

Body- and that's why you're storing fat or you're storing other dead cells that you don't need to keep in the.

Body, I guess, right? Right, because insulin is the signal saying tons of glucose around for energy so we don't need to burn fat for energy. So insulin is also a block on fat burning. So it's this chemical signal saying, too much glucose around, blocking it from getting into the cell, and also telling the body not to burn fat. So, of course, for people who are dealing with trouble losing weight, insulin is the hormone we really, really need to be thinking about. And so we reduce our insulin sensitivity. Now we have lots of glucose circulating in the bloodstream, but it's not able to efficiently get into the cell. And then you've got all these other things that can hurt our mitochondria. And really a mitochondria energy-centric view of health can really help us. Some other things that can hurt the mitochondria are oxidative stress. So, I know you talked about this a little bit on the podcast with David Perlmutter, but aside from glucose, eating too much fructose, so this comes with like sodas or fruit juice or things that have really high concentration of fructose, it's not going to actually stimulate insulin in the way that glucose does, but what it does is it goes into the cell and it's converted into something called uric acid. And that uric acid creates oxidative stress, which is sort of this damaging reactive molecule in the mitochondria and creates mitochondrial damage. So now again, you've got more trouble processing energy through mitochondria. Environmental toxins are actually a huge problem as well. They can directly damage the machinery of the mitochondria. So we're thinking about things like pesticides and a lot of the fragrances in our personal care products and a lot of the fragrances and chemicals in our home care products. These things actually go into our bodies damage our mitochondria, make it difficult to produce energy effectively. Chronic stress can damage our mitochondria through cortisol and through our stress hormones. So it's interesting to think about how all these different aspects of modern life fundamentally feed down into damaging this precious part of our cell that creates energy. And when we have the mitochondria. The mitochondria. And when we have problems creating energy in our body. This can happen in any cell type. Again, 37 trillion cells, you know, dozens of organs in the body. Where this is showing up most prominently in the body is where you're going to see symptoms. And this is why metabolic dysfunction and blood sugar dysregulation can look like so many different things. It can masquerade as so many different symptoms. And in the conventional system, we see those all as separate. But when we think about it as this is actually just where a fundamental core problem is showing up in different cell types. And so if you can address that, you can potentially kind of melt a lot of things away. So just as some concrete examples, if metabolic dysfunction is showing up in the blood vessels, well, if it's sort of most prominently showing up in the penis, that could look like erectile dysfunction. If it's happening in the heart, it could look like, you know, heart disease. If it's happening in the liver, it could look like fatty liver disease. If it's happening in the ovaries, it could look like polycystic ovarian syndrome, which is the leading cause of infertility in the United States, which is a metabolic problem. And if it's happening in the brain, it could look like Alzheimer's dementia. And so it's got all these different faces, but fundamentally is rooted in a core dysfunction in how our body is converting food to energy. And a lot of that has to do with this chronic overnutrition, overloading our cells with too much to process, gumming up these systems, and then the many other lifestyle factors like toxins, stress, sleep deprivation, and sedentary behavior that can also hurt the mitochondria.

Right, so blood sugar management and metabolism management, is that right? So the main things we should be thinking about. How does blood sugar and metabolism work together?

Yeah, so the way that those sort of things link up is that if your blood sugar is quite erratic, like let's say it's going up and down in big spikes and valleys.

Every day, yeah, you're having lots of sugar, you're just eating poorly, you're stressed, you're overwhelmed.

Yeah, and the majority of foods on the shelves in our grocery stores now have added sugar, like well over 60%. So it's not unusual for an American to be on that blood sugar roller coaster up up, down, up, down, up, down. And that's called glycemic variability. And that process of glycemic variability is very damaging to our metabolism through the mechanisms we spoke about of causing insulin resistance by stressing the body to make too much insulin over and over. But those high blood sugar spikes in their own right can cause damage as well. When your blood sugar acutely goes really high, like after eating a Pop-Tart or eating a pastry or something like that, or a big bowl of pasta, that spike can lead to inflammation. It can lead to oxidative stress because of the way that it's overwhelming our systems and creating free radicals. It can also cause a process called glycation, which is where sugar sticks to things in the body. And so if you can imagine, if your concentration of blood sugar is really high, it's kind of going to just stick to things more, like your blood vessels and proteins. and that's not good. That's like a signal for the body that something's wrong. And so all of these things kind of coalesce to just creating problems. So the more that we can minimize our glycemic variability and go from spikes and valleys to more gentle rolling hills, the better we are, the better we're going to basically be treating our cells. And it's not just It's not just the sort of like cellular optimization we're trying to do. It's also the way you feel. I think a lot of us have had that experience where we have a really high carb meal, a big dessert, and we feel like we kind of have a crash afterwards. It's like that post meal crash. We feel lethargic, like we may need to have another cup of coffee or even feel jittery after it, like a big high carb meal. We really understand how that works. The body sees a huge load of glucose from a high carb meal, the body then surges out that insulin, overcompensate, soaks up all that glucose, and you crash. And in that crash state is when we feel fatigue, potentially some anxiety, and it's when people usually feel cravings. So by limiting- you- want more when you crash. You want more to bring yourself back up because you've kind of crashed.

And then you're on that vicious cycle.

And I think the majority of American bodies are on that cycle, because you think about what we eat. It's like cereal, juice, toast, Pop-Tarts, pastries, you know, sweetened coffee beverages, that's all refined sugar and refined grains. Then you go to lunch and it's bread, tortillas, wraps, chips, you know, all of that stuff. And then you go to dinner, pasta, potatoes, whatever. And then it's dessert. And it's like, if you're not, if you're just going along the normal American cultural treadmill of what's normal to eat, you're on a glucose roller coaster. And that means that your day might be highly labile in terms of the energy, mood, performance, cravings. And so learning just simple ways to balance out that glucose roller coaster can be an amazing life hack and really a superpower for essentially getting your day under better control, making you feel better in the moment.

Yes.

And of course, creating the cellular conditions to set you up for long-term longevity and health and prevent that whole downstream insulin resistance cascade that we know is related to so many causes of death in the United States.

So let's speak to people that are listening or watching who maybe have active lifestyles, they like to work out, so they need energy for working out, they're driven, they're passionate in their careers or entrepreneurship, they have a lot of friends and activities they like to go to, so they need energy throughout the day. How can they get the energy without the glucose roller coaster happening? What are the best foods to be eating throughout the day? How many times should we be eating? And does it really matter or does it really depend on each individual's body type?

Yeah. So I think for the type of person you're describing, the key concept we want to think about is achieving metabolic flexibility.

Okay.

So metabolic flexibility means that we are able to use different forms of energy to make ATP based on what's available. And what I mean by that is if there's sugar around, we can efficiently burn sugar to make ATP. But if there's not, the body's fine. It's like, cool, we've got fat to use for energy. The average person is not metabolically flexible. And the reason is because they've been on the glucose roller coaster. Their body is so used to seeing glucose, that those pathways are super active. And they're constantly on that sort of craving hit. They want more of it. They haven't really given their, because glucose is the preferential fuel the body will use, it's the first thing it's going to grab. It's kind of that easier thing to use. It will never go and burn fat if there's glucose. It will not burn significant amounts of fat if there's glucose readily available. So something that we can do, essentially train our bodies, is to give it opportunities to burn fat. So this is where you start thinking about things like time-restricted feeding or fasting or potentially doing a fasted workout, where you're actually intentionally keeping your blood sugar levels in the low normal range. Signaling to, and of course the downstream effect of that, it's going to be insulin will be low, because if you're not having a glucose spike, spike, then insulin will be low. And that insulin being low takes away that signal to not burn fat. So now your body's like, cool, insulin's low, glucose is low.

I'm going to tap into my fat stores. So that's when it starts to burn the fat. Exactly. Exactly. So if you work out in the.

Morning without eating, you're more likely to be burning fat. Is that what I'm hearing you say? That's right. And there's actually a lot of athletes that are using this type of metabolic science to their advantage. There's a whole community of endurance athletes now that are doing low carb training. And the purpose of that is that they don't want to be super dependent on glucose during their event where they're just like every half hour having to take a goo or a bar or an energy drink or something like that and have these big spikes throughout their event. Instead, they've actually trained their bodies to use fat during an endurance workout and There are literally marathoners now who will run the entire thing fasted because they can so efficiently burn fat. But that's not-- those pathways have to be kind of worked and developed to be able to do that. And that's metabolic flexibility.

So how do you train metabolic flexibility for yourself?

I would say the key thing is to minimize these excessive glucose spikes to give your body an opportunity to be more in the stable, healthy, low range for more time of the day to keep insulin in a lower and healthy range so that your body knows to burn fat. One way that you can do this is, of course, with a continuous glucose monitor, which are becoming popular now. Wear it, see what spikes your glucose, modify it, and try and get to a more stable range. Or measure your ketones, which a lot of people are are doing now. And this is a finger prick device or there are breath monitors. You can also check in your urine. And ketones are a byproduct of fat burning. So if your ketones are super low or zero, it means you're not burning really any fat. And if your ketones are higher, like above 0.5 or up into the ones and twos, you are proving to yourself that you have gotten into a state where your glucose and insulin are essentially stable enough that you're burning fat for energy. And so something I like to see if I'm tracking these things is, okay, if I've kept my glucose quite stable and low for a couple of days based on the choices I'm making around diet and lifestyle, I start to see ketones rising up. And that to me is proof of metabolic flexibility. And I can test things like, okay, if I do the Peloton ride first thing in the morning after not eating, does it increase my ketones later in the day and start to do some experiments like that. And another thing that people can do is ask their doctor to do a fasting insulin test. It's not a test that's normally done on a regular yearly panel, but it's a really powerful test because, again, if insulin is quite elevated, it's going to be kind of that block on fat burning. And if insulin is a low and healthy range, it's a signal that your body's probably likely very insulin sensitive. You're not far down that insulin resistance pathway, I like to see it between about two and six. And shockingly, the reference range in a lot of labs will say that anything under 25 is normal, but that would be very, very, very elevated. So you want it to be tight and low to know that you're just giving your body that opportunity to burn fat and to work those different pathways.

So many people are talking about fasting or intermittent fasting these days. Is it different for men and women on the ways to fast in order to burn fat or is it the same for both?

You know, I would say it's different for every single person. Sure. And definitely for different genders, but it's different day to day. You know, I think intermittent fasting and time-restricted feeding, it can be a stress on the body, you know? And so, I tend to think of it as, you know, we've got a certain capacity within the body to manage different stressors. And we know that certain stressors can be helpful in building adaptations in the body to help us improve. So like cold exposure, heat exposure, fasting, high intensity interval training. But there's also stressors in our life that are maybe somewhat out of our control, like work stress or family stress or things like that. And we don't want to overload our body. And so, you know, if a woman is potentially in a part of her cycle, for instance, where her body's also already quite taxed... You want to do it then. You wouldn't do it then. And on a day that I don't have as much sleep, on a day that, you know, I might be doing a big podcast or something like that, like today, you know, I'm probably not gonna add, you know, I'm gonna be thinking very deeply about food though, because you also don't want to be eating a big meal and then crashing, right, during that time when you have to perform. So it's more about keeping things really stable and not being highly fluctuating. So I think about it more that way. I think that fasting is great if you're otherwise very well resourced with sleep, with psychological resilience, not putting your body probably under intense physical stress during that time, I tend to do more like zone two workouts, you know, sort of low intensity during fasts so as not to add too much stress. Stress to the body, yeah. And ultimately, too much stress can lead to breakdown. And so, kind of like bringing those things, just thinking of everything in a really holistic picture.

If you stress the body too much, does the blood sugar go up? Or what does that do to blood sugar and metabolism?

Yeah, stress has a fascinating relation with blood sugar. psychological or physical stress can both cause blood sugar to acutely go up, even if you're fasted, even in the absence of any glucose. Really? And the reason for this is that any stress signal to the body will release stress hormones like cortisol and catecholamine, like noradrenaline, epinephrine, things like that. These signal to the body that there's a threat, and the body has trouble interpreting the difference between a physical or a psychological threat. And so it's going to produce the same stress hormones.

So if there's an event that happens in life, let's call it something we witness or something we see or something we hear or experience, we think of a thing that causes a stress hormone to go to the body. Is that what I'm hearing you say?

Yes.

There's a thought that we have associated with the event or the stressful or the thing that we think is stressful.

Yes.

And then that causes a stress hormone to enter the body. Does it go throughout the entire body? Does it go to the heart? What happens? And then does it that just spike the blood sugar up?

Exactly. So it goes to the whole body and I would say simply put, in many ways our mind has huge control over our metabolism.

That's what it sounds like.

Yes.

Because we can think a thought and stress ourselves out and have high blood sugar just based on thought alone.

You can think your way into metabolic dysfunction, I think.

And can you think your way out of it too?

In some ways you can and it should be a part part of our strategy for optimal metabolic health. So the way it works is that these stress hormones, they travel throughout the body and they actually tell the liver, we've got a threat, there's a lion chasing us, we need to run, we need to have fuel for our muscles so that we can flee. You know, it's fight or flight. So the liver actually stores about two hours of really quickly accessible glucose in the form of something called glycogen. It's change of and it's like our debit account. It's short-term, it's ready to go, but it's only a couple hours worth.

Okay, so you've got your circulating and then you've got your stored glucose.

You've got it stored in the liver all the time? All the time, yeah. Unless you burn it for those two hours, then it's... Exactly, it depletes, and you deplete your liver glycogen. So that hormone says, dump it. So you flood the bloodstream with blood sugar to feed the muscles. And you can imagine if you are doing a high-intensity interval training workout and go to 90% your VO2 max in like five seconds. That is a stress signal, but you're going to use that glucose. Your body's actually, so you're going to see that rapid spike. And it's actually fascinating to see on a continuous glucose monitor, like I will do a sprint workout or a CrossFit workout and it's like within two minutes my glucose is going up and it can look like a big food spike, but the muscles are there using it. And the really cool thing about muscle is that it's one of the only cell types in the body that doesn't need insulin to take up glucose. So it actually can just take it up from the contraction. So it's not like it's really feeding into that pathway of insulin resistance like we were talking about. Like it's a sink for that glucose. So there's a supply sort of use match, which is good. But when you think about psychological stress, you're literally just like, you're sitting in your chair, you're on your computer, you get an email that's stressful. And you're like how are you reacting to it? body has that spike, but you're not moving. Isn't that crazy? Yeah, you're not using those muscles. It's just sitting there causing damage. And you can think about like, we're doing this probably 100 times a day in our regular life.

Or ruminating on something from the past or stressing about something in the future or reacting to the news or whatever it might be that we can react to. How much of the psychological aspect is related to the disease in our life versus just the straight food itself without the psychological, I guess, thoughts that come with it.

You know, I think it's so multifactorial. I always really say, I think that food is the foundation. You know, food is the substrate. Food is both what physically builds our bodies and it's also the molecular information that tells our body how to function. We eat about one metric ton of food per year, two to three pounds per day. This is just straight up chemical information that builds our body and tells our body what to do. You know, we're turning over constantly. The body we have today is not the same body we have in a week from a physical atomic perspective. We're shape shifters. We're constantly changing. So food is incredible. It's magical. It's this incredible thing that we're just constantly transmuting into ourselves. And so we've got to get that right. But while it's necessary, it's not sufficient for optimal health. You've still got to dial in the other factors. And when I really think about the pillars, I'm thinking about seven things. I'm thinking about food, I'm thinking about stress management, exercise, sleep, our micronutrient status, so not just like the macros we're getting, but what are the actual micronutrients, vitamins, minerals, and antioxidants, our microbiome, how that's doing, and then our exposure to environmental toxins. So yes, while food is the foundation, you've really got to get those other things dialed in. Any one of those things can shift you off course.

So you said food, stress, exercise, sleep, micronutrients. Micronutrients.

Which we often overlook.

Okay, what are those?

This is all the vitamins, minerals, and antioxidants that come from whole foods. So things we don't often think about like manganese and selenium and vitamin C and polyphenols and trace minerals like chromium that actually, they come from whole foods and unfortunately because our soils are becoming super depleted, depleted now because of our industrial agriculture practices and because of overuse of pesticides that are really hurting our soils, the nutrient composition of our food is declining and we're eating less whole foods. But when we think about metabolism and the mitochondria again, so your mitochondria is filled with all these little enzymes, these little protein enzymes that are essentially doing the work. They are the factory line that's taking that food and converting it to ATP. And every single one of those amazing little protein machines needs these micronutrients to actually work. And the way to think about it is they are lock and keys that bind into little pockets of these enzymes and create tiny, tiny structural changes that actually make it work. So if we're deficient in selenium or magnesium or manganese or zinc or whatever it is, these aren't working properly. And the majority of Americans are deficient in at least one critical micronutrient.

Right.

'Cause we're not eating real food. Right. And because stress can actually deplete a lot of these chemicals. Sure. So, you know, I really think about, it all goes back to thinking about those molecular machines that are converting food to energy and what they need to function properly. And micronutrients is a big one.

I've also heard examples of people who, let's say, eat perfectly but still have challenges. Maybe their relationships are off and they're in a stressful environment in their relationship or their marriage or whatever it might be, or they just react poorly. They worry often to things they see and experience. They're a warrior. And so every time they worry, there's a, I guess, the stress hormone is spiking, right? And sending hormones to the body, which is spiking blood levels. Is that right?

Yeah.

Blood sugar. So it sounds like the psychological side of things is also extremely important to understand and that every time you're allowing your body or your mind to ruminate on a consistent basis, it's sending a signal to the body in a negative way, which is helpful if there's a real life threat, but not when it's on a repeat every day. Is that right?

That'S exactly right. It's that chronic low-grade stress that can be really damaging. And there's, you know, something that's been really fun to experiment with is, you know, there's now heart rate variability monitors like Oura Ring or Whoop or Leaf Therapeutics. And what these do is heart rate variability is a metric that you can track that looks at actually the time between each heartbeat. And oddly enough, we want the time between each heartbeat to actually not be consistent like a metronome. We want it to have some variability. Yeah, like maybe 0.7 seconds and then 1 point, I'm sorry, 0.7 seconds, 1.1 second, 0.9 seconds. That's variability.

Why do we want that?

It really is a symbol of a dynamic system. You know, you want elasticity in the system and that can sometimes have some irregularity to it. Sort of the way I kind of think about it is like a stiffer system is going to be a little bit more, more more regular and there's sort of that, and these are subtle. It's not like you can feel it in your pulse if you just feel your pulse, but you can pick it up. And so we want more heart rate variability. And usually less, lower heart rate variability is an objective measure of stress. And I've worn these things and been giving a talk on Zoom or something like that, and I'm looking at my data afterwards and my heart rate variability plummeted during the talk or I'm processing email, my heart rate variability goes and then of course glucose may go up. And so you see these things happening together. And the immediate thing I think is this is where our tools come in. This is where the deep diaphragmatic breath, where the mindfulness, where having awareness of this happening. And then there are so many things we can do to modify that stress response, even telling your body, you,'re safe. Everything is actually okay. can have a huge difference. So really dialing into awareness and then where can I apply the tools? So I would say I take about 100 times more diaphragmatic breaths now than I did a couple of years ago because I realized, wow, if this is happening all the time throughout the day without my awareness, that's going to add up over the next 30, 40, 50 years and have a huge impact. But it's not actually just the chronic low-grade stress. There's been a lot of research showing that acute traumatic events, like loss of a loved one or divorce or childhood events, so adverse childhood events, which are usually there's an acronym, ACEs. People who have many of these tend to actually have worse metabolic health. And this actually may be related to changes in the brain that affect metabolism, so really changing our set point for stress thresholds early on in life. And so sometimes we'll have that patient like you talked about who's doing everything right. They're eating really healthy, but they're just really not quite making that progress towards thriving that they want. And a lot of those patients, I'm thinking about what is like the deep core wounds and what's the set point that's causing you to feel that this world is not a safe place, that is causing you to be inherently hyper Vigilant. And doing that work, even on myself, has been so positive because I think what you start to unpack as you go down that Journey is that your perception of the world and whether it's safe is very much dictated by your lifetime of experience. And I think for those of us who have been on a journey of, like, therapy, and now people are very interested in, of course, how psychedelics can fit into this, and then other modalities, long-term meditation, deep meditation events and things like this that can really unwind some of those amygdala-based, fear-based responses in the brain. I think there's huge potential there for that to potentially unlock a new level of health because what it's doing is changing the fundamental way you you see the world as a place of threat or a place of safety. And unfortunately, I think in our modern world, fear has become a currency that we've used to profit in a lot of ways. If we can get people to be fearful, we can get them coming back for information that assuages that fear. And we see that with social media. We see it with the news. There was that undercover reporting of one of the CNN executives who said, you know, was recorded saying, if it bleeds, it leads, you know, that we need to get people fearful for them to come back and watch. And what that's doing to our stress hormones, to our brain set point, to our desire to have dopamine stimulation to kind of get some pleasure in the face of all this fear, the way that's affecting our cellular biology is profound. and so, you know, I think all of this movement that we're seeing right now towards helping people, towards normalizing mental health care, normalizing, you know, psychedelic use is not an end all be all, but I think it's interesting how that's now being talked about as a way to really help people unlock some of this chronic, you know, fear. I think it's gonna have, you know, could have positive impacts on the body, 'cause if we're living with chronic fear, our bodies are not functioning properly, and many of us are.

Did you live with chronic fear for a while?

I think that the healthcare system, the conventional healthcare system, unfortunately uses fear as a way to control patients in a lot of ways. You think about a conversation between a physician and a patient, and it's like, you know, your cholesterol is a little high, you need to take a statin, and the patient might say, well, can I have some time to work on diet and lifestyle? Well, I mean, it's your choice. I mean, I'd recommend the statin right now because obviously I don't want you to have a heart attack, but, you know, sure, if you want to try diet and lifestyle. like that's the type of thing that's happening every day. Like where this fear of bad outcomes is, I think, driving very much a pharmaceutical and invasive intervention type of strategy. And I think that that really was unsavory to me because it's very disempowered. It's like if I can drive fear in a patient, then I can essentially get them to do whatever intervention I recommend. And as a surgeon.

Medicines, procedures, anything.

Right, exactly. You know, oh, well, if we don't treat this ear infection with antibiotics, then it could travel to the brain and create a brain infection. And it's like most ear infections resolve on their own without antibiotics. And overuse of antibiotics is causing huge, huge problems with our gut, which then leads to mental health issues and metabolic problems. But if people are scared of the potential outcome that may be very rare, then of course you can kind of get them to do stuff. And I think that I don't think that doctors are intentionally doing this. I think we have an incentive system in Western healthcare that really drives people towards intervention. But I think that, you know, I also think that with COVID we saw this happen where this fear of anyone being harmed from COVID or that we kind of got people to do anything and everything. And we're kind of losing this, we're losing kind of that rational sense of the risk that is inherent in living. We get in a car every day and there is risk involved in that, but we choose to do it. And I think that You know, there's just a lot of sort of fear-based thinking that happens in the healthcare system that unfortunately disempowers patients and pushes them to do interventions more quickly. When I think that there is so much opportunity to help coach them with diet and lifestyle, which takes longer, it's harder, but ultimately it generates health rather than just putting a band-aid on disease, there's no medication that actually generates health. Only diet and lifestyle strategies generate health. And so that should obviously be the foundation of our medical system, but unfortunately we're not very well trained as physicians to know that information or to coach on it. But yeah, to answer your question, I think a large part of my personal journey has been trying to overcome fear.

Really, personal fear?

Personal fear. I think one of the biggest examples of my mom just passed away. And about a year ago from cancer, and just as any normal person, I spent my life fearing my parents' mortality. Like it's like, oh, this is gonna be horrible and devastating. And I think a lot of people worry about premature loss of a parent. And, you know, I think going through that experience and it actually being a very beautiful transformational experience It was sort of a surprise and she had two weeks between her diagnosis and her death. We had this beautiful time together as a family. She was actually very much on the same page about sort of holistic health as me and knew in her heart that she was dying very rapidly. She chose to stay at home, be with the family. We were all together, had this beautiful time together. spectacular two weeks, the hospital system through every possible medium was trying to pull her into the system. It was pancreatic cancer, so it's like, you need a liver stent, you need a liver biopsy, you need a blood transfusion, you need to start chemo immediately. And the reality was she knew I'm dying right now. She ended up dying in two weeks. None of the interventions would have helped. We wouldn't even have had a, would.

Have lasted maybe a few more months.

Or a few more weeks, maybe you don't know. I actually don't. I think that-- Might have caused more.

Stress and more-- well, and it was.

COVID, so she would have been in the hospital and we could have not visited her.

Oh, that'd be tough.

So anyways, that experience of seeing her approach, seeing her pure joy in the face, she was just ended her last two weeks very joyfully, was very at peace. We had that time together. She was not just like locked in the hospital doing interventions that would not have helped very much. I realized, oh, something I've been fearing my entire life happened was the most transformational growth experience I've ever had. I still feel way more connected to my mom than I ever could have imagined. No one can tell you, oh, you're gonna still feel connected until you maybe experience that. And it kind of made me realize fear is kind of not useful. So I think that something like that, and I think it probably people have their own examples, just kind of makes you realize the futility of living in fear. And, you know, what does it do? It damages your body. It doesn't really change the outcome. A little bit of healthy fear is useful, of course. Like, you don't want to cross the street without looking. But the idea that we should be fearful all the time, like, then that's going to protect us is such a fallacy. So turning to stoic philosophers, turning to to some sort of Eastern texts, Buddhist and Taoist texts, sort of looking into traditions that have thought this way has been a really useful part of my journey and I think needs to be a part of how the healthcare system reforms because we weaponize fear of death as a way to control patients into doing anything we want. And I think fundamentally overcoming your fear of mortality, which is the only thing we can be certain of in this world. And really approaching that with a sense of awe and a sense of curiosity and a sense of what can this teach us about how to live, I think is an absolute foundational part of what we need to do as individuals, but also the healthcare system, because otherwise we're just using fear as this thing, fear of death as this thing, to just wrangle people into as many interventions and as pharmaceuticals as possible with the off chance that people think it's going to somewhat reduce their chance of mortality.

So what I heard you saying there was that there is no medicine that can actually make you healthier. Is that correct? Or that could actually solve the issue on the medicine itself?

The vast majority of all medications I probably wouldn't say all on a record, but I would say the vast majority do not generate health in the body. They manage.

They don't cure the disease.

If you take away a diabetes medication from someone, their diabetes is not gone. It's right back there where it was. Whereas if you get someone to really foundationally improve their cellular function, which can only be done through consistent dietary and lifestyle habits, they can truly reverse their disease. But there's no medication that reverses diabetes. There's no medication that reverses heart disease. There's no medication that reverses Alzheimer's dementia.

They just kind of manage the symptoms.

They manage the symptoms.

Maybe some relief a little here and there.

Relief, you know, life extension for some of them. but they do not create health. And what health is, health is optimal cellular functioning. We are just a big bag of cells, and each cell needs to be functioning properly for us to have health. What is a symptom? What is disease? That is cellular dysfunction happening on the individual level, happening in a, if that's happening in mass, that might be tissue dysfunction. If that's happening in a bigger way, it's organ dysfunction, and that's when we see symptoms and disease. So we have to really zoom in on what's happening in the cell. And what is a cell is being getting its information from what you're eating, what it's being built from, which is your food, what stress hormones it's seeing binding to its little cell membrane, what's happening with your hormones, which of course is dictated by stress and by sleep and by exercise and by food. It's the super complex milieu that can only be optimized by the choices that we're making every day, day in and day out consistently, even by the sunlight we're exposing ourselves to in the morning. And, you know, Andrew Huberman talks about this all the time, but literally the consistent exposure of sunlight first thing in the morning is chemical information to your body through the sunlight's energy. to tell your cells how to function. You can't put that in a pill. It has to happen through these millions of years of evolutionary involved processes. And so, yes, medications can't with their one pathway that they might be intervening on truly generate foundational cellular health, which is what we need to achieve.

They don't bring wholeness back to the cell. I guess there's what? some creams or something that might help you heal a cut or something like that, but we're talking about like a chronic illness medication, right?

Yeah, but even if you think about a cut, you know, I mean, a cut is like, it seems so simple, but it's actually so complex. It's like, for a cut, if you think about people with disease, like diabetes, for instance, one of the reasons that people with type 2 diabetes die is because of chronic wounds. They have wounds that won't heal.

Interesting.

Oh, yeah. And I know- Are they internal wounds or external wounds? External wounds. People can get something that happens with people with diabetes is they often have nerve damage because of the way the blood sugar is affecting the nerves. So then their feet become numb and then they might get a cut on their foot, they don't feel it. And then that festers and because of their high blood sugar, their immune cells don't work so they can't heal the wound. And then they die from the wound. And then they get a huge that might lead to death or an amputation. So, the majority of lower limb amputations are caused by diabetes, diabetic ulcers that are like wounds.

How many people have type 2 diabetes in the US? Do we know the number?

Oh, yeah. Well, there's 128 million Americans with pre-diabetes or type 2 diabetes.

Come on.

Of those 30 million have full-on type 2 diabetes.

30 million out of what? 300 million? What is that, 300 something?

Yeah, it's about 13% of the population.

Has type 2 diabetes.

Yeah, and it was less than 1% in the 50s and 60s.

And pre-diabetic, you're saying 100 million.

Yep. Around that.

What is pre-diabetic mean? Who is someone who might be pre-diabetic?

Well, it actually can be quite surprising. There are lots of young, healthy people walking around who look otherwise fit, who have pre-diabetes and don't know it. 90% of people with pre-diabetes do not know that they have it. How do you know if you have it? Well, the easiest way to do it is through a blood test. So you basically get a fasting blood sugar test from your doctor and if it's between 100 and 125 milligrams per deciliter of fasting glucose, that's considered pre-diabetes.

100 to 125. 100 to 125. Where do you want to be at?

What's a healthy range? So what's considered normal is 100 or below. 100 below. But I would say that that is way too lenient of a range because what we figured out is that people in the low end of normal are much less likely to develop long-term problems with like heart disease, stroke, or diabetes. So even if you're in the high normal range and your doctor says to you, oh, your fasting blood sugar is 97, you're great, you're normal.

That's very close to 100.

You see that as a huge red flag.

Wow.

You are metabolically dysfunctional if that's the case. And so really where you want to shoot for is about 70 to 85 milligrams per deciliter.

People get a test that they can order and do this themselves or you have to go to a doctor. Sure.

What are these? You can actually buy it at CVS or at the pharmacy.

What's it called?

Prick your finger. Or what are these called? One drop. They're called glucometers. So you can just, they're like literally $20 on Amazon.

There's Keto Mojo.

You just prick your finger.

And then it'll tell you right away.

Or in a few minutes.

5 seconds, yeah.

So then it just tells you what your level's at. What it is. And it's cool to check it actually day to day, like for a few weeks, because one thing you'll find is that let's say you have one poor night of sleep. Let's say you had a big work thing do and you got 6 hours instead of 8 hours. Your blood sugar in the morning might be 10 points higher. Come on. Oh, for sure, yeah. Or let's say you had a really late meal the night before, your blood sugar might be higher the next morning. So what it starts putting together for you is this is very dynamic and if I did these activities day after day, year after year for my whole life, I'm building. So figure out what allows you to be in that 70 to 85 range. Maybe it's like a really awesome workout in the middle of the day prior and getting to bed a little bit earlier and getting morning sunlight exposure and doing some deep breathing in the morning and all of a sudden you're like, oh, my blood sugar is 72 milligrams per deciliter, or fasting for 16 hours or something like that. But figuring out what works for you to stay in that low range and then dial it in for as many days of the week as possible as you can. The other really interesting thing about fasting blood sugar as a test is that the body, like we were talking about with the insulin resistance, it's very adaptable. And when the body starts becoming insulin resistant. So it's saying, we're seeing too much glucose around, we're producing, like, we're gonna create an insulin block. What the body does is it's like, well, we've gotta get this glucose out of the bloodstream, so it starts producing more insulin. So your insulin levels will actually start rising as you become insulin resistant to push more of that glucose into the cells. And so a study in the Lancet, a big medical journal, showed that you can actually keep your blood sugar levels normal for like 13 years prior to them elevating and all the while insulin is rising, but it's compensating to keep glucose low. Unfortunately, because we don't check fasting insulin in this country, we're missing that window where people are clearly becoming insulin resistant, but their glucose still looks normal on their yearly check. So to just make this concrete, you and I could both go to the primary care doctor and have a fasting glucose of 80 milligrams per deciliter. And so the doctor says to both of us, you're both in perfect health. If I'm really insulin resistant because I'm on that glucose roller coaster and I'm getting poor sleep and I'm chronically stressed and not managing it and I have childhood trauma that I haven't addressed, blah, blah, blah, all that stuff, I could be at 80, but I'm doing that by my insulin being elevated to like 35 or 40 and your insulin might be 2. So your body's not working hard at all to keep your insulin at 80 and my body is having to produce so much insulin. So I am clearly on the path towards metabolic disease, diabetes, and all the associated conditions, heart disease, stroke, cancer, Alzheimer's, fatty liver disease, gout, infertility, erectile dysfunction, blah, blah, blah, blah. And you're in the clear, but our doctor tells us that we're the same. So this is why I recommend that every patient ask their doctor for a fasting insulin check because you have a sense of what's actually happening under the hood. And if you're in that early range, and of course, this is talking about people who are in the normal range, that's not even included in the 128 million Americans who actually have a diagnosis of prediabetes. So this is like people in the normal who still may be on the route to problems. So it's now becoming like the majority of the country is dealing with a fundamental problem in how they make energy in the body, which is a core process that allows every cell to function.

And you're saying there's seven factors to this, but what would you say are the main couple? Is it food and lack of exercise or what?

I would say the four most important pillars are food, sleep deprivation, and interruption in sleep. Just the beeping and the buzzing and the blue light late at night that interrupts our sleep quality, the chronic low-grade stress and the fear that so many people are dealing with, and then the sedentary behavior, the fact that most Americans are sitting more than eight hours a day. And that is just sitting creates inflammation in the body. It keeps that glucose in your bloodstream and not going into the muscles. And the exercise one, I think, a really empowering, just a tip for people, It doesn't have to be like go out and run five miles or do a high-intensity interval training workout or do a CrossFit workout. It literally is as simple as walking, maybe walk 15 minutes after a meal, especially if it's a high-carb meal. And even walking for two minutes every half hour has been shown to statistically significantly reduce insulin and glucose levels throughout the day. It's actually the study was minute and 40 seconds. So it was looking at for people who just walked for 30 minutes in one chunk of the day, but otherwise sat during the day, versus people who walked for 30 minutes but broke it up into one minute and 40 seconds every 30 minutes throughout the waking day. Those people that moved more frequently, but the same quantity, had much lower glucose and insulin. And I think the reason is because if you think about sitting all day and then walking for 30 minutes, you basically just like been atrophying your muscles all day. Like you're just this like, you know.

Blobs sitting there versus the continuous of it like constantly.

Yeah, and again thinking back to the cells, you're activating these pathways. It's all just information to the cell, activate the pathways, get them moving, you know, clear the glucose every 30 minutes, you know. And so it's not like this is a lot of stuff you have to do. A simple walk makes a big difference but I think one of the, from looking at all this literature, one of the biggest takeaways I've realized is that moving more frequently, even if it's low intensity, is key.

It can't just be that one chunk. Yeah, and maybe if you're in an office or something or you're not walking or have the ability to walk, maybe you do some air squats or push-ups or just anything where you're moving your.

Body, some split squats, whatever it might be.

Just body weight stuff.

For a minute, a minute 40 seconds. Lift your knees up in the air, something.

Yeah, whatever.

Yeah, exactly. I love that.

That'S interesting. Some high knees.

Yeah.

Wow, this is fascinating. So 13% is that what you said, has type 2 diabetes in the US? Is type 2 diabetes reversible?

Absolutely. Yeah.

But beyond that, it's not reversible, is that right?

Well, type 2 diabetes is sort of the, that's like once you get into that range of type 2 diabetes, of course there's a spectrum of how how bad it is, right? And it's always easier to reverse these things earlier on.

Type 2 diabetes is the far, there's another, there's not a type 3 or type 4.

No, type 2 diabetes, so basically- what does that mean when you have type 2 diabetes? So it means, based on our criteria, it just means you meet a particular threshold of blood sugar levels. So if you're first thing in the morning fasting blood sugar, you go to the doctor, they take your blood, if it's below 100, Non-diabetic, 100 to 125, pre-diabetes. 126 or above, type 2 diabetes.

And you can reverse that the earlier you catch it back to the pre-diabetic or to the 100 to 125 and then hopefully below that with nutrition and lifestyle. Absolutely.

Yeah, and there's actually been studies showing, I mean Virta Health, Sarah Hallstead, she's an amazing, this company is showing reversal of type 2 diabetes with a low-carb, high-fat diet and coaching. I mean, it's not even an exercise intervention, it's just diet. And they showed that in 12 weeks.

The type of coaching.

Coaching, just nutritional coaching, like with a doctor.

Yeah, are you doing this every day?

Just checking accountability. Exactly. They're not even including exercise. It's that simple. And they are showing amazing reversal of diabetes to the extent where the American Diabetes Association, they did not actually recognize reversal of diabetes as something that's possible until this past year. They're actually calling it remission, which I think is a funny term. It's basically reversal. I mean, you're changing cellular function, you're becoming more insulin sensitive, you're lowering your circulating glucose levels, and the reason why you want to get on top of this early though is because the longer you have diabetes, again, coming back to the mitochondria, the more damage what you're doing to those cellular structures. It's harder and harder to reverse. It's harder.

How big of a business is type 2 diabetes in the US alone? A year.

Incalculable.

How much money is spent on the management of type 2 diabetes?

You'll see lots of different numbers, usually somewhere between 200 and 600 billion.

200 to 600 billion?

Yeah.

Just for type 2 diabetes.

Our health care costs are $4 trillion per year, about 17% of our GDP. We spend more than, of course, any other country in the entire world.

70% you said? How much?

17.

17%.

Yeah.

17%. 4 trillion is health care in the USA.

Yeah.

What is Canada?

I don't know.

Okay, gotcha.

But if you look at the curve, it's like all these little dots down in the lower left corner, and there's like the US up here in terms of cost.

200 to 600 billion of that is in the type 2 diabetes.

Metabolic management.

Management. Yeah. Holy cow.

And on top of this, our life expectancy is going down. So what's ironic about the American healthcare system, and for three years our life expectancy has been going down. You would think, right? This is sort of what perplexes me about physicians right now is that As a physician, you're really like a steward of the system. You are the person sort of calling the shots and doing the treatment. You look at this system and okay, every single year we're increasing healthcare costs. Every single year it's an increasing part of our GDP. We're now spending $4 trillion on healthcare. We're literally throwing money at it and outcomes are getting worse every single year. If you're not stopping and thinking, What is going on? What are you doing with your time? It's not working. We're getting sicker. Every single year we're getting sicker, we're getting fatter, and we're getting more depressed as a country, and just throwing money at it. And I think the key problem with this is that the modern American healthcare system has produced miracles, literally. We have 100 years ago first today, if you transported someone from 1900 to today, and they looked at what life expectancy and infant mortality and what happens when we get an acute illness, they would be shocked. It's unbelievable. But that's because we are very good at managing acute illnesses. So if you have an infection, something like childbirth, if you break your arm, if you're in a car accident, we can manage these things.

Whereas before we weren't good at that and so people would die or have massive complications with those.

Absolutely, yeah. And so that's great. We can manage that, but chronic disease is where we are abjectly failing. Chronic diseases are 90% of our healthcare costs. They are the things that are killing Americans, and they are based in diet and lifestyle. And those are the things that we are doing having, this is worse outcomes, the more money we spend.

So 90% of the $4 trillion, is that what it is?

Goes towards chronic disease.

Chronic diseases, which is what else besides type 2 diabetes is included in that?

These are the diseases that are like long term are considered to be develop over time and are generally rooted in diet and lifestyle. Like heart disease, Alzheimer's dementia, chronic respiratory illnesses, chronic kidney disease, chronic liver disease. You know, there's like depression, anxiety, chronic pain, chronic fatigue syndrome. gout. There are things that don't just like come and go like a cold or it's not overnight. Come and go.

So 90% of these of the money is going towards chronic disease and illness.

That's right.

And what I'm hearing you say is chronic disease and illness can be prevented with nutrition and lifestyle.

Or reversed.

Or reversed.

In many cases, of course not all.

Most of the cases I'm assuming a lot of the cases, right?

I think a huge burden of that disease could be prevented or reversed. Obviously, there's gonna be cancers that you can't reverse with diet and lifestyle, but a lot of the cancer we're seeing today could likely be prevented. But we're not trained on how to do that effectively as physicians or any practitioner.

How much money could we save if we just invested in the prevention and the lifestyle nutrition training and coaching versus just spending money on these things that are masking and not solving the problem.

I think trillions of dollars. Wow.

Yeah.

And the funny thing is, is that, you know, what taxpayers don't realize is that they're paying for this like four times over. It's crazy. We are paying taxpayer money to, of course, fund, you know, health care, Medicare, Medicaid, all these things. We are then going to the doctor and paying our co-pays, we're paying our insurance premiums, we're paying for that service. We are also paying taxpayer money for the farm bills and for the food subsidies that are making all the disease-promoting foods cheaper for Americans. So we spend $31 billion on our farm bills, which directly subsidize the foods that cause disease, making them artificially cheaper. So this is corn, sugar, soy, wheat, and other foods like that does not go towards the vegetables and the fruits, which are actually part of a separate very small horticulture bill, which is like not even, like a fraction of... 10.

Million or something, yeah, so small.

It's a tiny little amount. So they're paying for those that then make us sick. And then of course we're paying for the environmental damage of those terrible farming practices of the foods that make us sick that are then ruining our top soil and creating horrible runoff in our rivers and oceans. So literally, like you walk into the store and you grab, you know, Skittles or you grab Wonder Bread. And I think what people don't realize is that if that had a real price tag on it, it would be like $150. You know, because it's the health care cost, it's the cost of the food, it's the cost of the taxpayer money for health care for others, it's the cost of the environmental damage and it's the cost of the farm bills. We're paying all that.

That's crazy.

Yet it's $3.

Yeah, what I think what's cool that you're doing and a lot of other of your peers are doing is trying to give people information and access to take back control of their own health and prevent a lot of these things from happening by just making better choices every day. Having the information and the education of what makes you sick and what keeps you healthy with all these different factors you've talked about and also just staying on track with it, you know, staying on track consistently to prevent and stay healthy as long as possible. The challenge is there's so much temptation in the world. There's so much temptation and so much available at all the times to make poor choices, whether it becomes nutrition, diet, sugar, all these different things, processed foods. It's very challenging for a lot of people. Even myself, I wonder should I consider a healthy person active. I just ran a marathon three days ago for my first marathon.

Congratulations.

Thank you. But I still feel like, oh, but I still, I'm not in the best shape that I could be in, right? Because of the nutritional aspect. I can go months of eating super clean and healthy and then other months where I'm like, I feel great. Let me just have some sugar every day now. So it's the accountability, it's the structure, it's the Accessibility to so much processed foods, which I think is challenging for a lot of people. And I think that's what's one of the hardest things is just the discipline it takes. The personal discipline. So how do you manage it personally? Knowing all this information, do you still eat a lot of sugar or are you kind of like cut sugar out of your life now?

Yeah. Well, first of all, I think the points you made are so important. Like it is hard and that's why That is why I'm excited about technology that helps people eat better because like continuous glucose monitoring and of course what we've started with levels is because it's not like I want to walk around and see everyone being a cyborg with technology on their arm. I'm actually a very crunchy granola person. I'm not the most tech savvy person and I want to just be in the backcountry unplugged. That is my ideal. However, the cards are stacked against us so monumentally in the ways we've talked about. The past 50 to 100 years, the human body has had to be bombarded with all these external signals that it's never had to deal with in the tens of thousands, hundreds of thousands of years of evolution, and it's breaking our bodies. We have broken bodies, by and large, in America, as evidenced by the fact that six in 10 American adults have at least COVID-19, chronic disease, we're breaking. And so those cards are sort of stacked against us. Of course, there's governmental factors, there's all this stuff, there's food marketing, our school lunches for kids are awful. And so in the face of that modern reality, tools to empower ourselves to make decisions that are better, I think are very important. And ideally, you know, you could use these tools to gain awareness, to gain learning, to gain knowledge of how to eat and live in a way that keeps your blood sugar more stable, that keeps your metabolic health on point, and then maybe you don't have to use it anymore. You know, maybe it's just you- learn about it. You know, I'm not wearing one right now. I've been at this for three years, and I can go months now without wearing one. I mean, it can be very helpful.

For accountability at this point, but-- But.

You know what works and what doesn't work now. Yes, and it's a nuanced balance. And so that's what I'm so excited about is empowerment. I think that is the key word.

Yes.

Because your doctor might say to you, oatmeal, you've got high cholesterol, so eat oatmeal. This is a heart healthy whole grain.

That might be not bad for you.

Well, put a blood sugar monitor on your arm and eat the oatmeal and see what happens. And maybe for you, your blood sugar stays quite stable and you don't have a big spike. But for me, because I've tested this, one serving of Quaker Rolled Oats caused me an 80-point glucose rise and crash, which is about four times higher than the highest I want to go. I want to go up like 20 points after an hour.

You want to stay here, not here. Exactly.

So for my body, terrible metabolic choice. For yours, maybe it's okay. But the fact that the doctor's saying it sort of works for everyone, that's where we can kind of get into trouble because every single body is different. We are so biochemically individual and what works for you and me might be very different in terms of what causes a blood glucose spike. And it can also be different day to day. Like again, if I'm sleep deprived, it might hit me a lot harder than on the day that I'm not. So knowing what those variables are can be really useful information. So for me, like, When I started wearing continuous glucose monitors, when we started Levels, I was almost 100% plant-based. And what I learned super quickly was.

That there were- Before the monitor, you were plant-based.

And I'm still 93% plant-based. But I'll eat a little bit of really thoughtfully sourced animal protein now. But what it did for me was make me realize that within my plant-based diet, there were certain foods that were causing really big spikes and how I could modify plant foods and balance them with adding fat, protein, and fiber to my carbohydrates to keep the spikes much less.

Because you could be plant-based and be unhealthy.

Absolutely. Oh my gosh.

And if you're having sugar all day long and be spiking left and right still.

You can just be trashing your health that way. And I think that one of the things I'm most excited about with this personal biofeedback data about nutrition is that I think it's going to pull the rug out from diet wars and from.

All these really... Let's just show the proof.

Here's the evidence.

Yeah.

Because I can look, someone who's carnivore and this has happened, can be ripping on vegans on social media. And if I can come out and say, here are my blood sugar curves, they're flat. My insulin is three, my cholesterol is XYZ, my inflammation markers are this, my vitamin D is this, and my omega levels are this, how can you fight with me? This is work for me. This is healthy. And it might actually look identical to their lab work because the body is such a complex system. There are many different redundant pathways to kind of getting to the same outcomes, but the key is you have to be so thoughtful about how you're doing it. The run-of-the-mill vegan diet is probably not going to be great for people Neither is the run-of-the-mill carnivore diet. Exactly. And so just having insight into that, but I think it's again, it's like the proof is in the pudding and that's where I'm excited to see more data helping to quell some of the debate of what's better. Because each body's different and, you know. That's interesting. So tell me about levels then.

What are you guys doing at levels with this? Is it called constant glucose monitors? That's what it's called? Continuous glucose monitor.

Continuous.

Yeah, CGM. where you put on, you essentially put on a monitor in your skin, right? For two weeks, is that what it is? And then it monitors your blood levels for 24/7 for two weeks. Anything you consume or don't consume, it tells you what's happening. You have an app that shows you and tracks it. So why is this essential for someone to be curious about and to be potentially want to try this out?

Yeah. The reason why it's something that I think is relevant to pretty much everyone is because of the rates of what we're seeing in our country. If you're just living your life standard American diet, more likely than not you're gonna end up with a metabolic disease. That's just now common reality. And so having some information to both see what the trajectory is over time, have a real sense of ownership over what's going on metabolically in your body, I think that's really empowering. Right now, you get crumbs of information from your doctor once a year, but imagine if you could really have ownership over that foundational aspect of your health. That's one thing is just the awareness. Then the bigger piece is to have this closed-loop biofeedback on everything you're eating and everything you're doing to keep glucose more stable because we want to get off those ups and downs swings not only to improve our day-to-day functioning and the subjective experience of our days, the energy, the mood, the cravings, the fatigue, but also to set us out for the long-term avoidance of the glucose-related metabolic diseases. And so that's really the reason to use it. And what I love about it is just like with the oatmeal example, try a food, see what happens. The cool thing is even if you do spike, it doesn't necessarily mean you have to get rid of that food. forever, it means that you can potentially modify it and work with it. So let's take the oatmeal example, for instance. If you love oatmeal, like you're just like, I do not want to live without oatmeal, that's fine. One thing we've seen in our data set, so we've had about close to 25,000 people go through our program, we have over 50 million glucose data points, so we have a lot of information here. People who eat rolled oats, like instant oats, which are fairly processed, spike higher than people who eat less processed forms of oats like steel cut oats or groats, which are kind of like a chewy, very whole food form of oats. So eat one of the less processed ones potentially or add fat, protein, and fiber to that carb. The carb alone, if you're eating what I call like a naked carb, essentially a meal that's just like dominant carbs. Yeah.

No fat, protein.

Yeah, like two bananas or oatmeal or Skittles, like you think about some candies, like Skittles are basically just like sugar. Whereas like a Snickers bar actually has- Peanut butter. Peanut butter, chocolate, and nuts. And chocolate. And crazily enough, Skittles have an over 80 point glucose spike in our data set. And Snickers is like 35 or something. So it's like half, and 'cause Skittles are more of a naked carb. And so Skittles are actually the highest.

Spiking food in our entire data set.

Come on. Yeah.

Just a straight sugar ball.

Straight sugar ball. Skittles, Candy Corn, Milk Duds, it's like.

They'Re all very similar. Jelly beans.

It's like sugar coated on sugar. There's more sugar. That's crazy. So yeah, so you want to avoid that naked carb situation. So I see oatmeal with chia seeds, which has tons of fiber and protein, a little bit of almond butter, which has fat, protein, and fiber. Add a few maybe low glycemic berries, like a couple blueberries or raspberries or whatever, which have a good amount of fiber and antioxidants, maybe some flax seeds on top, which is going to be fiber and fat, mix it all together, and you're going to probably absorb the glucose slower. It's going to slow digestion. The fiber can actually block the amount of glucose that gets into the bloodstream. The fiber also has the effect of feeding the microbiome, which has downstream positive effects on metabolic health. So it's like, keep the oatmeal, but modify it. And if you're not wedded to oatmeal, then start experimenting with other breakfasts. So for me, I'm like, I couldn't care less about oatmeal. So if I saw that it spiked me and I think I never ate it again, I'm like, I don't even like this.

I just thought it was healthy.

So like... You cut it out or you're like... For me, that's gone. And if you look in our data set at what some of the best scoring breakfasts are, we see things logged like eggs and avocado, eggs and greens, we see frittata, we see we see chia pudding. We see actually one that we see is like green, some, there's a particular smoothie that we actually see logged a lot. It's called the Fab 4 smoothie. It's popularized by Kelly LeVeque.

Yeah, she's great.

She's amazing. And she, it basically is a really well-balanced smoothie that's low sugar, high protein and fiber and healthy fats, and there's some vegetables in there as well. a lot of our community logs that. And so it's actually got a very low glucose spike. So what you can see from this amazing data set is that there's all these options that have less than 20-point glucose spike. So choose those.

Choose those options.

As opposed to.

Interesting. So someone signs up for this, I guess there's a waiting list right now. But when they, what does it do for them? Does it coach them on the foods to eat? Does it tell them, you just ate this, and it's not good for your system right now, add this to it if you want to keep eating it. It kind of coaches you for those two weeks or what's it do?

Yeah, it does everything that you just said basically. So a Levels member will actually use it for a full month to start. So the sensors are on the arm for two weeks. So the first month of Levels is two sensors. So you put one on for two weeks, you peel it off, you put a new one on and so it's 28 days total. And throughout that process, it's just exactly what you're saying. You log your food, you take a photo of it, and then you get a score for each of those meals. So the score is essentially a one to 10 zone score is what it's called that tells you about the glucose impact of that meal. So you're shooting for tens, and one is like lower. So, for example, I could eat sushi, which of course has white rice, and sometimes the white rice has sugar actually added to it. And for me, like sushi, usually scores like a two or a three. Like I have a very, very high spike.

And you want it to be a one.

You want it to be a 10. 10. You want it to be a 10. So that's like a pretty, like that would look like a big, sharp, spiking crash. So what I learned and what the types of things that we talk about in the Levels app is like, okay, well based on what other people have logged, if you log sashimi, you're probably gonna score like a 10. A nine or a 10, 'cause that's of course just like straight fish. People are now logging cauliflower rice sushi, which is kind of interesting, which has like almost there's no glucose spike, and there's actually restaurants offering this now. Or, I mean, I think like me, there's some people who just don't wanna give up sushi. That's not like oatmeal. Like for me, I'm not giving up sushi. So then there's other things that'll suggest, like for instance, add preload your meal with, before the sushi, have a salad with protein and fat. 'Cause there's been research that's shown that if you eat, again, fiber, fat, and protein For carbohydrate, if you sequence the meal differently, you actually have a lower glucose response. So you can eat the exact same sushi, but if there's some other stuff in your stomach first, it's processing it at a different rate. It's processing it differently and it's changing the hormonal response to the food. Or it will say, you're going up, your glucose is going up, take a 10 to 15 minute walk right now. No way, and it'll bring it back down.

Oh yeah, for sure. I mean, it can definitely bring it back down.

It just tell you like live data.

Is like, okay, you need to add.

This or you need to go walk or... It's telling you in pretty close succession. Yeah, and helping you. If it sees a spike, it's gonna.

Say, when you're in this range, go take a walk or add this or eliminate that.

Yeah, and actually if you have a spike and you haven't logged anything, we'll say to you, hey, what happened here? What did you do? Interesting. And some people will see spikes if they're exercising, like we talked about because of the stress response. Usually if someone when someone's going above about 70 to 80% of their max heart rate, they're going to see a spike when they're exercising. A stress response type thing. And we can, people will be able to exclude that from their scores because we know it's not a food induced spike. It's not like the same as sort of a potentially damaging food induced spike.

This is fascinating. Yeah. Because it gives you information on your body. Yeah.

And then we'll give people tons of swap options. Like for instance, if they log a tortilla, like let's say they log tacos and they have a really big spike. We have a ton of content on like, here's 10 other tortilla alternatives that we don't know don't spike as much. So for instance, like, jicama tortillas from Trader Joe's. There's now, there's keto tortillas. Like, I just got to LA yesterday, first stop, Erewhon. Got their almond flour keto tortilla. I'm like, in love with them. I spent $70 on those. Yeah.

Oh, yeah.

They're like, you know, $40 a piece, but I love those tacos. Butter lettuce is great. So there's different options. So we'll give people those resources, give them Costco shopping lists, give them- that's pretty cool.

Okay, now I'm excited to try this. What do people need to do if they want to get on the wait list or sign up to be part of this?

So they just go to levelshealth.com and put your email address in and you'll be in the loop about the wait list and getting off it.

Because you're kind of like rolling it out every few months to new people, right?

Yeah, exactly. And then that'll also sign people up for the newsletter, which has just a ton of amazing information about a lot of the stuff we talked about today and a lot more tips. And there's certainly people who don't need a continuous glucose monitor to apply these metabolic health strategies. You can learn from what people in the program have learned and apply that to yourself. And so we try and put as much of that on the blog as possible so that people can learn. That's interesting.

This is fascinating stuff. Are you on social media a lot yourself, too?

I'm on social media at Dr. Casey's Kitchen, so Dr. Casey's Kitchen. And then Levels is at Levels. Okay, cool. And we post a lot of experiments that our members are doing. That's cool.

Yeah, and so get some fun ideas for people to try. How many people are using it at one time? Do you know? Because you said 25,000 people have done it over the last couple of years.

But how many people are on it right now?

Do you know? It's a good question.

Is it hundreds? Is it a thousand? I'd say a couple a couple thousand. I don't know the exact number for sure, but around that.

That's so interesting. Really cool stuff. I've heard a lot of great things about it, so I'm gonna have to try it myself. And I guess I'll be wearing a patch for a couple of weeks, for a month. But it'll be cool to see the research on myself. Really cool. So guys, go to levelshealth.com, check it out. Dr. Casey's Kitchen, if you want to see more about Casey as well. What else should we be thinking about or how else can we be support to you or Levels? Oh my gosh.

Well, I think the best thing you're doing is just having these fabulous people on your podcast. You've had so many wonderful people in the Levels community on and I think just spreading the word about holistic health and metabolic health, I mean, it's amazing how I think podcasts like yours and Andrew Huberman, David Sinclair, Dr. Perlmutter's podcast, Mark Hyman's podcast, Drew Pruitt, These things are becoming the thing that people look to to figure out how to actually create health in their lives. They're not necessarily getting it from their doctor. I think it's a really exciting time that we're in. I'm very grateful for the work that you do. That's cool.

I appreciate it, Casey. This is a question I asked everyone at the end called Three Truths. I think you know what's coming. Imagine it's the last day on Earth for you and you've lived an incredible life, done everything you want to do. but for whatever reason, you've got to take all of your work with you to the next place. So no one has access to this conversation or your blogs or content or anything you've ever done. But you get to share three lessons you've learned from life with the world, and that's all we have left to kind of be remembered by you. What would you say are those three lessons or three truths?

I think one of the biggest ones for me in terms of what brings joy and satisfaction to my life is to focus on the little things and just true awe in all the amazing things going around us. I think if you just step back for like one second, you know, and look at what's going around us, we're in this incredible cosmic journey, you know, we're hurling through space, we're made of trillions of cells, innumerable atoms, we're constantly, you know, it's like every time we eat, we're literally taking in matter from the universe and converting into our body and shifting our shape every day. We're part of this incredible continuum of energy and matter. I think it's just so awe-inspiring. So just step back, look at the awe, the fact that the sun is shining and telling your brain what to do. It's fascinating. So I think focusing on the little things and just having a sense of awe and reverence for everything around you who brings me just such intense joy every single day. It can help elevate you from some of the day-to-day stresses. So, awe. Live with awe and focus on the little things. And of course, that loops into being in the present moment because you have to stop and pause to see things. I think the second thing would be really, we talked about this a little bit earlier, but really focus on death, examine it. think about it, be curious about it. I think one of my favorite quotes, Steve Jobs talked about death as life's greatest invention. And I think that's so true when we overcome our fear of mortality and have a good relationship with death and see it as not an end, but a part of the process that's very natural. Think about the way that energy cycles through generations and we're a part of that, I think it's incredibly liberating. And again, getting back to the question of fear, if you can not be fearful of death, you have a lot of power to make your own decisions and not be controlled by external forces. And so there's a lot we can learn from it. So I would say on a practical level, yeah, read some of the Stoics, read some of the Buddhist or Zen thinkers. read some Mary Oliver poetry. There's people who are grappling with this and it can really make life, I think, more joyful, ironically. And then I think the third thing would be just never stop asking why. And really, if anything is conventional wisdom or is being kind of spouted by the large majority in a loud way or anyone's having be coerced to believe something is true or manipulated or like ask why and think about the bigger picture. When you keep asking why it just makes life so much fun. So for me, like looking at the healthcare system being like we're spending more money, people are getting sicker, why?

Why?

That was the best question of my life and led me to leave the surgical world, get into functional medicine, ultimately start levels and realize this incredible world of metabolic health and how things are connected rather than how things are separate. And I think that I just hope that doing that at every stage will continue to just open up whole worlds of new opportunities. So I would say ask why and challenge conventional wisdom and think for yourself.

That's beautiful. One of the reasons I keep asking questions on this show after nine years. I'm still curious and I want to learn more. I think those are great. I want to acknowledge you, Casey, for asking why many years ago and taking a shift in your career and your mission from being, I guess, in the practice of surgeries and prescriptions now into prevention and reversal of these, I guess, diseases for people and really helping people shift their thinking from having personal power, personal knowledge and information on their health. I acknowledge you for taking the shift. It's a big change, I guess, for it probably feels like a big change for a lot of people in the medical world to think differently than what they've been taught for so long. So I acknowledge you for seeing things and allowing yourself to reinvent an identity that you once held onto probably for a long time and shifted into a different part of your identity. So I really acknowledge you for the process. and all the great information you're giving people with levels. It's really inspiring to see what you guys are building. Congrats on that as well. Final question, Casey, what's your definition of greatness?

My definition of greatness is being able to achieve and embody sort of thriving in this world and to be able to enact your purpose and fundamentally be able to go out there and really really live your purpose and shine your personal light, that really requires us being healthy. And so that is what drives me as a physician and as a health tech entrepreneur is if we can help create more function in people's bodies, they can go out and share their light, which is, you know, their greatness, make their minds healthy, help make their bodies healthy, help empower them to take control of their health. And so that's really just how I think about how I think about greatness, being able to shine our light and embody our purpose.

Love it. Casey, thanks so much. Appreciate it. Thank you so much for listening. I hope you enjoyed today's episode and inspired you on your journey towards greatness. Make sure to check out the show notes in the description for a full rundown of today's show with all the important links. And also make sure to share this with a friend and subscribe over on Apple Podcasts as well. I really love hearing feedback from you guys, so share a review over on Apple and let me know what part of this episode resonated with you the most. And if no one's told you lately, I want to remind you that you are loved, you are worthy, and you matter. And now it's time to go out there and do something great.