Ep. 169 – Why Should You Care About Your Metabolic Health? Empowering a Deep Understanding of Our Bodies with Dr. Casey Means

I am delighted today to be interviewing Dr. Casey Means! She is a Stanford-trained physician, Chief Medical Officer and Co-founder of the metabolic health company Levels, an Associate Editor of the International Journal of Disease Reversal and Prevention, and a Lecturer at Stanford University. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tools that can help facilitate a deep understanding of our bodies and inform personalized and sustainable dietary and lifestyle choices. Dr. Means was recently featured in the New York Times, Wall Street Journal, and more.

Dr. Means has an interesting story to tell. She trained as a surgeon and an ear, nose, and throat doctor. Her interest in the impact of diet, lifestyle, and nutrition on people’s foundational health started at a relatively young age. She began focusing on nutrigenomics when she was still an undergraduate student at Stanford. It was an exciting time at Stanford because the human genome project was happening, and 23andMe was going online. She enjoyed learning about the correlation between nutritional compounds and gene expression and finding out that our genes are a blueprint and not our destiny.

Dr. Means is joining me today to talk about metabolic dysfunction and using continuous glucose monitors for facilitating your personalized diet. Stay tuned to find out more!

“The conventional practice of medicine has not caught up to our research understanding of systems and network biology.”

Dr. Casey Means

IN THIS EPISODE YOU WILL LEARN:

• Dr. Means talks about how her journey started and how she became interested in the impact of diet, lifestyle, and nutrition on people’s foundational health.
• The shocking amount of refined sugar that gets consumed by the average American each year and the impact that has on their metabolic health.
• What chronic inflammation is, what it does in the body at the cellular level, and why that is so detrimental.
• What happens in your body when you are overfed, when your blood sugar stays elevated over time, and when your insulin is kept high.
• What you should, and should not eat to maintain your metabolic flexibility.
• The benefits of fasting.
• Some practical ways of pairing proteins to help reduce blood sugar fluctuations.
• The impact of sex hormones on blood sugar control.
• What a continuous glucose monitor is and how it works.
• Why you need to know what’s going on in your gut microbiome.
• Why long-term adherence to a low carb or keto diet can cause reverse metabolic inflexibility.
• The correlation between blood sugar instability and debilitating hot flashes in women in perimenopause or menopause.
  

Connect with Dr. Casey Means

On her website   

Dr. Casey’s blog

On Instagram @drcaseyskitchen and @levels

On Twitter @drcaseyskitchen and @levels

Connect with Cynthia Thurlow

• Follow on Twitter, Instagram & LinkedIn
• Check out Cynthia’s website
• Check Out Dry Farm Wines: www.dryfarmwines.com/cynthiathurlow

About Everyday Wellness Podcast

Welcome to the Everyday Wellness podcast with Cynthia Thurlow! Cynthia is a mom of 2 boys, wife, nurse practitioner, and intermittent fasting and nutrition expert. She has over 20 years experience in emergency medicine and cardiology, but pivoted to focus on food as medicine. She loves to share science-backed practical information to improve your overall well being and is grateful to be interviewing leaders in the health and wellness field.  Her goal with Everyday Wellness is to help her listeners make simple changes to their everyday lives that will result in improved overall wellness and long term health.

Presenter: This is Everyday Wellness, a podcast dedicated to helping you achieve your health and wellness goals, and provide practical strategies that you can use in your real life. And now, here’s your host, Nurse Practitioner Cynthia Thurlow.

Cynthia: Today, I’m delighted and so excited to interview Dr. Casey Means. She’s a Stanford trained physician, Chief Medical Officer and co-founder of metabolic health company, Levels, and associate editor of the International Journal of Disease Reversal and Prevention, and a lecturer at Stanford University. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tools that can help facilitate deep understanding of our bodies, and inform personalized and sustainable dietary and lifestyle choices. She has been featured in The New York Times, Wall Street Journal, etc. Welcome, Dr. Means. It’s a pleasure to connect with you.

Casey: Thank you so much for having me. Thrilled to be here.

Cynthia: Yeah. And so, I know your story, but I think your story is really impactful, and I know that it will resonate with the listeners. You’re trained as a surgeon. You’re an ear, nose and throat doctor, but how did you go from practicing as an ENT to evolving into this biomedicine, biohacking entrepreneurial physician? How did that process and journey start? Because you’re still obviously quite youthful. So, you must have gotten this together in terms of the direction and trajectory of your career fairly quickly, and I would imagine the amount of chronic disease and inflammation that you were seeing probably shifted your perspective quite significantly.

Casey: Definitely. Yeah, and it really did start young for me this interest in diet, and lifestyle, and nutrition, and how this impacts our foundational health. Even as an undergrad, when I was at Stanford, I was really focused on nutrigenomics. It was an exciting time there with the Human Genome Project happening, and 23andMe was coming online, and I loved learning about the impact between nutritional compounds, and gene expression, and realizing that genes are not our destiny, genes are a blueprint, and really the interaction between the external world and those genes is what produces health or produces disease. Those was a really empowering thing to learn at 18 years old in my early biology classes, because it gives us hope that the choices that we’re making every single day, what we put in our mouths, how much sleep we’re getting, how much movement we’re getting, the stress, how we’re managing our stress? These things actually change the expression of our genes. That carried with me throughout my subsequent training.

Then flash forward to I’m an ear, nose, and throat, head, and neck surgery resident. I would say to really answer your question, how did this shift happen? It was really based on observations and patterns I was seeing in my training. I was about five years into my head and neck surgery training, when I really had this wake-up call, where I looked at everything that was going on around me and noticed these themes. One of the big themes was that so many of the patients were dealing with chronic inflammation. A lot of the conditions I was treating were based in that. It was sinusitis, thyroiditis, laryngitis, and all these itises, that’s the suffix in medicine that means inflammation. I thought, “Huh, inflammation is the immune system being triggered, because it senses a threat.” What is that threat? Why is everyone’s body in threat mode? Then stepping back and thinking about a lot of the other chronic illnesses that were facing the country, EMT is a niche part of the body. It’s a very narrow part of the body. But obviously, we’re one whole integrated system. You start seeing all the papers coming out of like, “Okay, well, obesity is an inflammatory condition, Alzheimer’s is an inflammatory condition, heart disease is an inflammatory condition, and these things shared this link, and it gets you to step back and say, “What is the body reacting to, what is it fighting, and why is it leading to all these different things?”

When you get into the even the deeper cellular biology of it, a lot of these different conditions like depression, Alzheimer’s, osteoarthritis, diabetes, obesity, they share some of the exact same, even inflammatory mediators like TNF alpha and interleukin 6, and these cellular mediators. So, is it possible that there’s something beneath all this that is leading to many seemingly desperate conditions that actually have a similar route? When I started digging more into that, it led me down this journey of what I would call, functional medicine or really, it’s systems and network biology is what I would say is the more like technical term for it, which is this idea that these aren’t actually isolated silos as we conventionally think of them. They are part of a system and when you actually study the physiology of these, you realize that there’s a web between them. We’re not treating the connections of that web right now in our current medical system. We’re treating the downstream symptoms. That’s why when we treat these things, all the treatments are different for each disease. That might be non-steroidal anti-inflammatories for arthritis, and an antidepressant for depression, and statins for heart disease, and insulin for diabetes, none of those get at that underlying core physiology that may be leading to all of them.

As you can imagine, that would be a much more efficient place to focus our clinical energy. The links between disease, not just reacting to seemingly different symptoms. So, really, conventional, practice of medicine has not caught up to our research understanding of systems and network biology, we’re still in this pattern recognition system. Putting that all together and looking at the Venn diagram between all of these different conditions, what I was treating in the operating room, and with tons of steroids and antibiotics and surgery for ENT conditions, and then looking at all the other chronic morbidity happening in the country with 88% of American adults having metabolic dysfunction, 72% of the country being overweight or obese, 128 million Americans having pre-diabetes or Type 2 diabetes. These massive, massive amounts of people with these chronic illnesses.

The center of that Venn diagram was really that chronic inflammation and then the next step was, well, what’s causing that, and a huge driver of that we know is diet and lifestyle. We are exposed to just such foreign things in our modern life that we take for granted, because they seem normal. The fact that we are eating, just basically the majority of our calories is American or coming from factory made, ultra-processed, ultra-refined foods. Different chemical structure of food than in our body was ever meant to see or witness, and in quantities that are just astronomical. The average American is eating 152 pounds of sugar, refined sugar per year. 200 years ago, we probably were eating less than a pound. So, it’s 150 times that we put our body probably could process. Our cells are totally overloaded, and that is a threat signal that can make the body rear up and get inflamed. We know that high blood sugar can lead to inflammation, many other things as well. Chronic low-grade stress from all the beeping, and the honking, and the text messages, and the emails, and all this stuff. This low grade, just insidious chronic stress. That’s a threat to the body constantly.

The immune system is going to see that as a threat and react to it. Our chronic sleep deprivation, the fact that we’re just not getting enough sleep on average. On average, an hour less than we were several decades ago, that’s a threat signal to the body. Why is this happening? Why aren’t you sleeping. So, all these things can trigger the immune system and create that low grade chronic inflammation that we’re seeing show up in so many chronic illnesses and these ENT conditions.

The one, I really got very passionate about was the blood sugar issue and realizing how much metabolic dysfunction in our metabolism. How we produce energy from food, how that process, which is core and fundamental to every cell working in our body or every cell needs a properly functioning metabolism to work? The way that refined sugars, refined grains are totally coopting in that process, and creating these just wide-ranging effects in the body problems, different symptoms is just something I became really passionate about, because I don’t think people are thinking about their metabolic health every day. We think about, wellness and whatnot, but metabolic health was not a term I was hearing constantly, and yet metabolic dysfunction is the core epidemic plaguing Americans today. So, it became really something for me that was, I was very personally passionate about getting that message out there, and then empowering people on how to improve their metabolic health.

One of the easiest things we can do to improve our metabolic health is manage our blood sugar, understand how our diets and our lifestyles are affecting our blood sugar, and keep it in a stable and healthy range so that we can really free up those metabolic processes to do what they’re supposed to do and effectively producing energy for ourselves. So, long story short, it was this journey of really being deep in my field five years in, in a training program, in your training, you’re told what to do. You’re not really there to think for yourself. But stepping back and saying, “Huh, this doesn’t really fully make sense. I’m not really understanding what’s causing these diseases. I sure know how to treat them, but I’m not really sure what’s causing them.” Then, looking at the bigger picture of what’s happening in America right now, and the fact that we have $4 trillion health care costs that’s going up each year, and people aren’t getting better because we’re dealing with chronic illnesses and we’re not treating them in a root cause approach putting all together and saying, “This isn’t working.”

I’m in the hospital, 80 hours a week, doing my craft. Patients aren’t getting better. What am I doing? Americans are getting sicker every year. I’m a doctor, we got to fix this. Then really having a reckoning and thinking about how to approach that at scale. So, that’s what led me to starting my company, Levels, which is focused on metabolic health. I’m really trying to scream that message from the rooftops.

Cynthia: Well, I’m so very grateful that your career has been on that trajectory. For myself, I feel like it took a little bit longer, but obviously in cardiology much to your point about ear, nose, and throat, it’s like chronic inflammation. I could say to myself, “Why we’re using this evidence-based medicine? People are on anti-platelets, they’re on anti-inflammatories, they’re on statins, they’re on blood pressure, they’re on diabetes medication, and my patient population,” because the NP service in our cardiology group saw all the hospital follow ups, and it was like a revolving door of the same things. People were coming in and it was like over and over and over again. I got to a tipping point, I remember saying to my husband, my kids were still little. So, I didn’t really have the bandwidth.

I remember, I was looking at doctoral programs, and I tried that out and hated it. Then, I did a wellness coaching program, and that was kind of meh. Then, I really dove into the nutrition piece, and finally the light bulb went on, I was like, “It all starts with food, but do we get an opportunity to really talk to our patients?” None of us are trained in the nutrition piece, or if we’re, we’re given a very cursory explanation. For me on so many levels, the whole metabolic health piece really started with the foods that we’re using in our bodies, and I have been someone that’s been really outspoken, for example about seed oils, and I love Ben Bikman’s work as I know, you’re very familiar with his work as well. I think the recent statistic that he talked about was that the number one oil/fat that’s being utilized in the United States is soybean oil. Because we consume so much processed foods in these oxidized seed oils and what they’re doing for driving inflammation and how this is hugely impactful on our health.

Now, for the benefit of the listeners, because obviously, acute inflammation is good. You break a bone, you stub your toe, etc., there is benefit to acute inflammation. But it’s the chronic inflammation that you’re referring to that can be so negative for our health. Can we talk a little bit about what chronic inflammation is, what it actually does at the cellular level, and why this is so detrimental, why we need to be more focused and concerned about–? You mentioned the lifestyle piece. So, what this actually does in our body that we need to know so that we can make changes to impact our health beneficially?

Casey: Yeah, absolutely. I think you drew the really important distinction, which is this difference between acute inflammation and chronic inflammation. So, again, inflammation is just the immune system in the body getting revved up or immune cells are some of our blood cells, and they fight infection, and they help mobilize this coordinated response in the body to address some threat, attack it, fight it, neutralize it, and then coordinate the repair that happens from that damage. It’s just an amazing system, the little army, but then also these little construction workers that help, fix stuff and it’s amazing. When you have a cut or you get a big injury, and your body is exposed to bacteria or whatnot, you want that to just immediately go into action, and this goes into action within seconds. Send those immune cells to that part of the body to assess the threat, clean up the threat, etc., Start the healing process. That’s amazing.

Then, you want that, once it’s healed to stop, you want that huge mobilization to stop. What happens with chronic inflammation is that, somehow the body’s continuing to see a threat. It’s like it sees a cut all the time. The body’s immune system is always in that assess monitor vigilance and repair mode. What that does is, you end up creating a lot of imbalance in the body where the system that was really just meant for just like this quick fix is now on all the time. That can really come up our systems in the blood vessels that can lead to thickening of the arterial walls amongst so many other issues, you really just want that whole system to settle down in between these acute little threats. But, again, like you’re talking about in the beginning, we now have these unnatural new triggers in our life that are perceived by the body as a threat. So, it’s not allowing that system to settle down. What happens with metabolism and metabolic dysfunction in part is that, a lot of and why it’s one of these centralizing forces that leads to inflammation is because when you overload the body’s cells and the energy production mechanism, the cells like the mitochondria, with factors that make them dysfunctional.

For instance, extremely high blood sugar over and over. You’re taxing the cell with doing much more than it was supposed to do. You’re driving many more cellular reactions through these processes. One thing that can do in the cell is generate what’s called mitochondrial oxidative stress, which is essentially, too many chemical reactions happening in the energy piercing part of the cell, and you leak these reactive molecules called reactive oxygen species. Normally, the body is able to clean those up. You have antioxidant systems in the body that neutralize those pro-oxidant molecules that are produced from all these chemical reactions. But when you have dysfunction in the mitochondria from all of these excess substrates that the body has to process, you get that too many of those reactive molecules, and that can be a trigger of inflammation. So, that’s one of the ways that there’s this link between essentially overburdening our energy producing systems with the cell, and how that then leads to a threat signal. So, the body was really meant to be in homeostasis, and to turn on and off these really nuanced systems when needed, and we’ve just gone way past that to where we’ve thrown everything off, and a lot of these systems are now just on total, total overdrive.

Cynthia: I think it’s this chronic overfed state, where we have conditioned our patients to believe that there’s just to have many meals, and snacks, and boost our metabolism, keep our metabolism up. In fact, ironically, we’re in a new city and my children both needed to have physicals prior to starting middle and high school, and they were fasting when they went in for these appointments. The pediatrician who was wonderful says to them, “We’re going to give you some, your due for a meningitis vaccine. But I’m concerned that you haven’t eaten anything this morning. So, I’m going to give you some Gatorade.” My kids eye light up, because they know exactly how I feel about Gatorade. I was like, “They’re fine. They’re both mature, young man. They’re not going to pass out from the shot.” He was fairly insistent that they needed to be, I said, “If you want to give them water, I’m all for that. But they don’t need Gatorade in order to boost their metabolism in order to give them a vaccine.”

I find it interesting that a lot of the rhetoric and the dogma that we as clinicians pass along to our patients is that we need meals, and we need them frequently, we need to keep our blood sugar stable. I think both of us would argue that one of the worst things we can do is meal frequency. So, let’s unpack what happens in our bodies when we’re overfed when our blood sugar is elevated over time when we keep insulin high? Because all of these things are really important for people to understand, and then we’ll leave in the CGM, which of course, I think continuous glucose monitors are probably one of the most important devices metabolically healthy individuals can utilize to empower them to make better choices.

Casey: Yeah, absolutely. That story about the pediatrician is– [crosstalk]

[laughter]

Cynthia: I was like, “Do you know what I’m known for?” I’m like, “I’m really cringing right now.” [laughs]

Casey: Yeah. I think I hope in about 10 years, we will not be living in a world where doctors are ever recommended high fructose corn syrup, and refined sugar, and Yellow 5, and Red 3, and all these things in their offices, but we’re working towards it. Yeah, so the chronic overfed, chronic overnutrition state is really what we’re dealing with right now. Like you said, we live through the 90s, where there was this dogma of like eat six small meals a day to boost your metabolism, and eat breakfast to boost your metabolism for the day. A lot of what we’re learning now in the research is that, it’s honestly the opposite of that, that actually training our bodies to function well in a fasted state is a key part of maintaining metabolic flexibility, which is really what we want for health. This really comes down to what’s going on hormonally when we eat. When we do eat, which for the average American for most people includes carbohydrates, those carbohydrates are broken down and turned into sugar in the blood, and that raises our blood glucose.

As that blood glucose travels around, it stimulates the pancreas to produce insulin, which is the hormone that helps us take that glucose out of the bloodstream, put it into the cells to either use it, have the mitochondria process it, turn it into energy, or store it if there’s excess, which there often is. That process when there’s a little bit of carbohydrates around in you bring them into the cell or process that or store it, that’s fine. But in our modern world, since we’re eating such an excess of refined carbohydrates and refined sugar, what happens is the body is producing has to produce so much insulin to drive all that sugar into the cells, and it’s repeatedly stimulating the pancreas to produce that insulin. So, you start getting into this over stimulatory environment. The cells actually as you know but just to go over it just briefly for the listeners who probably have heard about this a lot, that excess insulin that’s circulating because it’s constantly being stimulated by these snacks and these high carb foods that we’re eating, the cells become numb to that insulin. They say, “We can’t tell any more glucose in. There’s too much. You stop,” and so they become resistant. Then the body says, “Well, we got to get this glucose, and we got to bring it back down to normal,” and it over produces that insulin.

You get this process this spectrum of insulin resistance for now you are producing more insulin at baseline trying to drive that glucose into the cells. Over time, the cells become so insulin resistant. They can’t get it in. You can’t overcompensate. And the glucose in the blood just starts rising at baseline. That’s when you start seeing, you going to the doctor and they say, “Hey, your fasting insulin is going up,” or “Your average glucose is going up based on your hemoglobin A1c. When that happens, when your glucose is starting to go up on your fasting glucose test or your A1c is going up, you’re far down that road of this insulin resistant process, because your body’s been compensating probably for years trying to drive that glucose in and starting to really see instability. What’s interesting is that, many doctors are now checking fasting insulin levels as a way to pick up a lot earlier, early insulin resistance because as you can imagine, that is going to be showing up, and compensating long before, and there’s some say there’s a study in The Lancet that was done a couple years ago that showed that that process of insulin elevating may happen 10 to 15 years before you start seeing that fasting glucose go up.

Really interesting stuff happening there just as a result of us really eating far too frequently stimuli and that insulin way too much, and eating foods that are causing such high glucose spikes in the bloodstream that we’re our bodies are having to release these huge amounts of insulin. So, continuing that logic, things that we can do to keep our blood sugar more stable at a lower unhealthy level can take a little bit of the pressure off the insulin to constantly being secreted, and elevated, and help ourselves perk up again to the insulin signal, improve insulin sensitivity, and that’s really this concept behind a lot of what people are talking about in the low carb community, the keto community, the continuous glucose monitoring technology or community. How do we learn about how food is affecting our blood sugar levels, so we can have some control over this process? Because these days, the vast majority of American calories come from ultra-processed foods. So, it just seems normal to eat that stuff, and we don’t really have a sense of what it’s actually doing in our bodies, and how we can potentially do better. But a lot of this is in our control. One of the beautiful things about fasting, which is the anti-overnutrition is that, it gives our body just a complete break from this process. There’s step one, which is figuring out how foods affect your blood sugar and keeping that more controlled, keeping that more stable. Then there’s step two, which is actually just not eating for longer periods of time. That’s fasting. That gives your pancreas a break, it gives yourselves a break from doing all this process, and basically forces you to move through your stored energy in the body because you’re not getting it from your mouth during those times of fasting.

We have several hours of stored glucose in the body that’s stored in our liver that we can work through if we’re not eating food while we’re fasting, and then we have weeks’ worth of fat that we can break down and turn into energy. If we’re not eating not that we shouldn’t eat for weeks, but people have done it and they survive. We’ve got a lot of stored energy. The issue is that, we’re always going to use the glucose first. The first thing we’re going to use is the glucose in our bloodstream. Then we’re going to go to the glucose stored in our liver, and then we’re going to go to fat. The average American never gets to that phase of where they need to actually burn the fat, because we’re eating so frequently, we’ve always got something on board. The beauty of fasting and keeping glucose lowered by how we eat is that we will start actually using what we have stored and getting into fat burning. That’s great. That’s metabolic flexibility. That’s our body’s learning how to burn fat again, and I think most Americans are rarely ever getting there, and we’re seeing this show up in our overweight and obesity statistics. 72% of the country overweight or obese. That is a function of high insulin levels and not burning fat. The key piece here is that, well, one of insulins functions is to help get glucose out of the bloodstream into the cells. Another function has is to block fat burning. It’s a signal to the body, we’ve got glucose onboard, we don’t need to burn fat.

If we keep that signal high, we’re going to struggle with burning fat, which means we’re going to struggle with weight loss. Metabolic flexibility is what we want. And we can get there by understanding what’s happening with our blood sugar and keeping those levels more stable through how we eat, and how we fast, and then of course other things as well like exercise, which of course is going to also move through some of our stored glucose and help with our insulin sensitivity, and several other diet and lifestyle factors but really food comes first and that’s I think where a lot of us need to focus to get on top of some of these metabolic pathways and get them back on track.

Cynthia: I think it’s really interesting that for many people and it’s not a byproduct of anything other than some people just don’t know. I always love Jason Fung’s analogy about the way to break into the freezer, and to get into fat storage, you have to work through what’s in the refrigerator first. But I think for so many people, they’re familiar with a fasting blood sugar, they’re familiar with the hemoglobin A1c, which is that 90-day snapshot. The fasting insulin piece is one that I feel like when people start utilizing that, and asking for it, and it’s not an unusual test, I remind people that it’s a very standard test. I had a woman who was desperate to lose weight, was trying to intermittent fast. Her blood sugars were borderline like higher 90s not ideally where I wanted them to see. Same thing with her hemoglobin A1c, and when we drew her fasting insulin, it was 23. For anyone that’s listening, we want low like two to five or six depending on who you’re speaking to, and I said, this is why you’re not losing weight. This explains why you have these chronic cravings, and she had some degree of leptin resistance, which is another satiety hormone. I think it’s really important, if you’re listening, and you feel like you’re stuck, you need to be asking your doctor, your health care professional for some of these tests to dig a little bit deeper, because it can be incredibly invaluable.

Now, when we’re talking about monitoring our blood sugar, I think it’s also helpful for people to understand that different macronutrients, so protein, fat, and carbs have different net impact on our blood sugar. Obviously, carb has the largest impact on our blood sugar. But in terms of protein, because this is sometimes where the nuance where people are like, “Oh, animal-based protein is bad,” or “Plant based protein is bad,” because it’s going to spike your blood sugar. I’m like, “No, no, no, no, no. There’s all sorts of nuances that we want to look at.” We know fat has the most potentially negligible impact on blood sugar fluctuations. But what is your standard when you’re working with people and trying to explain to them the nuances like, I know, you did a beautiful job talking about blueberries that if I sit down and have a carton of blueberries, this is the net effect of my blood sugar. But if I add these other components, then it blunts some of that insulin and glucose response.

Casey: Yeah. Protein is a really interesting macro for a couple reasons. One is that, it can blunt glucose spikes. It can actually serve too, if you pair it with carbohydrates, decrease the amount of carbohydrates that get into the bloodstream, or just slow down how fast they get in. It creates a more gentle rise. Not this huge spike that can then trigger a huge spike in insulin. Protein can really be helpful that way, and there’s several studies showing that eating protein with carbohydrates or protein pre loading a meal with protein beforehand can help reduce the actual glycemic impact of the meal. Protein is also interesting though, because it can be turned into glucose, so the body can actually convert protein into glucose through a process called gluconeogenesis. Sometimes really excess protein can sometimes look like elevated blood sugar in a mild way. But that’s something to be cognizant of, if you are someone who’s eating really high levels of protein.

Then the third interesting thing about protein is that, it can actually stimulate insulin, even though it’s not a carbohydrate in high amounts, and it actually depends on what type of protein you’re eating. Dairy protein seems to have the highest insulinogenic effect compared to other forms of protein like plant-based protein. This is thought to be just the nature of the proteins in dairy. So, casein is one of them. But they actually found that these can really stimulate insulin three to five times more than other forms of protein. Something to consider when you’re eating a lot of dairy is that it may actually be stimulating that insulin which is, again, what we don’t want. If people are having trouble with weight loss or something like that, just something to think about, we sometimes will see in our data sets with our Levels members that people will eat something like ice-cream, and they will have very little glucose response, and even though there’s quite a bit of sugar in it. Part of that is because ice-cream is in a strange way like a balanced macronutrient meal. I wouldn’t recommend it for really any health goals, but it’s got protein, it’s got fat, and it’s got carbohydrates. So, you’re not just getting this carbohydrate alone load like naked carbohydrates just going straight into the bloodstream. The fat and the protein both can blunt that glucose spike.

But another thing to remember with ice-cream is that because it’s dairy, it may be very insulinogenic. Mean that’s actually causing your body to produce more insulin than the carbs alone would do normally, and therefore artificially make your blood sugar look like it’s lower than it would be otherwise, but at the expense of potentially a high insulin spike. Unfortunately, right now, we cannot test for insulin in a real time way like we can with glucose. But that would be a really interesting thing to look at is what’s happening with the insulin when eating those carbohydrates in the context of dairy. So, there’s a lot of nuance to it, but I think the top line things are that I think are the takeaway most practical things here are pairing some healthy, moderate source of protein with carbohydrates is generally a really good idea that is going to slow the amount of carbohydrates that are getting into the bloodstream, and will likely decrease the glycemic impact of that meal. I don’t want to overdo it, and also want to be thoughtful about dairy. But big picture, pairing protein with carbs is a good idea.

Cynthia: No, and I love that because I come to find, and this is really as women are north of 35, north of 40, all have certain foods they’ve been able to tolerate or not tolerated as well. For myself, I haven’t dairy in three years knowingly had dairy, I’m sure when I go out to dinner at a restaurant, I might get some passive exposure. But for me, dairy was a huge thing. I’d love to talk a little bit about the net impact of sex hormones on blood sugar control, because this is something that I found really, really interesting, and I think we were talking before we started recording that even though, I tried it a big research hospital, I never recall having conversations about how fluctuations, and estrogen, and progesterone really have this impact on insulin sensitivity or insulin resistance. So, I think a lot of listeners would find this particularly of interest, specifically, not only for people that are still cycling, still getting their menstrual cycle, but also for menopausal women. Women who’ve gone more than 12 months without a menstrual cycle, because it also applies to them as well.

Casey: Yeah, absolutely. There’s fascinating relationships between our sex hormones, and glucose, and insulin that show up at really every single layer of the woman’s life cycle from cycling and our hormones just during a normal menstrual cycle to if people are dealing with infertility, incredibly strong links between metabolic dysfunction, insulin resistance, and polycystic ovarian syndrome, which is the leading cause of infertility in the United States. Then moving into, of course, pregnancy and impact of gestational diabetes on American pregnancies, then you get into perimenopause and menopause. We know there’s a strong link between hot flashes, and obesity, and diabetes, and then postmenopausally. When we see women really unfortunately go off this metabolic cliff, whereas estrogen declines, women, we start to see increasing rates of obesity and diabetes. So, it’s every single stage we need to be aware of our insulin, our glucose, our weight, and how that’s impacting our sexual function. Not to mention the impact of metabolic dysfunction and insulin resistance on libido and on sex drive, which has been shown in both men and women.

Really interesting, and I think there’s huge opportunities for women to really take control of their health by understanding their glucose levels, by understanding their insulin levels, and understanding where they are in terms of metabolism, which I say that women need to take control because the system is not sharing this information. I have so many OB-GYN friends who I’ve talked to who really tell me that this is not taught in their programs that we should be treating people with infertility, with dietary education about carbohydrates and insulin. It’s just not a part of the standard really paradigm. We are often reaching for our prescription pads. So, to get into it in a little bit more detail talking about the cycle, as many of the listeners probably know there’s two phases of the menstrual cycle. There’s the follicular phase, which is pre-ovulation. There’s a luteal phase with post ovulation.

The luteal phase is characterized by increased estrogen and progesterone as the body prepares for fertilization, and then a drop before menstruation if no fertilization occurs. The follicular phase generally has lower progesterone levels, but an uptick of estrogen at the end of the cycle towards the end of that part of the cycle. What we know is that the estrogen to progesterone ratio seems to have a really strong impact on our glucose sensitivity and our insulin sensitivity, and actually, we see people being more insulin sensitive in the follicular phase of the cycle and less insulin sensitive in the luteal phase. This is thought to be because of the ratio between estrogen, progesterone. With estrogen being higher compared to progesterone as a protective pro-insulin sensitivity factor. You may see, if you’re wearing a continuous glucose monitor that blood sugar is actually easier to control and slightly lower during that preovulatory phase and higher in the luteal phase. So, that’s something to just keep in mind, perfectly natural and normal.

But again, given the way we’re eating these days, it could be quite pronounced. You could see big glycemic swings, and that could make you more moody and not feel as good as you’re in your premenstrual part of the cycle. So, it’s possible and certainly we don’t know this empirically yet it with studies, but it’s possible that really dialing into a balanced glycemically aware diet in that second half of the cycle could help with how people are feeling as they’re going into their cycles. That’s one thing to note with our periods, and I think time will tell if we can see in bigger populations and studies whether this might be a really positive intervention for PMS type symptoms. But I really would not be surprised if we’d see some improvement in that with a more stabilization of blood sugar during that part of the cycle.

Cynthia: I think there’s this real lack of awareness in terms of the interrelationship between where our insulin is fluctuating, where our blood sugar sensitivity is throughout the menstrual cycle, and there certainly, as you mentioned, your OB-GYN friends certainly, I had zero discussion about this, and it wasn’t until I started heading into perimenopause, and started becoming much more aware of what I tolerate, and what made me feel good, what impacted sleep, and stress management, and over exercising. Certainly, the integration of whether it’s a glucometer or CGM, which is certainly much easier, I had to laugh. I think you mentioned in another podcast that one of your colleagues, the only way to duplicate the information in the data that you get from a continuous glucose monitor is to prick your finger like 50 to 70 times a day. I’m not sure anyone listening would find that to be particularly beneficial.

So, let’s unpack, what a continuous glucose monitor is, little bit about how it works? Because I find it all utterly fascinating. I was telling my husband I’ve been wearing a CGM intermittently for about eight months, and it’s amazing to me to see the net impact and a metabolically healthy person of sleep, stress, nutrition choices, etc. But let’s talk a little bit about what the device actually is doing, and how you can see almost in real time, what’s going on with your blood sugar, which is fascinating?

Casey: Yeah, that person that you’re mentioning is my co-founder and the original founder of Levels, Josh Clemente. He really was pricking his finger 50 times a day or so to understand what was going on. He was in this fascinating situation where he was in his late 20s, he’s just the most remarkable guy. He was an early employee. He’s an aerospace engineer, was an early employee at SpaceX. By the time he was in his late 20s, he was managing a large team of people there designing life support systems for astronauts, and for the ships, and was really busy working hard, and was also on the side of CrossFit instructor and was jacked and really fit and, but he felt like crap. He did not feel good. He’s like, “Okay, in my late 20s, I’m super fit, I’m working hard, I must just be a little tired of work and whatever.” Somehow, he figured out something about blood sugar and energy like, “Oh, I’ve heard that, if blood sugar fluctuates, it could lead to energy problems.”

He bought a glucometer just from the pharmacy and started picking his finger, and he realized his blood sugar was way too high. It was going into the pre-diabetic, diabetic range frequently, and he was shocked, because from his outward appearance, you think he was just the picture of health, but he wasn’t. He was basically flirting with pre-diabetes. He’s like, “Oh, my God, I got to get on top of this, I got to figure this out.” He started checking his blood sugar more and trying to understand how food was impacting his blood sugar, and realize a lot of these fitness type foods he was eating were causing these huge fluctuations that he just thought were important for fueling, and recovery, and whatnot. He started really digging deep into, how foods are affecting him, and to do that, to see how a food is actually causing a blood sugar rise, you do have to look at several time points after the meal, because your glucose will probably go up maybe 10 minutes after you start eating, which I think a lot sooner than people would expect, because you have to obviously going from the GI tract into the bloodstream. But I’ve seen a handful of grapes raise my blood sugar in five minutes like start to go up. But it’s amazing how fast it is.

You got to get those early time points, see how steep the slope of that line is, like, how quickly is this going up? Then you obviously want to capture the peak, how high did it go? That gives you a sense of, probably how high your insulin was also going that spike often parallels and magnitude the insulin spike, and then you want to see how it comes down. Because it comes straight down, is the insulin causing just like a very quick return to normal in the blood sugar, or is it slowly petering down over two to three hours which actually has very different implications, and says very different things about how our body is processing that glucose, and how the insulin is working? So, to do that, you can imagine you need several time points. With a finger prick, that’s very hard. So, this is what a continuous glucose monitor really solves. As opposed to giving a snapshot of the glucose, it’s giving you a movie of the glucose. It’s actually a wearable device.

You stick it on your arm, or some people put it on their abdomen, and it’s got a tiny little hair like filament that goes under the skin, and that filament is coated with an enzyme that does a little reaction like a little lab test in your body that every five minutes or 15 minutes depending on the brand of the continuous glucose monitor is checking your blood sugar, and then sending that information to your smartphone. So, you end up with this amazing 24-hour graph of what happened every time you ate, and also in response to other lifestyle factors like when you exercise or walked after a meal. How did that change how your blood sugar returned to normal? Did it make it faster, or when you got poor sleep? Did that make your glucose more erratic the next day, or if you had a stressful call or a stressful conversation, did that make your blood sugar go up? Because we know that stress can actually mobilize glucose in the body from the liver. So, you can start to put all of this together and learn what is impacting your blood sugar, and then of course with that information, figure out how to channel that into a diet and lifestyle plan that keeps blood sugar more stable and flat. That’s again, what we want because it’s keeping insulin more stable, and helping us on that journey back to insulin sensitivity and all of the amazing health outcomes that come from being insulin sensitive. So, 24-hour monitor, it’s wearable, it’s painless, and it gives you just thousands and thousands of data points. So, you can really craft that personalized dietary and lifestyle strategy that works for you.

One other really interesting piece is, people might say, well, if I know all this information, I need to keep blood sugar down, and I need to exercise, and not be stressed, and sleep well, why don’t I just do that? Why do I need to actually monitor it? The interesting thing is that, it’s different for each person. It’s not like you and I would both eat the exact same meal and have the exact same blood sugar response. It’s actually very individual. There’s been studies on this. There’s this amazing study five years ago out of the Weitzmann Institute in Israel that was published in major medical journal itself that was called Personalized Nutrition by Prediction of Glycemic Responses. They looked at 800 non-diabetic healthy individuals wearing continuous glucose monitors and gave them standardized meals, they all ate the exact same thing, and they saw a huge variation in how people responded to that those standardized meals, which really changed the conversation around this concept of glycemic index, which is this idea that a specific quantity of food has a specific impact on everyone’s blood sugar level. It has some inherent quality of how it raises blood sugar. This totally changed that conversation, because what it said was actually, each person probably has their own glycemic index for each food.

A piece of white bread for you is going to look different in your bloodstream than it does for me. When they dialed into why that was, it was multifactorial. I think they found 137 things that they studied that were in some way impacting blood sugar, but a really big one was microbiome composition. What bacteria make up your gut, which is very much dictated by what we eat. But the way the bacteria are processing the food seems to have a big impact on how glucose is released from the food and is absorbed into the body. So, the bottom line is it’s complex, and it’s individual, and it’s also multivariate. if you’ve done a high intensity interval training workout this morning, the way that your body is processing glucose is going to be different than mine. If I’ve been sitting on the couch the last five hours, our cells are going to actually respond differently. If you’ve had different sleep than I have, it’s going to change our insulin sensitivity. There’s so many other parts as well. Micronutrient status, which rarely gets talked about. We talk about macros all the time, but micronutrients are key as well, or vitamin D levels, or selenium levels, or zinc levels, or manganese levels, or magnesium levels, vitamin C, these things actually all serve as cofactors for the enzymatic processes that allow us to process glucose. So, those things are obviously variable between people that has an impact on how we process food.

It’s beautifully complex. But when you’re looking at the data, you really start to realize these interrelationships and the whole purpose of Levels, the company that I’m one of the co-founders of is creating the software layer on top of the continuous glucose data stream to help tease out some of these really individual nuanced things, help people learn about the impact of through our education, micronutrients, microbiome, how environmental toxins affect metabolic health, how our exercise, our sleep, our stress, our food, our food pairings are all leading to that readout of our glucose. That’s what Levels does for people, and I just think it’s a really exciting time for personalized nutrition and personalized taking control over these things, because this is not a conversation you can really have easily in a 10-minute visit with your practitioner. Yet it is the core thing. We have to get right if we want to be healthy and have long, happy lives. Metabolic health and insulin sensitivity is really required for optimal aging and longevity. So, we’ve got to get it right. That’s where I think a lot of companies are trying to help move this along.

Cynthia: No, I think the big takeaway is bio individuality rules. Number two, if you’re listening and you’re trying to figure out like, how do I figure out the health of my gut microbiome, and so, there are companies, I like GI-MAP is one in particular tangentially, I just want to say that depending on the composition of our gut microbiome, we may extract more or less calories from the same food, and that’s really important. I always think about the bacteria, it’s in Firmicutes in particular, there’s a lot of good research in that area. Really knowing what’s going on in your gut microbiome, you touched on vitamin D, and all these other cofactors and minerals, and for anyone that’s listening, we should all know our fasting insulin level without question. We should all know our vitamin D status, because that impacts so many things, insulin sensitivity, immune function, etc., and actually, given the global pandemic, we know people that have done the worst with COVID, and many research studies are those of the lowest vitamin D levels and coincidentally also low testosterone.

But I think for anyone that’s listening and trying to piece all this together, obviously, we’re going to put contact information. But I had a couple questions from listeners, and one of these in particular, I’m particularly curious about I’ve been low carb or carb cycling for years. That’s worked very well for me, but I notice anytime I have a heavier, even if it’s like squash or sweet potato, I’m not talking about junky carbs, but a higher quality carbohydrate. I noticed depending on how large the portion I will see this massive blood sugar response. So, it’s why I actually kicked out plantains out of my diet. I do better with sweet potato and squash. But I know there’s going to be this paradoxical blood sugar response for those who’ve been low carb for a while, and I know, obviously, Ben Bikman’s on your team, and so, really looking at what actually drives that phenomenon in the body? Is it compensatory? Because multiple people had asked me, I’m just curious like I’ve been low carb for a while, and I almost feel like I’m carb intolerant, and I said, I wonder if it’s just we just give our bodies go a little bit lazy, because they haven’t had to process quite as much as before, even though we’re metabolically healthy.

Casey: Yeah, it’s a great question. It’s one that Ben Bikman talks a bit about as you said, he’s really just such an amazing expert on low carb diets as Dom D’Agostino, and I love everything they have to say about this. One thing that Ben Bikman talks about is this concept of reverse metabolic inflexibility, which is a result of essentially long-term adherence to a low carbohydrate or ketogenic lifestyle. This reverse, so we don’t want metabolic and flexibility generally, which is this process that we talked about earlier, where if you’re eating carbohydrates constantly, your body just becomes used to only using carbohydrates for fuel. You never give your body that opportunity to deplete the stored glucose and actually move into fat burning. When we don’t use particular cellular pathways, they get rusty in a sense. We need to use them to have the body be efficient at those cellular pathways. So, that’s why we use a term called metabolic fitness often at Levels because this is not like an on off switch, where you go low carb for one day, and all of a sudden, you’re an excellent fat burner. Actually, these things take time, and over time your body shifts into these states.

Going back to the question, long-term adherence to low carb ketogenic diets can cause this reverse metabolic flexibility that Ben Bikman talks about, which is rather than being stuck in glucose burning, our body has shifted to almost being exclusively in fat burning mode. As a result, it has low both as a cause and an effect has low insulin levels, and this is healthy. This is the body’s operating perfectly fine with prolonged reliance on fat as the primary metabolic fuel. But that does mean that a load of glucose can take longer to clear and your body, if it’s seeing a substantial load of carbohydrates, you can often expect to see a higher than normal glucose rise because you’ve really shifted your function towards being more low insulin, not needing to respond to insulin very frequently. So, it takes your body a little bit longer to clear it. It’s interesting and his feeling about this is that it’s perfectly healthy and a fine state to be in, but is a known observed phenomenon, that scene.

Cynthia: It’s really interesting, and for listeners, this is where I am in this stage of the game. So, that was a question that I had in sever listeners. One other question because I want to be super respectful of your time. For women that are in perimenopause and menopause, so five to seven years preceding menopause or not had a menstrual cycle for more than 12 months, the people that continue to have hot flashes throughout this time period. For me, I always had very minimal. I used to call like, it was almost like I never really got hot. I would just have this awareness and it was probably at the tail end of perimenopause. But for women who had profound debilitating hot flashes, I know there’s a correlation with this and blood sugar instability. What is the research that’s being done? Obviously, these are individuals that would really benefit from having a CGM, so that they could be monitoring what their blood sugar’s doing while they’re actually experiencing those power surges as they like to call them?

Casey: Yeah, absolutely. This is a really interesting area of continued research. But really, the big take home message is that people with insulin resistance, obesity, or type 2 diabetes tend to have worse hot flashes. People with the worst hot flashes tend to have a higher risk of developing type 2 diabetes. I believe that in some studies, the highest percentage of hot flashes per day had an 18% higher risk of developing type 2 diabetes in the follow up period. So, there’s clearly a link here, and it’s not fully established why, but it’s likely multifactorial. The way that metabolic dysfunction, obesity, insulin resistant affect other hormones potentially the impact of these hormones on vasomotor system of vasomotor activity. So, hot flashes really this vasomotor, meaning, our blood vessels, or are having this activity that’s causing all this blood to go to the skin and cause us to be really hot.

There’s some thought that insulin resistance in the brain because these things don’t happen in one part of the body, they happen everywhere. If we’re insulin resistant, that’s happening all over the place, and where that showing up is where symptoms show up. That in the brain, insulin resistance can look like so, so many different things, it can look like brain fog, it can look like depression, anxiety, it can look like Alzheimer’s dementia, chronic pain, fibromyalgia, but it can also potentially look like hot flashes, because the brain, if it’s not getting the glucose it needs because of insulin resistance that can cause this nervous system trigger to cause those vasomotor symptoms of hot flashes. That’s one theory is the way that essentially poor metabolism in the brain is triggering these symptoms. So, the question then is you know what to do about it? There’s no studies that have been done to show that keeping blood sugar more stable can improve hot flashes. But based on what, I’ve seen in the literature about these epidemiologic relationships and the proposed actual mechanisms, the way I would probably approach it is to figure out how to really improve my insulin sensitivity as much as I can, get that fasting insulin down before perimenopause, or during, keep blood sugar more stable. So, you’re not sending your body on these big swings that can trigger those vasomotor episodes, and really just try and move more into metabolic flexibility, give the brain the opportunity to burn fat, and you’d never or to use ketones for energy. So, it’s not totally reliant on glucose swings.

I would love to see those studies done, put people on a ketogenic diet or a low carb diet with his continuous glucose monitor on and see if you can really modulate severity of symptoms. But it brings up the second point as well, which is really what’s happening to women after menopause with metabolic health, and we mentioned this briefly before, but as estrogen declines after menopause, women start to see really increasing rates of obesity and type 2 diabetes. It’s not just because we’re getting older and this is what happens when you get older, it’s in large part because estrogen is protective and from a metabolic standpoint, and it promotes insulin sensitivity, and when we lose that, unfortunately, we’re at a disadvantage with our metabolic health. So, that really does mean that we have to be extra vigilant to understand what’s happening with our blood sugar, what’s happening with our insulin and stay on top of it. So, we don’t go down this just get carried with the tide of what’s happening without knowing what’s going on.

I certainly encourage people to ask their practitioners for a fasting insulin level to track their fasting glucose and really strive for it to be in the optimal range. If it’s starting to creep up from below a hundred for fasting glucose is all considered “normal via our standard criteria,” but if you start seeing your fasting glucose going from 78 to 85 to 95, that’s a problem if it’s going up. So, really be vigilant about those things and obviously, we’ve talked a lot about the strategies in this conversation of what to do about it. But menopause is a really important time to be thinking about those things, because we unfortunately get this kick of estrogen going down, and that has a big impact on our ability to be optimally insulin sensitive.

Cynthia: Yeah, and it’s interesting, because the standard Western medicine mindset is, “Okay, a woman’s gone through menopause, or is transitioning, or put her on hormones first,” and I think we would both argue that before the hormone piece, you’ve got to dial in on the sleep quality, you’ve to manage stress, you’ve got to get your macros better manage, you’ve to get your blood sugar controlled. If you do all those things first, if you need to add in hormones, and I think there’s less fearmongering like when I was finishing up grad school around 2000, that was at the time really at the peak of when I started seeing, there was reflexively a lot of data suggesting that solo estrogen was non-beneficial for women. So, I saw a lot of patients being taken off their estrogen, which is almost cruel, but you need estrogen. If you have a uterus, you have to have estradiol and progesterone together like peanut butter and jelly, minus the bread. But the point being really being strategic about how critically important that may be, and the health of our brains in our 40s and 50s are really reflected in our 60s and 70s.

Really important that we’re managing and mitigating our blood sugar way before we go through those middle changes, because it can just get exacerbated. Now, I want to be super respectful of your time you just returned from vacation, but I would love for listeners to be able to connect with you. How can they sign up? I know that there’s a long waiting list for your CGM, but your blog is amazing, your website is a fantastic resource, and obviously they should follow you on social media. What’s the easiest way to connect with you, get more information about Level CGM, connect with you on social media?

Casey: Yeah, so personally, I’m @drcaseyskitchen on Instagram, Dr, Casey’s Kitchen. Levels is @levels on Instagram and Twitter. And I love following the Levels account because a lot of our members are posting what they’re learning with their continuous glucose monitors and the insights that they’re having. So, it sparks lots of interesting ideas for what you can learn and how to experiment with it when you have the CGM. So, that’s @levels. Our website is levelshealth.com, and as you said, there is a waitlist for joining our beta program right now. But sign up on the homepage there and you’ll get access to our newsletter and to the waitlist, and ideally later this year, we’ll be able to open up the program to many more people. Then levelshealth.com/blog is what you were mentioning for our Levels blog, which is just this amazing source of information about metabolic health and thinking about metabolic health through this really forward-thinking lens and how we can all really improve with or without a continuous glucose monitor. So, lots of great articles from just pre-eminent thought leaders in the space. Ben Bikman, Dom D’Agostino, Dr. David Perlmutter, many others and so definitely recommend that as well. But looking forward to connecting with anyone on those platforms.

Cynthia: Thank you again for your time.

Casey: Thank you.

Presenter: Thanks for listening to Everyday Wellness. If you loved this episode, please leave us a rating, and review, subscribe, and remember, tell a friend. If you want to connect, visit the link in the show notes.