EP086: Leveling the Health Playing Field with Sachin Patel and Josh Clemente, Founder of Levels

Welcome to the Perfect Practice podcast where we share the most innovative strategies to help you build a successful functional medicine business, attract your ideal patients, serve your community, and get paid what you're worth. Each episode is packed with practical steps that you can take to immediately grow your influence and serve more people. Our mission is to share golden nuggets from successful practitioners, technology experts and innovators from around the world. Your host, Sachin Patel, is a functional medicine and success coach, international speaker and best selling author. He's calling in all his favors to bring this information to you so you can create your perfect practice.

All right, hello everyone. Welcome. I'm super thrilled today because we have a very special guest who's got some great insights he's going to be offering us. So I wanted to welcome Josh Clemente. Josh, welcome to our mentorship group today.

Thanks so much for having me on.

Well, it's such a pleasure to have you and it's such a pleasure to learn about people like you who are doing amazing things in the world to make health more accessible to people. And as the founder of levels, I'd love for you to tell us a little bit more about you. You've got a very unique background and I want you to share a little bit about what's got you so hyped up and interested in helping people fine tune and regulate their blood sugar.

Yeah, well, my background is not in medicine or physiology or biology. I actually am a mechanical engineer. I started out at SpaceX and I spent about six years there. And the last half of my time I was developing life support systems for the astronaut program. And so it was actually there that two things happened. I personally pushed myself to the point where I kind of hit a breaking point in terms of my personal well being. I was burning out mentally and physically rapidly. And most of it was due to the fact that I was burning the candle at both ends and trying to pull off a really, obviously a strong program for SpaceX and also do it in the most effective fashion and keep my team going. And so I was sleeping very poorly, I was eating whenever I could, and I was just working out as hard as possible, trying to make up for it in the gym. And I got to the point where despite not having any sort of outward signs of, you know, concerning, any sort of outward sign of concerning health, I felt like I had a terminal illness. And I actually told my doctor that and asked him to please help me work to figure out what was going on. You know, I was just experiencing these crazy sort of fatigue issues in the Middle of the day where I need to kind of sit down, my mood would go right off a cliff. I would be frustrated, irritable, and kind of shaky. Feel this cold sweat. And it was very strange. I've never experienced anything like that in my, you know, in my life. And being somebody who is also a CrossFit trainer and putting in a lot of effort in the gym, I thought that I should be really healthy. So that was the first thing that was happening. It's just kind of this breaking point. And then the second thing that was happening was I was deep, I was deep in the research from NASA on how they're thinking about long duration missions for astronauts who can't get access to the typical medical system. And much of this is nonstandard. So there's a lot of biomarker tracking, there's a lot of nutrition analysis, and there's a lot of mindfulness and stress management. And I was just thinking, huh, throughout my life I've heard about those things, but they've never been a meaningful part of anything I'm doing. I go to the gym and work out hard, and that's about it. And as long as I don't look unhealthy, I thought that that was, you know, the best proxy for being healthy. And so, yeah, so those two things kind of came together and I just decided to take into my own hands. I was like, you know, I'm a, I'm an engineer, I use data. And everything I do, I have absolutely no data telling me whether or not my daily decisions are the right ones for me. And so I wanted some quantifiable information. And I started pricking my finger to measure blood sugar because I assumed I had an energy issue of some kind, given these, like, crippling fatigue episodes. And I couldn't make much of it. It was sort of a point cloud in the morning when I would wake up and a point cloud in the evening when I could test again, and nothing in the middle of the day and nothing at night. And so I finally asked my doctor for a CGM and continuous glucose monitor. And he said, no, that's for people who have diabetes. You don't need to think about glucose until you know you're diabetic. And that, that felt off to me as well because I was thinking, huh, well, like, doesn't it become deranged over time? It's not sort of a lightning strike that happens. So I, I, you know, I continued to try and get one. Eventually I did. And this is where the real light bulb Moment happened within about a week. I, and with my doctor's agreement, found out that I was either borderline pre diabetic or fully pre diabetic. And this was due to the postprandial responses. I was experiencing a lot of long duration elevations and then reactive hypoglycemic crashes and just general instability throughout the entire day. And I use that data to completely transform my approach to living. I changed my nutrition, I changed my. My approach to sleep and sleep hygiene. My understanding of stress management completely changed. And. And then I actually de. Emphasized exercise or at least my approach to it changed dramatically. So that was being kind of a patient zero for this experience. And then all of the benefits that have come from it. I decided to leave what I was doing, team up with a really strong set of experts in their various fields and bring this to more people.

I love that. I love that. So where, where, where was that? Where did you first turn to? Did you turn to the Internet? Did you turn to somebody in your gym? Like, I just want to kind of understand that really like absolute bottom where you hit and then who are you grasping and reaching out to help for, just so we can understand this from a client or patient's perspective what they might be experiencing and what they might be, where they might be looking for answers.

Yeah. So I was actually, I remember vividly the, the minute I decided to start checking blood sugar myself. And that was when I was chatting with a friend and he was doing. He's basically a big data analyst and looking at causes of morbidity in just globally. And he basically said the leading indicator of death is endocrine breakdown. So if you start to see dysfunction associated with the endocrine system, you're more likely to die a young death. And I was like, huh, well, that's interesting because I have like terrible energy issues right now and I'm wondering, do I have some endocrine dysfunction happening? And he was like, well, you know, blood sugar is one of the easiest ways to figure that out. So if you're interested in that, and this was just a casual conversation, maybe you could try checking one of those finger sticks out from cvs. And that was it. You know, I just, it was a friendly conversation. I had never kind of heard of it framed in that way. And all of the data on the metabolic health crisis was totally hidden from me. I had really no idea how rampant it was. It had never touched me personally. My family doesn't have diabetes. We do have cardiovascular disease and dementia, which I later learned are metabolic in nature. Or at least closely associated. And so that was a moment of kind of personal breakthrough. It was like finding an edge. Oh, cool, I can check this, this molecule. And at least I can. That's something, you know, it's something. Whereas right now I have nothing.

So I love your perspective as an, as a non healthcare provider, but also as an engineer, because engineers have a way of thinking, right? There's gotta be logic, there's gotta be reproducibility, there's gotta be some sort of structure. And when you look at the healthcare system as an engineer, you quickly identify where it starts failing people. So what was that revelation for you? Like, what was what clicked for you as an engineer, looking at the medical system from the perspective that you did?

Yeah, my own experience of just, first of all, you know, identifying that this was something interesting to me that was potentially going on in my body and then not being able to access it due to a disagreement with my physician. My physician basically said, no, you don't need to worry about that and therefore you don't need to measure it. And that felt wrong to me in two directions. Firstly, it felt like shielding the inputs from the outputs, right? So you have. I am taking action every single day. I'm making lifestyle choices and those are having some physiologic response in my body, yet I'm not allowed to see them. And then the second thing was that not allowed part, which really rubbed me the wrong way, which was that, you know, shouldn't the relationship between my physician and myself be something where I share data with them such that they can help, you know, better achieve outcomes? With me, it felt like very much a kind of a gatekeeper relationship as opposed to a, you know, an expert, a partnership, you know, who. Someone who knows much more than I, taking the data that I, that is happening, you know, inside my body anyway, and helping me better understand and interpret it. And so that, that felt, you know, and of course this is not, I think this was a specific example, but I think my point was just that it felt like approaching the problem backwards, where we wait until something breaks before we start trying to solve it. To put a kind of a financial metaphor in there, it would be like giving somebody a bank account and telling them not to overdraw it, but then not letting them check the balance. And so the deposits and withdrawals are totally hidden from you. You have, you have no real idea whether or not what you're doing is working and it's too late by the time you're told. And so that was kind of the way I was thinking of it, very simplistic terms, but it just, I was thinking, there's got to be a better way. And then when I did discover that there was something going on under the hood that was very, A, preventable, it was decisions I was making. And then B, so closely tied to these metabolic outcomes that are rampant in society, it just felt like maybe this is the opportunity we can empower the individual, decentralize the problem so that each person is just focusing on becoming better. And then at a large enough scale, you are changing society. It's not that you've passed some piece of legislation that fixes everything at once, it's just that each person is tackling the problem individually.

Yeah, you know, I have a. I've been using a CGM from Abbott for a few years now and when I learned about it, I was like, wow, this is amazing to have this information decentralized and democratized so that people can start using and making super informed choices about themselves. And one of the things as functional medicine practitioners, we recognize very early on in our training is that there's multiple inputs to a problem. It's never just one thing. But there are some markers that we can measure, like HRV and blood sugar. I think those two markers, there's so much data in that, there's a lot of information in those numbers being wherever they are. And it's so great to see that HRV is now being decentralized. Right. With HeartMath and Oura Ring. And it's great to see, at least in Canada, that people, if they want to, they can access the blood sugar monitors here. And I love that you're now doing this, but I'm curious, what, what obstacles are you encountering? What resistance are you encountering in helping bring this to the market as quickly as possible?

Well, as you mentioned, the devices themselves are much more accessible in other parts of the world. And here in the United States, the Freestyle Libre is a Class 3 medical device and the Dexcom G6 is a Class 2, both of which require a prescription, which for the indicated population makes sense. Someone with type 1 diabetes needs to have a really rigorous device that is not going to fail them and is not going to cause them to miss Bolus insulin. And so for the population that we're currently working with, which is general wellness, informational purposes, the intention is to close the loop between actions you're taking every day and the reactions your body's experiencing and help educate you on and inform you on the way you personally respond. And so it's it's not a therapeutic use case, it's not, not diagnostic or even, it's not even screening. If something is looking really off, we would recommend that the person go and work with their primary care provider next steps. So with that in mind we have a much lower risk use case and it wasn't really contemplated actually by the state of the regulations here in the United States. And so people we've spoken with across the regulatory industry and medicine are all very on board. It's just that right now there's this complicated situation where the devices we're using were not sort of developed for this population in mind. So right now all of our, all of our levels members have to get a prescription for the devices. And we are using the off the shelf hardware, we're using the Freestyle Libre and we're working on an integration with Dexcom G6. And so what we've had to do is build essentially a practice where the telehealth consultations can be performed as conveniently as possible to allow this to be more of a consumer like experience. You know, it's hard to get someone to adopt a new technology when they have to jump through a lot of hoops, you know, and, and so we've worked very hard to meet the intention of the regulations as they exist here in the US Ensure that we're protecting patient privacy while also facilitating relationships or consultations between licensed telehealth providers and our interested potential members. So that's, it's kind of a complex platform that we've had to build and it took us a long time. You know, frankly we were in kind of stealth mode for about six months before we could even start trying to get our first customer because we had to build that framework. It's now up and running and I think it's, it's a testament to how strongly people feel that they need better information. You know, the adoption rate has been amazing and we've been growing very quickly and a lot of varied, you know, demographics and backgrounds are interested in this product. This is not just biohackers, you know, and quantified selfers who are interested in. And I think you're seeing something similar with aura and whoop where people who are non athletes are monitoring HRV in order to understand how well they're recovering. And I think it's a really great thing.

What would you say are some of the limitations of the tech at this point and where do you see it going?

So the limitations are. Well, first of all, the devices right now are, although they're fairly convenient. There's a large difference between a medical device developed for a medical population and a consumer product developed with consumer delight in mind. And some of that stuff is a little bit subjective and some of it is objective. Right. It's this device, the filaments break the skin and they have an interstitial filament measuring interstitial fluid. And so that's. You don't have many consumer products that. That do that. Right. So it's likely that we will be working with medical devices for the foreseeable future. I think that the classification of the devices will change and they'll become sort of Class 1 or over the counter in the next, I would expect two to three years. And specifically for the general wellness population. Now, if that happens, you have to be sure that the devices are not being used for the management of diabetes in order to ensure safety for both populations. So the devices have to change a bit. The way that they display data has to change a bit, probably truncating the ranges so that, say, the range does not go as high as a device usable for diabetes would. It may just display a high value and a low value such that you can't really use that effectively for bolusing insulin. I think we'll see stuff like that and then integrating into a form factor that's a bit less medicalized. You know, there, there's. It's not that it's bad that these devices were developed for a medical purpose and that they look like medical devices. It's just that right now we, I think, have a stigma around metabolic health where even people that do have a condition that they're working with, a preexisting condition, they're sort of ashamed of using the devices, it seems. And I've spoken with hundreds of people both with and without diabetes, and I hear the same thing is that these devices kind of look like they're for sick people. And so when you wear them, you feel like a sick person. You want to hide it. And so what we're focused on at LEVELS is changing that paradigm entirely and making it clear that no matter where you are on the metabolic health spectrum, this product is something you are using to live a healthier life. You're taking action. You are empowering yourself to have better information and to make healthier decisions for yourself, for your family, for your loved ones. And that requires a lot of change. The devices themselves have to look appealing. People across the entire metabolic health spectrum, including athletes, have to use them so that it kind of gives it this sort of perspective that this is an empowering tool. And so there's a lot of ground to cover on the product side to make this something that is really mainstream and that people are using in large sort of volumes. And as someone mentioned in the comments here, Krista mentioned the error rates. So interstitial fluid to blood is phase shifted by about 20 minutes. So if you correlate those two values, they're always going to be off, especially if things are changing rapidly. But also the existing devices were developed for a very, very wide range, right. They're trying to sense anywhere from like 40 milligrams per deciliter of blood through to like 400. And that's, that's such that you can accurately bolus insulin. And the, the outcome of that is that the accuracy is quite low. So, so precision, sorry, precision is low and accuracy is sort of the best compromise across a wide range. One of the benefits for non medical use cases is that we can tighten up the range something closer to like 60 to 200 and then improve the precision. And so I think we do have to also make that adjustment so that people have faith in the measurements that they're getting. Because if you do do a finger stick and you see that things are off by, you know, 60%, it can feel like you're being misled by the technology. So.

And I think we can also look at trends too. Right? So, you know, looking at the area under the curve, even. So even if it's phase shift a little bit, it still gives us an idea of how we're being impacted by it. You know, when I.

That's right, yeah.

When I did mine, this was when I, when I worked for the first time. I remember I was on an annoying sales call. Somebody was trying to sell me something and they just wouldn't take no for an answer. And I could see my blood sugar increasing and it was like so fascinating to see that. And of course that makes sense because as you increase cortisol, you start increasing blood sugar. And so that was like a big revelation for me. I know some people also get a rise in their blood sugar when they check email because they're probably getting more cortisol production. So what was the thing that maybe surprised you the most about you? And I know that I'd love to hear some of the bio individual stories about different people and how they respond differently to the same food. But what was your big aha moment when it came to your blood sugar?

Yeah, there were several. I mean, firstly, coming from a background that was mostly focused on sports and physical fitness, there's a ton of, you know, some people call this bro science, but you go into a gym and you hear a lot of conversations happening that are loosely based. In fact, we'll say, and it's really hard when, when you're trying to get physically fit. We have this culture where we do whatever the pros are doing. And so this is like, some of this is marketing, but everyone's training like they're an elite athlete and fueling like they're an elite athlete, even though most of us are not. And so this for me was the, the, the twin, twin threat of carb loading and glycogen replenishment. So I had these ideas in my mind, in my mind that before every workout I had to have a ton of carbohydrates in order to be ready for the workout. And after every workout, I had to funnel a ton of, you know, both protein and carbohydrates into my body to make maximum use of the muscle building, like 30 minute window that I've heard over and over again. And what that meant in practice was eating a ton of food that I was extremely sensitive to. And this was like, even though these were, you look at the glycemic index, these were decent. This is like brown rice, sweet potatoes, whole wheat pasta. I was eating them in such quantities, and I now know that I am. So I think glucose or carbohydrate intolerant, that I was creating this mechanical feedback loop where I was having massive blood sugar spikes every couple of hours. And the intention was to be healthier. And the reality is that I was just out eating my, my body's ability and my insulin sensitivity or my, my body's ability to maintain insulin sensitivity. And that manifested in many different ways. One of them was I would always eat at least a protein shake, if not another meal, right before bed. And I now know that my blood sugar would remain elevated, you know, be oscillating from 1:20 to 1:50 all night long, you know, essentially for four or five hours. And that was completely destroying my sleep quality. And at the time, I was not even getting much sleep to begin with. So by first changing my nutrition and seeing the effect on heart rate variability through the night, I immediately became aware of just how disruptive that was. And then by then extending my sleep window and embracing things like, you know, blackout curtains and moving my cell phone out of my face earlier and kind of getting longer, more restful sleep, I then saw an even further improvement in my both baseline glucose and my postprandial responses. So I think that also has to do with like, like a constant state of cortisol or just stress that was coming from being chronically under slept. So those were kind of two of the biggest breakthroughs for me was just the effect of nutrition on like my, my daily experience. And then by getting rid of those crazy blood sugar spikes, I was also removing those reactive hypoglycemic lows and all hormonal irritability that came with them. And then the relationship of sleep was a big breakthrough for me. There were many more examples and I'd love to get into the personalized element as well. I have been fascinated by the degree of individuality, both, you know, just in the, in the small team that we have at levels, but also across the user data set so far. And I think there's a ton of research needed to really understand the factors here. I personally think it's context like we touched on could be body composition, background, environment of other hormones like insulin. But then also I think the genetic and microbiomic effects could be stronger than we otherwise anticipated. Some of the studies out there, like the 2015 cell trial from the Weissman Institute that showed that two people who eat a banana and a wheat cookie can have equal and opposite blood sugar responses. And then the predict trials from the UK which followed that up by showing that even identical twins with 100% DNA share could have the same degree of variability. It's fascinating. It indicates that potentially, you know, assuming that insulin responses are equally variant, we could, we could really have a situation where technology is necessary to, to find the ideal diet. And so looking at our data set, you know, we've seen the same degree of variance. It's, it's amazing. Some people can just literally eat bananas with no move off baseline. And myself, you know, I might as well drink a Coke, my blood Sugar goes to 165 or 170 from a banana. And I also just don't genuinely feel good afterwards. And so I've biased much more towards green vegetables, cruciferous vegetables. I avoid starches for the most part, whereas other people on my team, like Casey Means, who's a plant based, you know, 100% plant based vegan, she eats a lot of starchy and green vegetables and she's able to maintain exceptional blood sugar control. So there's a, there's a ton of variants and individuality and I'm really excited to dig deeper, run legitimate trials to understand what's happening under the hood there.

So I guess there's I mean, there's a few layers to it, right? It could be the immune response to the food, it could be their genetic predisposition to starch, metabolism. And then the microbiome, of course, could play a role too. Do you have any suspicions? I mean, it's probably a combination of all three, I would assume, right?

I think so. I think, you know, the microbiome I've always thought was too low in the intestinal tract to be involved with glucose metabolism, but I'm not, so I'm not so sure. I really, I think it remains to be seen. I, my guess is that the hormonal environment is the biggest factor. So the, you know, just simple environmental factors like sleep. You know, if someone is, let's say you look at identical twins and one of them recently became apparent and is not sleeping well because they're up all night with their baby, you can see the difference there manifesting as just higher cortisol and reduced insulin response or reduced insulin sensitivity. And that can have a dramatic effect on how you're going to respond to the same food, you know, calibration food like a banana. So I'm guessing that, you know, with, with better, with some targeted studies looking at specific hormones, we're going to be able to discover this quite quickly. I'm sure microbiome and genetics have, have some degree of involvement here, but I would bet that hormones have a larger degree.

All right, who's the youngest person you know of that's worn one of these? I want to put one on my son. He's 10. But have there been studies done on really young children, toddlers?

We haven't done any pediatric use cases yet at levels and the Dexcom G6 was recently approved for pediatric use and I believe the Libre just receive that approval for, for the Libre too. So yeah, it'll be interesting to see. I think what's fascinating is that the, the younger groups that have, have used levels, and this is like the 18 to 22 crowd, seem to have exceptional blood sugar control despite eating really, really badly. And so I'm interested to see the way that that plays out longer term. You know, if we can get some longitudinal use cases, multiple years of at least monthly check ins with CGM data, I think we're gonna start to see the way that that kind of transitions into, you know, we know there's an age related insulin resistance thing, but it seems like it happens quite quickly because by the time we have people in the program who are in their late 20s and early 30s, we're starting to see a lot more glucose responsiveness, longer duration, elevations, more variability, lots of time out of range. And so that scene. I'm wondering, you know, if that decade of, like, the 20s is a decade where things start to break down, if you know what I mean. And being someone who in my younger years, I could eat a lot more junk, and I did eat a lot more junk. I would often in college eat. I would eat candy for dinner. And I'm embarrassed to say it, but I cared about working out, and I did not really care about what my calories were. It was just eat whatever I want and work out hard. And I think there's a lot of people that are living under that sort of approach right now in their, you know, early 20s, late teens, and inevitably that. That can't be held or that can't be kept up for too long.

Yeah, eventually you pay the price. Right. It catches up to you. You know, I had a client who's a friend of mine, and she came up to me during a mentorship conference that I went to, and she's like, my dad has diabetes. He won't listen to anything I say. Can you talk to him? I'm like, listen. Usually when somebody tells me to talk to a parent, it doesn't go very well. It's got to be the initiative of the individual. I said, the best thing I can do is if he's a logical person, then how about I send this unit over to you? And he can track his own blood sugar. And over the course of a week, he gamified it. So I saw her a few months later, and she thanked me profusely because by the end of the week, her dad's blood sugar was normal. And we're talking about a diabetic for years, so he was able to at least use food. And I also told him, monitor behaviors, too, not just food, but what other behaviors are problematic for you. And it kind of. It's a fun exercise for people if you've never. If somebody's never done this before, because you can really just try out a whole bunch of things like, hey, let's see what happens when I stay up late, or let's see what happens when I eat dinner late. Let's see what happens when I skip breakfast or I do a water fast or have one meal a day. You can really get to learn about your body's response to different types of interventions very quickly, and it creates some massive behavior change. And I love it for that is the, you know, people can hold themselves accountable to the process. Are you finding that as well with the users on your end?

Absolutely. You know, one of the interesting things is it's very different to tell someone something and for someone to see something happen, especially when it's happening to them. And I think that what we've kind of zeroed in on as the real benefit of the program we're building is, is that people feel like they're in conversation with their own bodies with no one else, kind of, there's no advice involved. It's, this is happening and I can either choose to put my head in the sand or not. And most people choose not to put their heads in the sand. They, people don't want to be unhealthy as far as I can tell. They generally don't want to do damage. And if there's some evidence that they can cling to that's showing the direction of their, their actions, they're going to take it into account. And so the program that we've kind of settled on right now that we're testing in the beta is a four week program. In week one, we recommend people don't change anything, just do whatever you normally do, see how it's going. This is the first time for most people that they have any sort of real time feedback and, and so it's really enlightening for them. And so just sleep the way you sleep, eat the way you eat and, and, and let's see what, what's happening. And then in weeks two and three, we recommend a lot of exploration, so digging into the boundary cases and understanding like you were mentioning, you know, how exercise affects things, how sleep affects things, how different foods that you do or do not regularly eat affect you whether individually or in combined sort of macronutrient portions and balanced meals. And you know, some of the big breakthroughs are really quite intuitive. You know, it's when people see the difference in their blood sugar response to, for example, an indulgent meal like a personal pizza and then sitting on the couch versus that same pizza and taking a 20 to 30 minute walk. The blood sugar response is significant for most people because you're, you're pulling that glucose right into the muscle and that little bit, that little micro optimization of knowing that if I do, you know, kind of cheat, all I can, all I have to do is get up and walk in order to limit the damage. That, that's an edge for people. That's something significant that they, they really cling to. And a lot of people love sharing those little anecdotes. Another one is understanding the difference between, you know, like a pressed juice and a whole fruit or a whole vegetable. A lot of people, you know, are kind of in this category of if some is good, the most must be the best. And so they'll, they'll kind of try and combine as many fruits and vegetables as possible into one drink and chug it down as quickly as possible. And although that might work for some folks, I think that at least in my experience now I've only gone over 220mg per deciliter of blood sugar a few times, and most of those had to do with smoothies or pressed juices. Um, it, it has a worse blood sugar response for me than soda. And so I think that if people see that and then see that you can have a, you know, the same nutritional density eating the whole fruit or eating the whole vegetable, but you're going to reach satiety much sooner. Um, a lot of them really benefit from that. And so I think, you know, it's, it's up to the individual how they want to approach, you know, those types of things. But seeing the data, I think is really helpful. So, yeah, you know, I think that the, the independence of just having, having the data stream and being able to take it into account really has a different psychological effect for a lot of people. And my parents are, are an example. Both of them, you know, are currently using levels, and I've been fascinated by how involved they are. If I told my dad to go get blood work done repeatedly, he would never do it. But the fact that he can put this little gadget on and just see in real time, he's kind of making a game out of it. And so the behavior change component, I think is really strong. And we're leaning into that with the levels program design making it very social, very gamified.

I'm curious if you don't mind sharing what blood type you are.

I'm A positive.

Okay.

And so I saw some, let's see, I saw a question in there about blood type. I don't have any data on that yet. It's something that we want to do, you know, sort of in the, in the clinical trials, but I'm not really sure what we're going to find there. I've heard that there is a eating for your blood type approach to diet, and I'm not, I can't quite tell what the mechanism would be there. And I'd love to learn more about it though.

Yeah, I mean, I don't know much about it. But I, but I know that there's probably people in this group that have studied it a little bit more than I have. I know people, the majority of the populations type O and they generally don't do well with grains. I'm ab so I'm like the anomaly of them all. But A positives generally tend to do, you know, my wife is a as well. They generally tend to do really well with a fish plant based diet, fish, chicken, maybe a little bit of less of red meat. So I don't know if there's, you know, what's there. But I feel like this, this tool can really gamify things. I feel like it can really give people that ownership. You know, not even, you know, I think it takes a certain type of person to even wear the tool.

Right.

They have to want to help themselves versus continue to sabotage themselves so that in and of itself gets buy in from them. And then they have the information to then make better decisions and learn when to say yes and when to say no. And then if they can't say no or they're in a situation where they've made a bad decision, they have tools to remediate them based on exercise and so on and so forth. So I really feel like it, I can almost see this going viral like I could see this being like a great like advertising campaign even to kind of promote how people can get valuable information like this so readily. I know you keep your blood sugar pretty tight so I'd love to hear what your daily routine looks like if you don't mind sharing.

Yeah. So we have a research group that we're, that we're putting together led by my co founder Casey Means and she's a, she's a former ear, nose and throat surgeon turned functional medicine doctor. And so she and, and our other research members went through all of the literature on that is readily available on non diabetic glucose and essentially took the lowest quartile of risk of the different available metrics like variability and postprand peaks. And that's what we base the levels ranges on. So when you're using the levels operating system in combination with a cgm you will be able to, you know, interpret like we have metrics and algorithms that are driven by your blood sugar response and those appear as zone scores to meals. They appear as what we call our metabolic fitness score which is the quality, you know, sort of the quality of your blood sugar control throughout a 24 hour period. And those ranges were, were based on that research, you know, the, the lowest quartile of risk. And so that that range is 70 to 110 milligrams per deciliter. And again there, there are certain. We're focused more on patterns and trends than absolute values for a number of reasons, not the least of which is device accuracy. But I feel that there is very little risk in striving for those ranges. 24, seven including meals. And so that's what I am currently focused on. And that requires for me a protein rich, moderate fat, low carbohydrate diet. For Casey, that is a plant based, highly carbohydrate rich and some fats and proteins mixed in diet. And it's interesting because the two of us can have blood sugar patterns that are very similar with very different macronutrient blends. And when I try and eat the way she does, I cannot maintain that control. So in order to kind of hit the dietary or to hit those numbers, for me I eat a ton of green vegetables, a lot of kale, a lot of broccoli, a lot of brussels sprouts. I like to roast them or grill them. I eat a lot of salads and then I have meats and I enjoy tahini, almond butter, lots of nuts and seeds. And so I eat almost exclusively whole foods. I try not to process things too much and yeah, that's generally been my approach. I don't do much smoothie stuff anymore. I used to, before every workout I used to do it would be like brand flakes, banana, some protein powder, milk, and I would have just this crazy blood sugar spike. I'd be driving to the gym, I would get into the gym, start my first set and my blood sugar would just be absolutely plummeting from the peak. And so when I'm doing my first rep, I'm just feeling so fatigued and I'd be yawning and I just remember being in the gym and like so surprised. Why is this happening to me? I just had that huge smoothie, um, and, and so that I've kind of trimmed all those peaks out and I now go just for large meals. I eat very similarly throughout the day. Breakfast, lunch and dinner don't have much meaning to me anymore.

What did you discover with fasting? I'm curious about that.

Yeah, fasting is an interesting tool. Um, I, I have done several, I'm not super advanced, but I've done done 72 hour fasts and I find that there's a really interesting like 24 hour period where I'm assuming this is stress related. And again, I wish I had more, more cortisol availability. But I think that the, the first 24 hours I experienced like a stress elevation as my body is transitioning into, into the fast and my blood sugar will typically elevate and I'll be in like above 100 milligrams per deciliter average throughout that first 24 hours. And then as I get into the second day and the third day, I'll taper down to about 60 to 65 milligrams per deciliter. Just completely flatlined and I feel really good. And coming off the fast, I will be more sensitive to carbohydrates for sure. I think this is the sort of glucose sparing effect of muscle insulin sensitivity or muscle insulin resistance, adaptive insulin resistance. But I, once I come sort of, I'll like slowly refeed eating mostly vegetables and meat. And then, uh, if I do eat some carbohydrates, say the week following, I. And again, I have few data points here. I want to carefully asterisk that I do think that I achieved some better insulin sensitivity after a prolonged fast. It's not significant, but it's just the peaks seem to be lower and the duration seem to be shorter of my glucose elevations. If I eat, you know, carbs that I know I'm sensitive to, that effect seems to wear off after a few weeks. So I don't know, you know, I don't really know how effective this is long term, but it seems to be something that would be positive for people to do like on, on a secular cyclical basis.

You know, I'd be super curious about seasonality even with the same food, like if you're eating food out of season and also sunlight exposure. Yeah, I'd be curious about how, you know, because usually people who live in the tropics have more sunlight exposure and they tend to generally tolerate fruits much better. So like, there's so much, there's so much. I'm looking forward to getting one in my arm and starting to look at this from a new lens and tell us more about levels, tell us more about how we can use this, get involved, support you use this with our clients. I'd love to know more about that.

Levels is we're seeking to answer the question what should I eat and why? With real time data. And the first way we're doing that is building an operating system for continuous glucose monitoring in the context of lifestyle. So the system that we've built, the software that we've built, interfaces with both the Freestyle Libre and the Dexcom G6. Although we've only currently released the Libre integration and you can track your diet, exercise, sleep and stress in the software. And so we integrate with Apple Health Kit and Google Fit to incorporate activity, heart rate data and sleep data. And all of that is then interpreted along with your glucose responses to give you a good understanding of how both individual decisions like the foods you eat and combinations. So food plus activity can, or food plus sleep can affect your overall glycemic control and ultimately your, what we call metabolic fitness, and we use that term very specifically. So we're focused on improving metabolic fitness for people. The reason for that is that most folks think that they are in a binary situation like I'm healthy or I'm unhealthy and metabolism is either good or bad. And the reality, I think, as we all know, is that we're on a spectrum of metabolic function. And with focus, effort and repetition, the same way you go to the gym and train, or the same way that you train in a mindfulness practice, you can improve your metabolism and improve insulin sensitivity and improve your overall risk of these sort of chronic illnesses. So that's what we're oriented around, is just helping people understand that every day you're going to make a series of decisions and the decisions you make will compound either positively or negatively. And here's kind of the direction we encourage you to go in. So right now we're still in development. We have, let's see, I think we've had about 3,500 people go through the program where it's all invitation only right now. And the reason for that is that we're, we're very focused on feedback. You know, we try to interview every person that uses the product. We're a little bit behind on that, but we're doing what we can. And the intention is to build the best behavior change system there is. And over time in the next several months, we're going to start to expand that beta and eventually, you know, our full launch where people can go to the website and just order it. I think that, let's see, I think in terms of how we can, we can work together. You know, we're always looking for research opportunities and we're definitely considering ways to empower physicians and practitioners to work with their patients more effectively. Like either leveraging levels directly or better interpretation of what optimal glucose and normal glucose looks like. I'm very optimistic that our data set, which even now is the largest of its type, we're not aware of any data set for non diabetic glucose information Especially combined with lifestyle data that's larger than ours. And so as that continues to grow, I think it's going to be a really valuable resource for research purposes to better understand, you know, sort of what people should be striving for, what's achievable for different individual types, whether based on demographics or based on just sort of glucotypes, which Stanford publicized that, that name. But just how people respond to calibration foods could be useful to predict treatment options and then also I think to improve understanding of diabetic management. So if you have a really good baseline to compare against, you can do, I think, a better job of understanding how diabetes management can be approached. So I would love to, yeah, just would love to be. To make Levels available as a resource at some point so that practitioners can be even more effective working for glucose control for their patients.

Awesome.

Then.

Have you ever connected with BJ Fogg? Does that name ring a bell for you?

I've heard the name. I have not connected.

He's a Stanford professor that specializes in behavior change and his student was the guy that invented Instagram.

Oh really?

I would love to connect you with him because he's one of the world's leading behavioral experts and he wrote a book called Tiny Habits and he's really big into health and stuff like that too. So I think that would be a really great connection for you to help facilitate that behavior change for people because it is so important. So let's just say, let's just say I could wave a magic wand and get my hands on one of these units. What would that look like? Is it an app that we download on our phone? And do we pay for the app? Do we pay for the sensor? Like, how does, what does that process look like?

So right now, because we're building this with a direct to consumer sort of product mindset, the process is you sign up on the website and you include a short medical history questionnaire. So you fill out some history about yourself that is forwarded to an independent network of telehealth physicians that we work with. They decide whether or not to prescribe CGM for this individual and then they just let us know levels. And so Levels can then fulfill the order directly through our pharmacy partner. So Levels, we do not practice any medicine, we don't provide any medical, any sort of medical advice. And however, we do have that independent third party that does all of our consultations. We then fill a kit that comes to your doorstep. It includes two CGM devices, it includes some performance covers which are these fabric covers that our more athletic folks like to wear and they help to adhere the sensor. And then you use the levels software to engage with the CGM system. And so currently it's a two app experience. So you have one app which is the manufacturer of the CGM device. In this case like the Libre link for the Freestyle Libre. That's what you scan the device with and then the data gets pulled into the levels system. And that's the two app situation is kind of due to some existing regulations that we're working on eventually getting to a single app solution. But the levels app is where you're going to kind of deeper dive into your glucose data. You're going to log your food, you're going to log activity sleep and you're going to receive your scores and reports. So we're also working on additional integrations with folks like Eight Sleep Zero Fasting. We're working on BioSense, which is a breath acetone monitor incorporating ketones into the, into the platform. Eventually we really want to have multiple metrics all integrated into a single operating system. But as of now, today it's activity sleep and glucose. And so you use it for 28 days. And if you'd like to continue, we do have subscription options.

Okay. I love that. I mean, it's right around the corner, right. And you know, we're hearing it from you. I love your enthusiasm, I love your passion. I love that this is going to be available to us and our patients. I've already signed up, so hopefully I'll get a response here shortly. And so people can go to levelshealth.com and they can enter their information if they want to get on that waiting list and be contacted. And I would always use it on yourself first as the main patient zero, so to speak. And you'll find this information is really game changing. It really is the data that you get from it, the personalization that you can create from it and you know, a big thing that a lot of us focus on, Josh, is weight loss. And maybe you could comment on that. And then I know you've got to run, so we'll let you wrap things up as well.

Great. Yeah. Um, so weight loss is, is really interesting. We're, you know, I think that one of the complications with glucose control specifically is that it's, it's not a panacea, first of all. And then it's also can be complicated by background hormones like insulin. And so if you're a very overweight person who has hyperinsulinemia, your Glucose can appear to be totally normal. And so that's one of the tricky things that we're kind of dealing with is figuring out, okay, how do we calibrate the algorithm, understanding of the individual's health and sort of situation if you don't have direct access to insulin? So we're going to kind of take this in two approaches. One is machine learning. So you can do a lot with training these pattern recognition algorithms to identify and potentially predict insulin based on other factors like say, waist to hip ratio. And then also trying to incorporate insulin directly into our measurements, which we're kind of looking into that now. So we've been doing, we've been doing some interesting, I think, kind of peripheral, I wouldn't call it studying, but we do have folks who are looking to lose weight who have used the product and, and just by trying to control their glucose and maintain 100% below 120 milligrams per deciliter per day. We've had a few cohorts of weight loss folks who have lost an average of 9.8 pounds over the 28 day program. And that's been interesting because there's no dietary philosophy baked in there. There's no nutrition guidance. It's sort of just try to control your glucose. The effect could be better controlled insulin and corresponding weight loss. And so that's what we've seen so far. Again, this is, this is a small N and we need to do a lot more work on this. But I would say that it's definitely the direction this is going to go. Whether we can do so directly just with glucose or eventually by adding sort of calibrations with fasting insulin measurements. I think this is going to be the best weight loss tool ever because people are very engaged with it does not feel like having to stick to a stringent diet or calorie cutting. People feel like this is kind of, kind of a GPS system. You know, if you can keep it inside range, it explains to them why they are or are not, are not losing weight. And I think that's kind of a breakthrough psychologically for, for folks who need to lose weight.

Awesome. Thank you. You mentioned insulin as a potential other marker. Are any other markers that you see on the horizon?

Yeah, so I think ketones is likely to be the next one. We'll, we'll try and incorporate ketones because it's quite available and that can give you a good idea of what energy substrate you're burning. But then from there we're definitely interested in insulin. I would love to get cortisol, though I'm not super optimistic about either of those in a continuous platform. I think we're more likely to get to cholesterol, triglycerides and ketones in a real time form factor with point measurements for insulin and cortisol. The holy grail is of course a multi analyte sensor that gives you all of the above and will give you I think the best understanding in real time of your metabolic condition. And I hope to see something like that in the five year timeframe.

Awesome. Well, thank you Josh. This has been super enlightening and let us know, let me know. We'll connect after this. If there's anything that we can help you do to accelerate this. I'm happy to connect you with some people that can help you move this in the right direction and create optimized behavior change. And we're here as a community to support this because it definitely helps us help our clients better. And if you ever need people to do some studies on, then know that we're, we're most people probably already signed up. So you should have a little influx from, from us. Thank you again. Is there anything you want to say in closing?

I really appreciate everyone's support and of course, you know, we're, we know that we're very much in development and this is the beginning and so we're feedback is the, is the biggest help, especially from experts. So just understanding where we can improve our approach is the best thing we can do. So please, if you're open to it, I'm@joshevelsouth.com so I'm very excited to get any emails on the subject and then of course trying the product out giving us feedback directly would be huge and I'm just excited for where things are going to go over the next few years. So thanks all for joining.

Thank you my friend. Have an amazing rest of your day.

You too. Happy holidays everyone. Bye.