Ep. 361 Metabolic Health: Addressing Mitochondria, Medicine and Advocacy with Casey Means, MD

I am delighted to reconnect with Dr. Casey Means today.

Dr. Means is the Co-founder of Levels, a health technology company dedicated to reversing the global metabolic health crisis. She is also the co-author of the book Good Energy, along with her brother Callie Means. 

In our discussion today, we dive into mitochondria and metabolism, looking at the impact of cognitive dissonance and the reductionistic philosophies of medical specialization. We explore the effects of siloing, the challenges posed by our broken medical system, the Flexner Report,  the role of RVUs, the effects of insulin resistance on metabolic health and mitochondrial dysfunction, and the symptoms commonly seen in women. Dr. Means also offers her insights on advocacy, continuous glucose monitors, and the labs she finds impactful, and she shares the incredible story of her mother’s health journey. 

“There has been great research showing that if we focus on improving our metabolic health, PCOS often goes away.”

– Dr. Casey Means

IN THIS EPISODE YOU WILL LEARN

• How energy gets created in the body
• The link between insulin  resistance and acne
• How insulin resistance impacts fertility
• How underpowered parts of the brain and neurological system can show up as depression or anxiety, potentially leading to dementia
• The problem of our siloed, reactive, and specialist-obsessed culture
• The importance of getting your biomarkers tested and learning simple strategies to improve your metabolism, based on the results 
• What are the conditions encompassed by the metabolic spectrum disease? 
• The labs that Dr. Means finds most impactful
• Dr. Means shares her thoughts on continuous glucose monitors.
• The benefits of looking at your basic eating patterns in a non-judgmental and curious way before implementing any changes
• Dr. Means shares the powerful story of her mother’s health journey.

Bio: Dr. Casey Means

Casey Means, MD, is a Stanford-trained physician and co-founder of Levels, a health technology company with the mission of reversing the world’s metabolic health crisis. Her book on metabolic health, Good Energy, comes out in May 2024 with Penguin Random House. She received her BA with honors and MD from Stanford, was President of her Stanford class, and has served on Stanford faculty. She trained in Head & Neck Surgery before leaving traditional medicine to devote her life to tackling the root cause of why Americans are sick. She has been featured in The New York Times, The New Yorker, The Wall Street Journal, Forbes, Women’s Health, and more. 

Connect with Cynthia Thurlow

• Follow on Twitter
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• Check out Cynthia’s website
• Submit your questions to support@cynthiathurlow.com

Connect with Casey Means

• On her website
• Good Energy 
• Newsletter signup
• On Instagram, Twitter, TikTok, YouTube, and LinkedIn

Good Energy, by Casey and Calley Means, is available from Amazon and most anyplace good books are sold. 

Transcript

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

[00:00:29] Today, I had the honor of reconnecting with Dr. Casey Means. She’s the Co- founder of Levels, which is a health technology company with the mission of reversing the world’s metabolic health crisis. She is also the co-author of Good Energy with her brother, Callie Means. Today, we spoke at length about the role of mitochondria and our metabolism, the impact of cognitive dissonance and the reductionistic philosophies of specialization in medicine and the impact on siloing, the role of the broken medical system, the Flexner Report, the role of RVUs, the impact of insulin resistance on metabolic health, mitochondrial dysfunction, and common presentations and symptoms in women. The impact of advocacy as well as specific labs that Dr. Means feels are very impactful. The role of continuous glucose monitors, as well as her incredible story of her mom’s health journey. This is an invaluable conversation. I truly feel like Good Energy is a tour de force work that would be of benefit to every listener, every clinician, and will certainly be a book I will be recommending often. 

[00:01:50] Well, Dr. Casey, such a pleasure to have you back on the podcast and talking about subjects that are so near and dear to both our hearts. I would really love to kind of start the conversation from a place of cellular energy, helping people that are listening, understanding the value of our mitochondria, the value of why they are so important in our health, and kind of weaving that into the conversation. Because I think if we start there, everything else will make a great deal of sense. 

Dr. Casey Means: [00:02:21] Oh, absolutely. I mean, I love starting by talking about the mitochondria, because I think it’s just this underrecognized part of our health that if we understand it and understand how to nurture it, so much of the things that cause struggle in our life often will just kind of melt away. And so, when I think about metabolism and the mitochondria, we’re thinking about transformation of energy. We’re thinking about the creation of power in the body. And when we think about creating energy in the body, how I think about it is like if there’s a pyramid of health, the base of that pyramid, it is power. It’s how we create cellular energy in the body, because nothing else can happen in the body unless we have the power source working properly. 

[00:03:10] Like, we talk about hormones and we talk about what’s happening neurobiologically, but all of it, even to make a hormone, requires energy. So, we’ve got to get energy and power right for everything else to work properly. And that’s happening in the mitochondria. People remember from high school biology the powerhouse, the cell. And when I think about food, food has so many purposes in our life and our world. One of the purposes of food is to be the building blocks of our body. I am always astonished by thinking about the fact that every single molecule in our body is made from food. Literally 100%. We are totally 3D printed from food. So that’s one purpose of food. Food is also a signaling molecule. It can change our gene expression and the activity of our cells. 

[00:03:52] But a third thing that food is, is its potential energy. It’s energy from outside our bodies, potential energy that could be used to power ourselves in our lives, but we have to transform it into a currency of energy that our cells can recognize. So we take in, like, 50 metric tons of food in our lifetime, and we have to transform it into something that actually our body can recognize. That’s metabolism, that’s what’s happening in the mitochondria, and that is what is dysfunctional in 93% of modern Americans. This is so unprecedented. Even 50 years ago, metabolic issues were so much less in terms of rates, but because of a confluence of factors in our modern, industrial, urbanized world, across our ultra-processed food, and not getting enough sleep, and too much low-grade stress from our devices, and synthetic environmental toxins in our food, water, air, personal care products, all sorts of things are conspiring right now, at this moment in history, to synergistically hurt our mitochondria. So, we’re dealing with an issue where essentially the vast majority of American adults have a problem with this transformation of energy process. So, we’re getting underpowered cells. And what the science is showing us is that these underpowered cells, metabolically dysfunctional cells, mitochondrial struggles in our body, actually underlies the vast majority of chronic illnesses and diseases we’re facing in the country today. 

[00:05:20] Unfortunately, our system has a metabolic blind spot, and the healthcare system doesn’t focus on metabolism as this unifying, connected link between so many of the diseases. We treat the diseases in silos, in different specialist office, and we treat the symptoms. And so, the real thing that I think people need to realize is that this metabolic root cause is very likely one of the things that needs to be addressed for anyone listening who has any chronic symptom or diagnosed condition. This metabolic underpinning is somewhere that we really need to focus and understand for ourselves, because it’s actually really quite a blind spot in the healthcare system. And the great news is that it’s actually quite easy to track metabolism. It’s quite easy to improve metabolism, but we need to be aware of it and choose to focus on it. So that’s kind of the landscape of mitochondria and the metabolic health issues that we’re facing today. 

Cynthia Thurlow: [00:06:11] Yeah. What do you think in terms– because you’re both a clinician and a thought leader, why do you think most clinicians struggle with understanding this? Clearly, every clinician has taken microbiology or cell biology, and so they learned about these connections. But yet I feel like there’s still this kind of rampant disconnect from our traditional kind of allopathic peers and kind of understanding that we really do need to look at these lifestyle measures to be able to fully support our patients and health and wellness, because clearly, over the past 25 years of me being in the medical community, we’re not heading in the right direction. You mentioned the 93% of Americans are not metabolically healthy. And so I’m curious, what your personal feeling is like, what is driving a lot of the cognitive dissonance around this? 

[00:07:08] Dr. Casey Means: Yeah. I think it’s because in our western paradigm, across pretty much everything, I mean, so many different industries, we are very reductionist, and we’re very into fragmentation, and we celebrate. We think about America it’s a very individualistic culture. Like, we’re not a collectivist culture, like many other cultures. We’re very individualistic. And we’re so into siloing, and we think that specialization is advancement. That’s a very western thing. And so, on every level, that’s kind of built into how healthcare is practiced and how medical students and all sorts of medical practitioners are taught. So, you actually think about the way the curriculum, at least when I was at Stanford Medical School, it’s actually taught, like, by organ system. 

[00:07:59] So we’re taught, “Okay, we have the gastroenterology block, and we’ve got the cardiology block, and we’ve got the neurology block, and we’ve got the hepatology block and the renal block.” That’s literally the way the curriculum is structured. You don’t even think twice about it. Like, of course there’s different body parts we teach that way, but there’s actually a totally different way to teach that. We could teach which is less focused on organs and more focused on actually, like, intracellular physiology. So, there could literally be a block that’s like the mitochondria block. And then what we would do then is say, “Okay, here’s all the way the mitochondria are getting hurt in our modern world.” In this block on mitochondria, the six weeks we’re going to talk about how that emerges in different organ systems, how that looks, how mitochondrial dysfunction looks in the liver and how it looks in the brain and how it looks in the heart and how it looks in the ovary. That would be a totally different way to structure the curriculum. 

[00:08:58] But I think the average person would just never even think, like, we have different organs, of course we should teach that way, but it’s different sets of goggles. One is more of a connected root cause approach. One is more fragmented. Now, “Why is it this way?” I think a lot of it comes down to two things, really. I think one is money, and that’s maybe a little more sinister. And the second is actually just slowness. So with the money one, we have a huge healthcare system. $4.3 trillion are spent on healthcare every single year, so 23% of the largest GDP in the world is spent on healthcare. That’s big business. Fastest growing industry in the United States. There’s tens of millions of people employed in healthcare. And if you think about if we separate the body into 100 different parts, which is what we do, there are over 100 medical subspecialties now. Then and you sort of ignore the connected root causes, well, then you can take a person with arthritis and prostate cancer and depression and early heart disease and brain fog and a rash, and you can put them in six or seven different specialist office all of who can bill that patient, can prescribe them a drug, a different drug, and who can see them, if they can sort of manage that condition but not cure it, they can see that patient in their office 10,15 times over the course of the next few years and bill every single time. So it’s very profitable to silo. It’s very unprofitable to heal root causes. 

[00:10:34] Now, I’m not saying that I think doctors are taking advantage of patients or practitioners are taking advantage of patients. I think that we are so blind to the fact that this matrix that we’re living in is happening, and we literally are so deep in it that we actually think it’s the only way. And actually, we so value specialization that to become more prestigious in our system, you have to become more hyper specialized. So, when I was an ENT surgeon, to become more prestigious and to be more likely to have a chairman position at a big hospital, I would actually go from being an ENT surgical subspecialist to just focusing on ear, nose, or throat. I could have become a rhinologist, laryngologist, or otologist. So hyper specialization is literally what we celebrate. So that’s one, that’s money. The second piece is slowness. And this is more like I just think this is what I think we really are trying to wake people up to, which is that when we were classifying diseases, like, over the course of history, basically, and we didn’t have the technology we have today to understand a lot of these invisible processes happening inside the cell. Like, you think about, like, proteomics and metabolomics and microbiome sequencing, this is all brand new. 

[00:11:50] So, previously we used to categorize diseases based on what we could see, which is the symptoms. So, obviously, someone with Alzheimer’s has a different set of symptoms than someone with sinusitis or someone with fatty liver disease. And what we could see was, like, what was emerging in their body, the symptoms, maybe some lab tests, the biomarkers. So we said, “Okay, Alzheimer’s is this collection of symptoms, and fatty liver disease is this collection of symptoms and imaging findings, and sinusitis is this collection of symptoms.” And what happened is now that we can actually understand what invisibly is happening inside the cells, what we’re learning is that all three of those conditions, a lot of the same stuff is happening in those cells, just in different parts of the body. Things like mitochondrial dysfunction, things like chronic inflammation, things like oxidative stress, these cellular physiologies that are just showing up in different parts of the bodies. So, we actually now kind of know what’s really causing disease, but we haven’t updated the medical system to practice that way. So, I’d say the nugget there is that even though we know better, we are still confusing symptoms for the disease. 

[00:13:08] The disease is the invisible stuff happening inside of cells, the dysfunction inside the cells. It’s not actually the symptoms. The symptoms are the representation of that happening. And yet we’re still treating as if the symptoms are the disease when we know that there’s actually something deeper happening. So that’s the catch up that needs to happen. And I think we’re in the middle of that starting to happen. Although there’s kind of a financial war against it. So the call to action for anyone listening is to just really try and put on those root cause goggles when you’re thinking about your body and when you’re pushing your doctor to probe deeper, because there’s some forces at play that are stopping that from happening, and they’re not in your best interest, because what’s in our best interest is ripping out the problem from the root, not just trimming the weeds on the surface. 

Cynthia Thurlow: [00:13:57] It’s such a good point. And one thing in the book that really stood out to me was the concept of this Flexner Report. So, you mention in the book that it was an outline vision for medical education. It was instituted in 1910, and essentially it stigmatized, “nutritional, traditional, and holistic remedies.” So, over 100 years ago, there was a broader perspective on how we looked at medicine to treat patients. And from 1910 on, correct me if I’m wrong, this is how it was affirmed by Congress. So, this was at a federal level, credentialed medical institutions had to follow the Halstead-Rockefeller based model. And that, you know, as someone that’s a licensed healthcare provider, I was like, “Why didn’t I know this?” 

Dr. Casey Means: [00:14:48] Yeah, yeah. It’s astonishing to know, like, what powerful people throughout history with strong influence, with very specific pieces of policy and legislation, like how that’s had a ripple down effect that we don’t even understand when we’re in the system, because that history is kind of a little bit secret. But, yeah, with the Flexner Report, essentially, Rockefeller was doing a lot with essentially the processing of oil and crude oil and had all these sort of, like, petroleum-based byproducts that they needed to do something with. And they kind of found that they could use them for drugs that you could give to people. And so really was pushing Congress and then medical education culture to focus on a very pharmaceutical intervention-based approach for conditions. And then, as you know, and I think in that time a lot of the medications people were taking were for acute issues. They were for issues like an –infectious antibiotics were kind of starting to come around, and these pills for things that a disease like an infection or something that could kill you immediately. But if you take the medication, the infectious disease goes away, and then you can move on with your life. 

[00:16:03] So that’s a medication for an acute issue, which I have no problem with. “What has happened though, is that as we become more industrialized and urbanized, and technologically advanced with our food system.” And I put that in major air quotes. We have, of course, really damaged our bodies. We’re living out of alignment with nature in every possible way. Our bodies are very confused, and we’re now developing chronic conditions that don’t go away with a single pill. So. what they require is long term, “treatment or management.” And so, this Halstead model of, okay, how do we basically demonize holistic strategies, really focus on pharmaceutical interventions, which do really work well for acute issues? How do we actually now apply them to chronic issues? So, people have to take this pill forever. Again, something we take for granted, this idea of, like, taking a long-term medication. But this is, like, a brand-new phenomenon that we’re buying into as, like, a strategy that is just a default. But in reality, I think we need to realize that, like, “This is very much by design. Nothing could be more profitable, nothing” for a pharmaceutical company, and for honestly, doctors who can bill for each visit than having a patient on a medication for life. 

[00:17:22] And one of the most sinister things is that if you really step back and think about the darkness of the financial incentives in healthcare right now, which is, simply put, almost every institution that touches our health in the modern American world makes more money when patients are sick, and they make less money when patients are healthy. And what is most profitable for the system right now is having more patients going through the system for a longer period of time, having more things done to them. That is what is profitable for our system. And so that has corrupted every level of the way we do research, the way we educate doctors, such that we create norms that we convince ourselves are fine and good, when in reality, there is a different way. And that’s the way that I’m really trying to present in good energy is like, there is a different way to do this. We kind of do need to wake up and look around and realize that our current system isn’t working. But the most devastating thing, I think, is that, based on that reality of the financial incentives that I just said, nothing is more profitable for the American healthcare system than a very sick child. 

[00:18:27] Because if you have a chronically ill child, a child who is essentially getting lifestyle diseases earlier in life, that is a patient who may be going through the healthcare system and being chronically treated with different meds for decades and continuing to rack up comorbidities as they get older, this is devastating. But if you look at what’s happening, that’s the financial incentives of our system. And we are seeing kids get very sick with lifestyle issues. We’ve got 30% of teens having pre diabetes now. We have 40% of 18-year-olds having had a mental health diagnosis, 18% of young adults with fatty liver disease, 50% of children with overweight or obesity. So, these chronic lifestyle issues are going up massively in children, of course, also the behavioral issues, ADHD, autism, neurodevelopmental issues. So. you have to step back and scratch your head, like, “What is this system that we’re buying into that is really not having the outcomes we want? And how do we have a different vision?” I think a lot of this traces back to some of these early pieces of really corrupted influence in legislation, like the Halstead report, that essentially disincentivize, and in some ways criminalized practicing root cause holistic medicine. 

Cynthia Thurlow: [00:19:44] And I think understanding a bit about the history explains the way things have evolved. So, thank you for that beautiful explanation and touching on teens and children. And even as I was reading your book, really emphasizing the health of mothers is very important on the health of infants and neonates. And when I read that the impact of metabolic health of mothers during pregnancy is paramount, the impact of something called macrosomia, so large babies. I remember in Baltimore, I’ll never forget this, there was a woman that had a vaginal delivery, a 15-pound baby. And I looked at my instructor and said, “Why didn’t anyone tell this woman she had diabetes?” And that was in the 1990s, and they just weren’t screening the way that we are hopefully doing now. So, understanding that the health of the mom, infants, children, teenagers, begets the health of adults. And I think, for me, like, helping people understand that some of the common disorders and illnesses that we’re seeing are increasing at alarming rates. I think about just insulin resistance. 

[00:20:57] I know that this is something that is at the basis for nearly every chronic health condition, and yet we’re not talking to our patients often enough about how that shows up. You know, back in the dark ages, when I was in nursing and my nurse practitioner program, 140 mg/dL for blood glucose was considered to be abnormal. Now it’s above 100, but I know that we would both argue it needs to be even lower. But what are some of the more common, probably common, but perhaps less commonly known ways that insulin resistance can show up? Let’s just say in women, as an example, what are some of the less common things that are not being addressed, that are related to underlying insulin resistance? 

Dr. Casey Means: [00:21:44] Mm. Such a great question. So, first thing I just to help, just in case there’s any dots that aren’t connected yet for people listening. So, when we were talking in the beginning about metabolic dysfunction and mitochondrial dysfunction, this is that sort of problem with the body converting food energy to cellular energy and the food energy to cellular energy. If we get a little more technical, it’s things like glucose and fatty acids through the mitochondria to ATP, which is the currency of energy the cells can use. And we talked about how the mitochondria are having trouble doing that because of a confluence of environmental factors that are really hurting it, like less sleep, too much stress, too many toxins, too much artificial light and ultra-processed food, amongst some others. When the cell recognizes, essentially because the cells are infinitely wise, if there’s anything I’ve learned from really diving deep into this, it’s like the cells know better than we consciously do, and they will always work to protect themselves so that they can protect us.

[00:22:42] And one of the ways they do that is by generating insulin resistance when there is mitochondrial dysfunction. A lot of the times we talk about insulin resistance as the problem, but actually insulin resistance is still not the root cause. The root cause is actually inside the cell with a mitochondria that can’t do the work. And so, if that glucose can’t be shuttled through the mitochondria effectively to make ATP, the cell is going to say, “Stop bringing glucose into the cell because we actually can’t process it.” So, since insulin is the hormone that lets the cell take glucose into the cell from the bloodstream, the cell will create insulin resistance, essentially a blocking of the insulin signal so that glucose can’t get into the cell. So, then what happens is the body is blocking. The cell is blocking glucose from coming in through the process of insulin resistance to protect the cell from doing work it doesn’t have the capacity to do. And then the body responds again and says, “Well, we don’t want this glucose floating around in the bloodstream, so we’re going to actually produce more insulin to try and force the glucose into the cell to overcome that insulin resistance.”

[00:23:43] So now, of course, if you’re imagining the cell is blocking, then the body’s trying to overcompensate with more insulin. We have insulin levels rising, and eventually the glucose levels in the blood are going to rise when the cell essentially tuckers out and can’t keep trying to force more glucose in. So then, you’ve got this process that essentially is representing mitochondrial dysfunction, but also in the blood looks like high insulin and high glucose levels. This can cause so, so many issues in the body. Because that insulin’s floating around the whole bloodstream. That glucose is floating around the whole bloodstream. One of the things that glucose can do is, like, stick to things in the body when it’s too high in the bloodstream, and that can cause problems all over. So specifically for women, like, let’s just kind of talk through, I’m 36, so, like, sort of in my age group, what this could show up as, one is belly fat and weight loss resistance. Because that insulin, that higher level of insulin flowing around, that’s anabolic hormone, that is a pro-growth hormone. 

[00:24:41] And insulin basically tells the body to deposit that extra glucose as fat, to store it as fat, and often around the midline, which is where it’s actually quite dangerous, coats our organs, and is very inflammatory. So one is belly fat. Two is that it can actually lead to skin issues. So many issues we’re fighting with creams and lotions and lasers and all this stuff are actually really result of insulin resistance and high blood sugar. So this can show up as eczema, it can show up as acne, it can show up as premature wrinkles and aging. And I think the wrinkles one is a really interesting example, because when that high glucose is floating around, it’s sticking to collagen, which is the most abundant protein in the body, one of the big structural proteins of our skin. And when glucose sticks to collagen, collagen cross links in a different way. And that can create the wrinkles that we don’t want. [chuckles] 

[00:25:32] And so that’s another way. When we think about something more like eczema, that is actually the result of that high insulin and high glucose generating chronic inflammation, which shows up as an inflammatory skin condition. And then we’re talking about acne. This one’s really interesting. That high insulin, again, insulin is anabolic pro-growth hormone. And insulin is going to be floating all throughout the body, and it can literally bind the receptors on the oil-producing glands of the hair follicle and tell them to produce more oil, the sebaceous glands. So, you’ve got insulin, again, results of mitochondrial dysfunction, telling the oil producing glands in the skin to produce more oil, that’s going to create acne. So that’s just like three skin conditions that I think a lot of women are thinking about, that all are actually fundamentally related to the same problem. Let’s then move on to something like fertility. 

[00:26:24] So right now, I’m 36, I want to have kids in the next year or two. I’m thinking about fertility a lot right now, and the best thing I genuinely believe we can do for optimizing our fertility is to keep our blood sugar and insulin levels under control, to be metabolically healthy for a couple reasons, one, pregnancy is one of the most energy intensive things we’re going to do in our lifetime. You’re building a human, you’re 3D printing a human, you’re building an entire new organ with the placenta and a baby. So, we need our energy production processes and our mitochondria to be at top notch to tell the body that we have the capacity to do this job, the most monumental job our body will ever do if we choose to have children. And we know that there’s a big problem in this link between metabolism, fertility, because polycystic ovarian syndrome, which is the leading cause of infertility for women in the United States, is skyrocketing. And worldwide, some studies show that 26% of women now have PCOS, which is fundamentally a metabolic issue. It has both lifestyle and genetic components. But what’s happening on this cellular level is that high insulin levels in a woman’s body are stimulating the ovary, the ovarian theca cells to essentially produce more testosterone. That disturbs the delicate balance of hormones in the body and can cause problems for ovulation and menstrual irregularity, along with a lot of other symptoms.

[00:27:46] And so, like, it’s incredible, because over 50% of women with PCOS will have type 2 diabetes before they’re 40, it’s amazing. And so, there’s been great research showing that if we focus on improving our metabolic health, PCOS often goes away. So, skin issues, weight, fertility, then let’s get into another thing that’s affecting women so disproportionately right now is mental health issues. We’ve got depression and anxiety in women outpacing men. And people might think, “Well, how does blood sugar have an impact on the brain?” Well, the brain is one of the most energy hungry organs in our entire body. And even though the brain is 2% of our body weight, it uses 20% of our body’s energy. So underpowering and mitochondrial dysfunction, blood sugar issues, insulin resistance, they’re all kind of the same thing, that showing up in the brain can look like so many different things. Because, you think about it, underpowered different parts of the brain [chuckles] and our neurologic system, being underpowered can look like a lot of different things. It can look like depression, anxiety. It can also look like migraine, headaches, fibromyalgia. It can look like dementia, Alzheimer’s dementia. 

[00:28:57] There’s lots of different ways that underpowering in the brain can show up. And all those conditions I just mentioned we know are in some way linked to or rooted to metabolic dysfunction. It’s essentially underpowering showing up in different parts of the brain at different parts of our lifespan. So, specifically for depression and anxiety, there’s a very strong relationship between insulin resistance, blood sugar dysregulation, mitochondrial dysfunction, and higher rates of depression, anxiety. So, if we can get those things under control, the blood sugar and the insulin, often mood symptoms will improve. And Dr. Chris Palmer from Harvard wrote an incredible book called Brain Energy, which goes way deeper into that. And he actually has a theory that almost every mental health issue is fundamentally rooted in mitochondrial dysfunction. The last two I’ll mention with women, because we could go on for 3 hours talking about the symptoms that affect women that are related to blood sugar and insulin. But I think just the other couple I’ll just mention briefly is we know that autoimmune diseases, which disproportionately affect women over men, have a very high sort of concordance and relationship with metabolic issues. 

[00:29:59] So what that means is that, like for people with MS or rheumatoid arthritis or lupus, much higher rates of diabetes in people who have these issues. So there’s some relationship there, worse menopausal symptoms. And I know I’m speaking to an expert here on perimenopause and menopause, but people who have poor blood sugar control tend to have worse vasomotor symptoms and mood symptoms in menopause, and then post menopause, when estrogen declines we know that women, in many ways, kind of even get such a metabolic hit. And that’s when we see the rates of obesity and diabetes and Alzheimer’s really starting to kind of take off for women. So across, just thinking of my age onward, that’s just a handful of things that we know are so linked to blood sugar and insulin resistance and mitochondrial dysfunction. And unfortunately, because of our siloed, very reactive, very specialist obsessed culture, I think a lot of those conditions, women will be going to different doctors. 

[00:31:01] Maybe the OB-GYN for one, the psychiatrist for another, the rheumatologist for another, and probably being offered pills and probably not being told a lot about what are the tests they could get to understand their metabolic health, and then what are the simple strategies they could do to try and improve it. But everyone listening, I think, really should know that’s an avenue they should go down. They should get those biomarkers tested, understand where they stand on metabolism, and then learn how to make some simple strategies to improve it, because they may find that some of those symptoms really do actually ease up. So that’s a brief overview. But, I mean, yeah, to simply put that the metabolic spectrum disease is. Includes almost every chronic condition and symptom we’re facing in the western world. That’s just a few that we just talked about that specifically affect. I think, that a lot of women are thinking about. 

Cynthia Thurlow: [00:31:50] Well, and I think this is such an invaluable conversation because many people may not be connecting those dots. Maybe with PCOS,-

Dr. Casey Means: [00:31:57] Yeah, 

Cynthia Thurlow: [00:31:58] -maybe with some of the mental health stuff. But even thinking about hearing loss, this was something that I found really interesting in the book. You talk about the prevalence of high frequency hearing loss impairment with elevated fasting glucose was 42% versus those with normal values at 24%. I mean, how many adults that I talk to on a day-to-day basis will just casually mention, I do feel like my hearing isn’t nearly as good, and these are individuals that are probably at greater risk just based on the age ranges that they’re in, that the changes of estradiol signaling changing in the body as they’re kind of navigating late perimenopause into menopause. Even men, many of whom are dealing with fertility issues, low testosterone in many instances related to common in insulin resistance. 

[00:32:45] This is really a problem that everyone listening should be asking their providers specifically, could this be related to some degree of insulin resistance? And with that being said, “What do you think are the labs that are most important for everyone to be asking for?” Because unfortunately, we’re still in this model of, I check a hemoglobin A1c, I just check a fasting glucose, and your fasting glucose is fine. And yet, Dr. Robert Lustig talks a lot about the values of 90 to 99 mg/dL. They’re at 30% greater risk of developing diabetes. It is not benign. And so, what are some of the labs that you feel like are every adult listening should have drawn, or certainly anyone that’s at risk for developing insulin resistance? What are the ones that you feel like are most important to ensure that they’ve had done? 

Dr. Casey Means: [00:33:40] Yeah. So, I think the most important test that people can get to understand insulin resistance is a fasting insulin test. And I think that, this is one that you’re going to have to ask your doctor for, and they may push back and say, “That you don’t need it,” which I would just reject, because, again, 93% of American adults have some element of metabolic dysfunction. So, we really need to understand this. If your doctor won’t order it for you should get it through a direct-to-consumer lab testing company, like a Function Health or InsideTracker, a functional medicine doctor in your area, like a Parsley Health or Levels does blood work, but, like, find a way to get it, because it’s going to be a clear signal of whether there’s insulin resistance in the body, which, again, is really tracing back to mitochondrial dysfunction. And when there’s insulin resistance, our body will secrete more insulin. And this can happen so early, it can happen a long time before we start to see the blood sugar rising, because the body can force glucose from the bloodstream into the cell by secreting extra insulin for a while, it can essentially jam the glucose through the insulin block. It can push past that for, like, 10 years before things get so off the rails that glucose actually starts to rise in the bloodstream.

[00:34:57] So, [chuckles] it’s a couple hurdles, one is that we have to actually just get someone to order this test for us. The second thing is that when we get the results back, the lab slip will often say that, like, “Less than 25 [unintelligible 00:35:09] is normal.” So you might see, like, a green check mark next to your number and think it’s fine. But actually, the reality shows that a much lower insulin level is actually healthy. Once you’re getting up to having level of 25 in your bloodstream, that’s probably a sign that there actually is insulin resistance happening. So, we want it to be probably between more like one and five or six. We don’t want no insulin because that’s actually that’s pathologic. But so between, like, about one and six, if it’s really rising above 10, like, that’s a sign that the body’s having to, like, produce a lot of insulin. Probably could be a sign of insulin resistance. So that’s, number one, is fasting insulin. That’s probably my number one favorite test of all tests. I also just really encourage people to make sure that they’re getting all the basic biomarkers that essentially define metabolic syndrome at least two or three times a year. All of these should be free at your annual physical. And if not, you could probably get them all out of pocket for $100. 

[00:36:06] And so the ones that really define, like, just categorically from the healthcare system’s perspective, metabolic syndrome is a fasting glucose, a fasting triglyceride, hemoglobin A1c, HDL cholesterol, waist circumference, and blood pressure. So, based on sort of the criteria that you’ll see in the papers, we want fasting glucose less than 100, triglycerides less than 150, hemoglobin A1c less than 5.7%, HDL above 50 in women or 40 in men, waist circumference less than 35 in women or 40 in men, and blood pressure, less than 120/80. And essentially, we want all of those in that range. The bad news, unfortunately, is that even though those are what the standard criteria are, I think we would both argue that for some of those, we actually want a tighter range for truly optimal health. So, like, the criteria that they put forth is fasting glucose less than 100, but we probably actually want it like 70 to 85 for optimal health. These criteria, say triglyceride, “Less than 150 is good.” I like to see it less than 70, usually for people.

[00:37:07] With all that said, and all of these ranges and optimal ranges are in my book, but the ones that I just listed, what’s wild is that for people who just meet those more lenient criteria, if you have all of those in that criteria, not on medication, you represent 6.8% of Americans who are considered, “metabolically optimally healthy.” So, it is very rare for people to actually even meet those more lenient criteria. So, you need to know where you stand on those basic biomarkers at least a couple times a year, because it will give you a snapshot of essentially how your metabolic health is doing. Once you meet that 6.8%, then try and refine to the even better, more optimal ranges, but at least you need to know if you’re in that category. So those are some great ones. And then so, insulin, the basic biomarkers of metabolic syndrome and dysfunction and then a few others that I think are just really, really valuable, that I think doctors will often order now, is hs-CRP. So, C- reactive protein, which is an inflammatory marker. People who are dealing with metabolic dysfunction and an underpowering of their cells will often have inflammation, because basically the body’s responding to this perturbed state of underpowering. 

[00:38:18] So, inflammation, inflammatory markers like CRP. I love liver function tests. I think they’re underrated. But AST and ALT are a sign of our liver function. And the liver is like the center point of our metabolism in the body. It detoxifies, it secretes bile acids. It’s the first pass for all the nutrition from the gut. It’s directly connected to the pancreas, which makes insulin. So if the liver is getting dysfunctional, it’s going to really drive. Since it’s connected to the pancreas, which makes insulin, it’s going to drive more insulin secretion, and be a big instigator of insulin resistance throughout the whole body. So, we want the liver to be like pristine and fabulous, and so we want those liver enzymes to basically be low to show us that our liver is, like, happy and healthy. I love vitamin D because it’s very involved in insulin sensitivity. Those are some of my key ones. So that’s maybe what, 10 tests that I think can give you, like, a really great gestalt of how your metabolic health is.

[00:39:14] If we’re looking at them through the lens of metabolic health, and not just looking at them algorithmically as independent sort of tests. One other I’d throw it in there is like, ApoB or LDL, these are tests that can tell us about the, “bad cholesterol.” And so those can be really– Interestingly, it’s not actually included in the metabolic syndrome criteria, but also helpful to kind of know where you stand on that. And I’m sure you’ve talked on the podcast before about more like advanced lipid testing and things like that. These markers can sort of be flawed in telling us the full picture of the bad cholesterol, because you need to look at them in the context of insulin sensitive. But having a low, healthy number of ApoB is a good sign for cardiovascular and cardiometabolic health as well. So that’s kind of the ones that I focus on, that I think everyone should be getting two to three times a year, because not only it tells you where you stand and how you’re doing and gives you an honest [unintelligible 00:40:10] metabolism, but the other thing is that if you’re checking them regularly, you can make tweaks to your diet and lifestyle and see how your metabolic health is responding. 

[00:40:20] And if those labs are moving in the right direction, you can really feel more confident in your strategies, which I think everyone’s looking for, because there’s so many voices in the health space right now, and everything feels so confusing around fitness and nutrition and everything. So, if you can actually understand and track your few key biomarkers every six months or so, you can be really confident whether your strategies are working. And every biomarker I just talked about can change drastically in two to three months with consistent lifestyle changes. So, if they’re not in a good range when you get them done, do not worry, but focus on doubling down on healthful strategies and then check them again and see how things are moving. 

Cynthia Thurlow: [00:41:00] Yeah. I love all of what you included, especially the ApoB. We’re in the midst of a lipid series with Dr. Thomas Dayspring, and it is definitely, who lives in my area, if you can believe, of all places, and has really reaffirmed the importance of ApoB. And for anyone who’s listening, if you do not have diabetes, you want your ApoB below 80 mg/dL. If you have insulin resistance or diabetes, you want it lower, so less than 60. But Dr. Casey is absolutely correct these are routine straightforward labs that should easily be accessible. And just even based on really great information in her book, you can kind of navigate that. Now, I would be remiss if we don’t touch on a couple things in particular. So I think now there’s so many ways for consumers to be able to monitor their blood glucose, to see the net impact of nutritional choices and sleep quality and where they are in their menstrual cycle or not. What are your thoughts? Obviously, I know your thoughts around continuous glucose monitors, but I think this is one of the most important ways for individuals, the lay public, to be able to monitor on their own what is going on with their blood glucose in response to nutritional changes. 

Dr. Casey Means: [00:42:14] Hmm. Yeah, yeah. So, as you know, I am a big fan of continuous glucose monitoring. And I think that one of the great things about it, even as a temporary tool, like, not using it all the time, but for a couple weeks here and there, maybe seasonally, is that especially as women, I think just cutting through the noise and just, like, all the conflicting information out there and be able to see and trust our own bodies and what’s actually happening and be able to say for ourselves, like, standing on two firm feet, saying, like, “I am clear that this thing that I’m doing or eating or the fitness routine that I’m doing, like it is serving the goals that I want, which is metabolic health. And so, I’m going to stick with it despite what the noise around me says that might be trying to, like, get me to buy something or manipulate something.” So to me, it’s all about being more confident in your decisions and having a clearer relationship between your choices and your body and what’s happening, so that you can ultimately build more body intuition, no sensor necessary. I think having some cycles of that feedback loop of trying different things and then feeling what that feels like in your body along with the data, can build like, a really powerful intuition loop that I think is really, really, really helpful.

[00:43:38] Especially because a lot of foods that have been, I think we’re getting past this now, but in the 90s and the early 2000s, the things that were so marketed towards women like, that were healthy, was like low fat and kind of packaged grab and go foods and bars and smoothies and acai bowls and all these things that were marketed as healthy, but, like, actually might put us on a total energy depleting hormone flying glucose roller coaster. And so in a way, it can, I think, sometimes give women more confidence to, like, order the steak and order the eggs and, like, order the higher protein things, because you can, like, see how much more stable that keeps you if it does, you know, everyone’s different. That’s the other thing, is that it’s biochemical individuality. And not only is there individuality between each person in terms of their metabolic responses to food and different types of exercise, but it’s biochemical individuality day to day, it’s different, our blood sugar responses and insulin sensitivity is different throughout our monthly cycle. We become more insulin resistant during the luteal phase post ovulation than we are during the follicular phase. We can see how sleep deprivation and poor-quality sleep is impacting our metabolic health. 

[00:44:48] And I think it really, actually, for me personally, it gives me a lot of great motivation to prioritize my sleep ruthlessly, because I can actually see how if I skimp on sleep, it’s actually having a damaging effect on my metabolic health and my blood sugar. So that’s really motivating. And it’s been something that’s really helped me feel even more motivated to do resistance training, because when I build more muscle and when I’m consistent with my heavy lifting, it just literally, it’s like a silver bullet for keeping my blood sugar under better control. So essentially, having something that lets you feel more confident with your choices and understand what’s working for your unique physiology, that’s, I think, the power it gives you in today’s modern, confusing, loud world, where a lot of cards are stacked against us, especially with ultra-processed foods that have so many, like, health claims on them. 

[00:45:41] So it’s so much I think people sometimes confuse the CGM as, like, the purpose is to just game how to not have any glucose spikes. And it’s such a misconception. It’s not about that. It’s about understanding your body better in the face of a culture where so many of the cards are stacked against us and where we have a lot of systems forces telling us to doubt our own intuition and doubt our own choices, and to, “trust the science and trust everything outside of us.” Like, “How do we actually come back to trusting ourselves?” And that’s where I get so excited about it. It’s not about having flat glucose, it’s about having curiosity for what your body is constantly trying to tell you through both symptoms, but also through amazing biomarkers like glucose. 

Cynthia Thurlow: [00:46:28] Yeah. I think that’s such an important point because we’ve now gotten overly preoccupied with glucose spikes to the point where, I’ve had patients share with me, “Well, my blood sugar went up by 20 points,” and I’m like, “Well, that’s not a problem. That’s a normal physiologic response to what you consumed.” And I think for a lot of individuals, there’s still this curiosity, like, “When does a postprandial, so a post-meal glucose increase,” like, for you personally, what is there a number? Like, do you like to see it less than 30 post-meal rise, like when you’re talking to consumers and patients and kind of giving them a sense of where your concerns lie. Because I think that the health and wellness space has gotten very noisy to the point where people are fearful of seeing any– as you mentioned, they want to see a flat over the course of a day. That’s not what I want to see, but I think for a lot of individuals, they have this fear that if they see a glucose spike, that means they’ve done something wrong, when, in essence, in many instances, it is just a normal physiologic response to a protein bolus, along with some non-starchy carbohydrates, etc. 

Dr. Casey Means: [00:47:38] Right. Yeah. I think for each person, I think what’s really helpful is to see your baseline. So, eating the normal food that you’ve been eating and kind of just with total nonjudgmental curiosity, just like, looking at what your sort of, like, basic patterns are, just starting there. And then based on what your baseline is, seeing if there’s opportunities to maybe even before taking anything away, actually adding things in to keep glucose a little bit more stable. So that could be like adding more fiber to your meals or adding more protein to your meals or taking a walk after meals. So, seeing your baseline and then starting to tinker with add ins to keep blood sugar under a slightly more stable range and then going a little deeper and thinking, “Okay, well, I had this breakfast and I had a very, very large spike and I didn’t feel good.” And starting to build that curiosity around, like, “Okay, when I go up 50 points, I notice that I actually crash afterwards.” And I actually, like, overshoot my baseline when I come down and I feel lethargic or shaky or like I need more sugar to bring my blood sugar back up. But when I go up 30 points after a meal, I don’t crash. My body just kind of comes back down to baseline and I feel okay.”

[00:48:56] So, you can kind of find your own personal threshold of like, I mean, I know for me personally, if I’m going up 50 or 60 points, I’m going to get a crash because my body– it’s a big response for me in terms of glucose rise. My body’s probably secreting a lot of insulin to take that all up and then my blood sugar plummets and then I feel exhausted. So, I don’t want that. It’s not about a fear around that spikes going to cause diabetes. It’s more like, I just know that that’s not going to make me feel great. So for me, if I can actually get it closer to like a 20 or 30-point rise after a meal, then it’s not going to crash. It’s going to be a much more like, gentle response from my body and I can just go straight into the afternoon feeling more energized. So, there’s not a hard and fast rule. I think what we do know is that, like, long-term glycemic variability, meaning ups and downs, ups and downs, ups and downs, big peaks, big valleys, big peaks, big valleys. That type of pattern is associated with poor health outcomes if it’s happening over the long term. So, like you were talking about with people who get nervous about one spike. We don’t want to confuse a single spike for what is could be a long=term multi-decade pattern. The average American, 70% of our calories in the grocery stores are ultra-processed food built on three ingredients, ultra- processed grains, ultra-processed sugars, and ultra-processed seed oils. The ultra-processed grains and sugars are going to absorb into the bloodstream fast and cause a big blood sugar spike, and then the seed oils are going to hurt our mitochondria and build less capacity for ability to even process glucose. 

[00:50:36] So altogether, that 70% of the calories in our grocery stores are going to essentially be promoting glycemic variability. So the spike itself, the one spike after the sweet potato, it’s not a problem. It might make you feel crummy, and you may want to learn to, like, add protein and fiber to that to make yourself feel better, but that’s not the problem. The problem is that the vast majority of the calories in America are putting us on a totally regular, all day glucose roller coaster that, over the course of decades, will cause problems. And we need to be aware of that and work to limit that. So it is a nuanced thing, but the purpose of wearing a monitor is not to berate yourself over the 50-point spike you had after eating grapes. Like, there is learning to be had there, for sure. But it’s more about understanding your baseline, learning the basic modulations that can be useful for stabilizing glucose, seeing how you feel after a big spike, seeing what a crash feels like, learning to intuit that in your body, and then, of course, seeing over time, are there some pretty dramatic ups and downs that you’re experiencing on a regular basis? And take that seriously, because we don’t want that to happen day after day, week after week, year after year, because that’s a lot of chaos for our body, and we want to keep things a little bit more stable for the body. 

Cynthia Thurlow: [00:51:55] Yeah. Such a beautiful explanation. And I would be remiss if I didn’t touch on something that really impacted me when I read your mom’s story in the book. I would love to kind of end the conversation today talking about your experiences with your mom, obviously, who’s no longer with us, but from the perspective of things that were coming up in your mom’s story throughout your lifetime that were being handled by multiple specialists and how this metabolic health was at play with many of the things that she was experiencing throughout her lifetime. 

Dr. Casey Means: [00:52:32] Mm. Yeah. So my mom, I feel like it’s sad to say that she, I think, is sort of an archetypal story for what so many Americans, I think, are going through today, which is this funny situation where we’re so dependent on the healthcare system and we are faithful to it and we do everything it says, and then we’re just not getting the outcomes we want. And, like, we’re not really actually fully healing. And there’s this mismatch between being that good patient and actually healing. And so my mom, unfortunately, dealt with the most tragic sort of outcome of this, which is dying very prematurely with probably decades more to live if we’d had a metabolic lens for her life. But briefly her story, which I write about in the book, she was living in New York in her 30s, and she did smoke, and a lot of people smoked then. And she was eating out a lot and all that stuff but was very thin. Very, very thin but kind of living that, it was the 70s kind of probably not the healthiest lifestyle, working hard, owned her own business. She ended up meeting my dad and having me a little bit later in life. And when she was 40, she had me. And a couple things happened at that time that I feel like was like the start of her, like, most obvious metabolic issues. But she gained about 65, 70 pounds during pregnancy. I was a nearly 12-pound baby. She had to have a C-section because I was so big. 

[00:54:03] And then she really couldn’t lose the baby weight even though she tried really hard. So really big baby, lot of weight gain during pregnancy, tough time losing the baby weight. Of course, what she heard from her doctors was, “Oh, my God, congratulations on this big, healthy baby.” Oh, my God, it’s like almost exciting and celebrated when you have a big baby. No one told her that weight loss resistance and gaining that much weight during pregnancy and having a fetal macrosomic baby, like, literally, clinically too big of a baby, that those actually were all signals that she could have insulin resistance, like too much insulin floating around, which can literally drive a baby to put on excess fat in utero and, of course, could make it harder for her to lose weight after pregnancy. So that happens, she goes on in time. She ends up having a very tough menopause. I remember vividly, like, she was sleeping in a different room for my dad because she was dripping with sweat at night and was up a lot during the night, sleep issues, sweating, mood symptoms and of course, the doctors were just like, “Menopause is tough. We kind of got nothing for you. You’re getting older. This is the way it is.”

[00:55:07] And so she just gritted her teeth and bared it, and it was hard. It was so rough to watch with no one there to really help her. And then in her 60s, she kind of racked up all the American diseases. She got the high blood pressure diagnosis, the high cholesterol, the high blood sugar. They put her on the Metformin, the ACE inhibitor, the statin. And again, her primary care doctor, who was a very nice person, was like, “Oh, you know, you’re getting older, and I prescribe like 10 of these a day. It’s totally normal, it’s okay.” And 200 million statin prescriptions are literally prescribed every year. So, it was just all this sort of, like, “This is normal, it’s okay, take this pill.” And she did and then when she was 72 and really, like, outwardly thriving, I mean, she was doing great, but she did have all these issues under the surface. She’d been putting on weight over the years as well. She had some belly pain and went to her primary care doctor. And this was very unusual for my mom, so they ordered a CT scan, and the CT scan came back and she had stage 4 widely metastatic pancreatic cancer. And 13 days later, she was dead. 

[00:56:09] And I think what was just so poignant for me and my family was that, at the time of her death, she was seeing some of the best doctors, like people would say she was seeing the, “best doctors in the country.” She was being seen at Palo Alto Medical Foundation, which is connected with Stanford. She was being seen at Mayo Clinic intermittently for executive physicals. She had the best care. She was taking all the medications. And they said to us, “We’re so, so sorry. This is so devastating. This is so unlucky.” And I think through their lens, through this oncologist’s lens, it does seem unlucky, right. Because in that siloed, reactive, fragmented matrix that we’re living in, of course cancer is different from high blood sugar. And of course, high blood sugar is different than bad menopausal symptoms. And the big baby, how could that be related to her high blood pressure and her cancer? But through that different lens that we’ve talked about, through a metabolic lens, through the invisible cellular physiology that’s brewing inside all of us in America, or most of us, they’re all connected. They’re all fundamentally rooted in mitochondrial dysfunction, oxidative stress, chronic inflammation, and other core disturbances caused by this incredible environmental mismatch between how we’re living in the modern industrial world and what our cells actually need to thrive. 

[00:57:25] So, my mom was lost in that. She was lost in this slowness [chuckles] of us catching up to practice root cause medicine. And she paid the ultimate price. And I think about and I talk so much about this in the book, if we can focus, if we can understand this stuff, which we all can, and then learn how to actually shape our dietary and lifestyle choices, to really focus on building the capacity of ourselves to function properly, building the capacity of our mitochondria to process energy effectively, then everything becomes a lot more clear, and then use our biomarkers to track whether it’s working. Like, if I think about how my mom, if she had been. If every doctor in her orbit had said, this is what you need to do, when she was 40, she would have done it. Like, it’s not like she wasn’t following their advice, and she had a personal trainer, and she was doing different dietary strategies, but none of them were actually focused on building mitochondrial capacity. 

[00:58:22] So, to give an example, like, she did years of Nutrisystem, which is like a ultra- processed, packaged dietary strategy that is all about calories in and calories out. It’s all about just, like, trick your body to basically eat fewer calories, but really, you’re just eating ultra-processed garbage. So, she made the effort, but it wasn’t an effort based on anything we know about cell biology that really would support the needs of the cells with, mitochondrial, nutrient dense cofactors and omega-3s. So she tried, but it missed the mark. She had a personal trainer, and that trainer had her doing a little bit of lightweight repetitions, maybe once or twice a week. And there was some yoga and things like that. But in my mind, I’m like, “If we’d had a metabolic lens, we would have had her doing heavy weights three times a week. We would have had her walking at least 10,000 steps a day. We would have had her doing a little bit of sprints every now and then, and she would have done it if someone had told her that’s–” “Hey, Gail. We’re trying to build mitochondrial capacity by building more mitochondria with resistance training.” So how do we focus all the efforts we’re all already trying to do on what actually matters? So that’s really the mission that I have based on, of course, my mother’s experience, and then just sort of what I really saw in the brokenness of the healthcare system as an ENT doctor focused on end of the line symptoms when there probably was lots of time to intervene a lot earlier before patients got to the operating room so.

Cynthia Thurlow: [00:59:56] Well, thank you for sharing her story, and certainly it really ties everything together why you’re so passionate about this. Please let listeners know how to connect with you on social media, how to get access to your new book, Good Energy, how to learn more about you and how you work with patients and clients. 

Dr. Casey Means: [01:00:12] Aw, thank you so much, Cynthia. My best place to find me is caseymeans.com because all my social links are all linked from there. So caseymeans.com and I have a newsletter called Good Energy Living where I share kind of my newest, latest and greatest things I’m thinking about and lots of practical information for people. The book is everywhere books are sold, Good Energy and goes into really, I think we set the stage here for sort of why this matters, but a lot of the really focused lifestyle strategies are very deeply described in the book and I don’t see patients anymore. I’m so focused on writing and entrepreneurship and so I don’t work with clients individually, but put out a lot of content and then co-founded Levels which gives access to continuous glucose monitors. That’s levelshealth.com.

Cynthia Thurlow: [01:01:00] Awesome. Thank you again. 

Dr. Casey Means: [01:01:01] Thank you. 

Cynthia Thurlow: [01:01:03] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.