Why Measuring Your Blood Sugar Level is Important | Dr Casey Means
Casey Means, MD is a Stanford-trained physician and Chief Medical Officer and Co-founder of metabolic health company Levels. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech-enabled tools that can inform smart, personalized, and sustainable dietary and lifestyle choices. Dr. Means’s perspective has been recently featured in the Wall Street Journal, New York Times, The New Yorker, Men's Health, Women's Health, and more.
In this episode we discuss:
– Why is blood sugar regulation important?
– The impact of too high or too low blood sugar levels.
– The best and worst foods for blood sugar.
– What are the impacts of medications on blood sugar and your body composition?
Dr. Gabrielle Lyon [0:00:01]
Welcome to The Dr. Gabrielle Lyon show where I believe a healthy world is based on transparent conversations. In this episode of The Dr. Gabrielle Lyon show, I sit down with Dr. Casey Means. She’s a Stanford-trained physician and Chief Medical Officer and Co-founder of the metabolic health company Levels. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech-enabled tools that can form smart, personalized, and sustainable dietary and lifestyle choices. Dr. Means’s perspective has been recently featured all over the place in the Wall Street Journal, New York Times, Men’s Health, Women’s health, and more. I love to sit down to talk to Dr. Casey Means. We have a lot of similar viewpoints. And in this episode, we talk all about why blood sugar regulation is important.
The impact of blood sugar variability, whether it’s too high or too low, the best way to eat and move to regulate blood sugar, and, surprisingly, the worst foods for blood sugar. And finally, what is the impact of certain medications on blood sugar? And what does that mean for your metabolic health and body composition?
If you liked this episode, please take a moment to like, subscribe and share. And just a reminder, I’m so excited to share with you my new book Forever Strong that is coming out October 17th. If you head on over to my website, drgabriellelyon.com, I have a whole bunch of free things for you if you preorder the book, a whole bunch of stuff. I have e-books, I have workouts, and, surprise! We are going to be doing an in-person event in Austin in January. Please take a moment to help share this message. You know how important getting out the concepts of muscle centric medicine are. So head on over to my website or you can get it off Amazon. My website in case you don’t know is drgabriellelyon.com. And there you will see Forever Strong. Okay, it’s time to get on to the show.
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Dr. Casey Means, thank you so much for coming on the show. I am very excited to talk to you about all things blood sugar related and tea, your transition from conventional medicine to more well-rounded medicine. Tell me a little bit about how you got here. So now you’re traditionally trained as an ear, nose, and throat physician.
Dr. Casey Means [0:05:41]
That’s right. Dr. Lyon, it’s so great to see you today. I’m so thrilled to be on your podcast and happy to tell you a little bit about the journey briefly. I trained as an ear, nose, and throat, head and neck surgeon. I did my medical school at Stanford and then I went to Oregon Health and Science University up in Portland, Oregon for ENT training. And it was really interesting, I was just starting my fifth and final year of surgical residency. And I had this total wake up call, it was almost like an out-of-body experience actually where I was doing my third sinusitis surgery of the day. And I think this person had been in for 2 or 3 surgeries. It was like a multiple revision sinusitis surgery. And I just realized I do this all day, every day. But I don’t actually really think that this surgery that I’m doing right now is going to actually fix the problem or make this person actually healthier. She had pre-diabetes, she was overweight, she had high cholesterol, she had all these other issues. And I just felt like I can just keep busting holes in these sinuses all day, but am I really actually making this person fundamentally healthier? And what are the actual chances that this sinusitis that she has and has had multiple bouts of and revision surgeries is actually completely unrelated to all these other more chronic metabolic conditions that she has, and just sitting there nine years into medical training and I don’t really feel like I understand the full picture of what’s going on with this patient in front of me.
And that was really eye opening. And it really sent me down this road of digging into more of the root causes into what was really driving the physiology and the patients I was seeing. Then one of the big wake up calls for me was that I realized that every single condition I was treating as an ENT surgeon was inflammatory in nature. And so obviously, like the suffix -itis in medicine is inflammation. And if you think about what an ENT doctor treats, it’s sinusitis, otitis, masterda is laryngitis, parotitis, cellulitis, it’s so much -itis. And I was like, Oh my God, I’m an inflammation doctor. And I didn’t really realize it. And so much of the tools we use in Ear, Nose, and Throat are actually to just quell the immune system. So it’s incredible how many types of steroids we can use. It’s like IV steroids, topical steroids, oral steroids, inhaled steroids, nasal steroids. And so basically, what I was doing in my field was treating inflammatory conditions with these heavy-hammer steroid medications, but never, ever being asked to think about what was actually causing that inflammation in the body. And when I started going down that journey of being obsessed with figuring out why these patients have so much inflammation, we never ever, ever, ever, ever asked why. It led me directly to metabolic health, and really an obsession with mitochondrial function and metabolic health, because when you think about a cell that is essentially under threat, it is going to release chemical mediators to recruit help, and that help is going to come from inflammatory cells and the immune system.
And so you then say, Okay, why is a cell releasing these fear signals, these threat mediators to try and recruit help from the immune system? And what is the problem that that cell is facing that actually is causing it to be chronically sending out alarm systems and therefore chronically rubbing up the immune system? And why isn’t it ever actually resolved? Like, why is it not acute inflammation? Why is it becoming chronic inflammation? And that pathway basically led me to realize that the threat is actually inside the cell. It’s the fact that the cell is underpowered. It’s metabolically dysfunctional, the mitochondria is essentially dysfunctional. As we know, in most American bodies, at this point, the majority of American adults have metabolic dysfunction.
And so it’s the sad situation where you’ve got these cells in the body that are underpowered because of mitochondrial dysfunction; they’re sending out these alert signals to recruit the immune system. But the immune system can’t actually help because the problem that the cell is threatened by is inside of it. So all of this journey essentially got me to actually leave the surgical world and leave ENT and devote my life to the metabolic health crisis and essentially become a warrior to try and help people improve their mitochondrial function. And what I’ve come to realize and understand is that the things that are synergistically crushing our mitochondrial function, and essentially creating underpowered cells that are experiencing the sense of threat – it’s the way we’re living in our modern world.
It’s all these different environmental factors that synergistically work to hurt different elements of our ability to make energy in the body properly and synergistically through all these different ways, essentially causing mitochondrial dysfunction. This ranges from our sedentary behavior, our being under-muscled, our ultra-processed, our fad diet, our lack of micronutrients in the diet; the 80,000+ environmental toxins that have entered our air, water, food, and homes over the past 50 years; getting lack of sunlight during the day, not sleeping enough, chronic low-grade stress – all these different environmental factors. And that’s where I’m at now. And that is what inspired me to ultimately start the company that I co-founded called Levels, which is right in the center of this whole ecosystem that I’m talking about, which is helping people understand their own metabolic health, understand their own blood sugar levels, which are of course one of the readouts of metabolic health, and then learn to optimize them through really holistic approaches that impact all those different vectors that I was just mentioning.
Dr. Gabrielle Lyon [0:11:54]
It’s pretty incredible. For those of you who are not physicians who are listening, Ear, Nose, and Throat is a very competitive specialty. Individuals that go to Ear, Nose, and Throat have typically done the top of their class, it is extremely competitive, you have to be published, it is extraordinarily rigorous. You put 9 years into that, and then you left to advocate for a mission that you believe deeply. And I am sure that that was met with some backlash in your life, and your family probably thought you were a bit crazy at first, because everyone that is an innovator individual often says that they’re crazy until they figure out that they are right. And Levels – it’s so fascinating. This idea of glucose regulation is critical for everybody, including the provider, when we think about how do we regulate blood glucose, there are multiple ways to regulate low levels of blood glucose, whether it’s the hormonal response, versus the catecholamine response, versus there is one way that the body has to regulate endogenously elevated levels of blood glucose, and that’s insulin. And ultimately, the issues that you’re talking about as it relates to insulin resistance are critical, and probably at the root cause of nearly all of the things. And from a physician’s perspective, I think about it as food, drugs, exercise. And you have become very skilled at looking at, probably all 3 of those things. And in particular, when it relates to blood sugar, what are some of the things that we see from a practical aspect that contribute to – number 1 we should start with: Why is the variability in blood sugar not ideal, the ebbs and flows of blood sugar not ideal?
Dr. Casey Means [0:13:53]
Great question. So variability refers to essentially how much our blood sugar is going up and down throughout the day. And what’s starting to be uncovered in the research literature is that when the swings in glucose, like a big up after a meal, and then a big crash, that big swing is actually independently associated with the future risk of Type 2 diabetes and premature mortality. Even if you’re fasting blood sugar is normal, and you don’t actually meet the pre-diabetic or Type 2 diabetes range. So glucose variability is independently associated with worst outcomes no matter what bucket you fall into based on standard diagnostic criteria. So we want to move towards or the research is starting to suggest that we want to move towards much lower ups-and-downs in our blood sugar throughout the day, as opposed to these big peaks and valleys.
One of the amazing papers that really, I think helped solidify this in a non-diabetic population was Michael Schneider out of Stanford. He wrote a paper about what he called glucotypes, which are essentially, how do you take people who are non-diabetic or in the prediabetes range, put continuous glucose monitors on them. So this tool that you can wear on your arm that can show you a movie of glucose throughout the day, as opposed to just single time point measurements that would not show you variability. So a continuous glucose monitor can actually show you this movie of the ups and downs. And he put these sensors on people and showed that you can bucket people into 3 different categories: low variability, medium variability, and high variability. And that was for people who might not have any diagnosis of diabetes. But even if someone takes five ostensibly healthy non-diabetic people, they could fall into these different buckets of how high their blood sugar was going up and down throughout the day. And he showed that when you correlate that with other metabolic biomarkers that we care about, like fasting insulin, hemoglobin A1C, fasting glucose, triglyceride levels, that they got worse for every biomarker as you went from low variability to high variability.
So there’s a strong correlation between overall metabolic biomarkers that we know are predictive of future cardio-metabolic diseases and high variability. So that doesn’t really get us the chicken and the egg, like which one is causing which, but what it basically shows is that there’s an association with variability in poor health outcomes. He also showed that based on our standard diagnostic criteria, which are fasting glucose, and oral glucose tolerance tests, and hemoglobin A1C, those are the 3 ways that we would diagnose someone with prediabetes or Type 2 diabetes, that if you put a continuous glucose monitor on someone and looked at their variability, he showed that people were reaching prediabetic levels of glucose 15% of the time, even if they were totally normal by other criteria, so you’re probably able to catch a lot of people with early metabolic issues, if you’re able to see variability that you’re going to miss if you just do the standard diagnostic criteria.
Some evidence is starting to show that this variability might actually be an early sign of insulin resistance, if we could catch it through variability before fasting, glucose starts to change. The reason for that is because as you become more insulin resistant, and your cells are starting to put up this block, due to underlying mitochondrial dysfunction, intracellular lipids, all these things that are blocking the insulin signal from being transmitted within the cell and then causing the body to compensatorily increase its insulin levels, as that process is happening, the fasting glucose is still going to look normal, because the body is becoming insulin resistant, it’s over producing insulin to overcome that block. And that works for a little while.
You’re hyperinsulinemic and fasting glucose looks okay. But that person may start to have issues clearing glucose out of the bloodstream after a meal. So let’s say you eat a high carb meal, and your glucose spikes, their peak might be higher, and it might take longer to actually get all that glucose load out of the bloodstream into the cell because there’s that early insulin resistance. So by looking at variability, you might be able to pick up some nuances about difficulties clearing glucose, i.e. early insulin resistance before the fasting glucose actually gets to the prediabetic or Type 2 diabetic range. So that’s why variability is starting to emerge is something really important. And we’re at a time now where continuous glucose monitors are gaining awareness amongst practitioners and consumers and patients. And so there’s, we’re in this interesting time where both the research and the landscape of access to technology are meeting up and I think it’s going to be really exciting for future diagnostic potential, but also for prediabetes, reversal strategies and things like that, but it has certainly not made it into mainstream guidelines yet.
Dr. Gabrielle Lyon [0:19:12]
That is absolutely fascinating. Eventually, I believe that it will be a tool that is utilized so much more frequently, for exactly those reasons that you’re speaking about. If we can do early intervention, then we can actually change the trajectory and precisely what you said. There’s a discussion in which skeletal muscle insulin resistance is liver insulin resistance. There are 3 main sites that insulin really works on. We think about muscle, we think about liver, we think about adipose tissue. Is there an impact on the brain? Of course, but ultimately, when we have issues with glucose homeostasis over time, insulin resistance creates a whole host of very significant issues including elevated levels of triglyceride, increase in circulating free fatty acids – there are multiple issues. When we measure fasting blood glucose, you mentioned that potentially, the normal ranges are a bit high. Is there a target that you’d like to see that the collective data likes to look at? That would be not normal, but optimal?
Dr. Casey Means [0:20:26]
Great question. From reviewing the literature of essentially how risk for future diseases shows up based on where you are on the fasting glucose spectrum, and also just from really talking to so many, like experts in the space, who are metabolically savvy physicians, so merging expert opinion and also the research literature, it really seems like the optimal fasting glucose range is between about 70 and 85 mg/dL. And as you know, and for people who may not be practitioners listening, so anything less than 100 mg/dL is considered nondiabetic for fasting glucose. So you walk into the doctor’s office, and let’s say your fasting glucose is 97 mg/dL, I’d say 9 times out of 10, the doctor is not even going to mention it, they’re just going to say, oh, yeah, you’re totally fine, metabolic stuff looks good. And it’s a huge disservice to the patient. Because if you actually look at the curves, the odds ratios, and the risk ratios of getting future Type 2 diabetes, developing obesity, developing ischemic, or thrombo-embolic stroke, premature all-cause mortality, it’s J-shaped curves for all of these where basically, the lowest risk is around 70 to 85 mg/dL. And then it goes up sharply as your fasting glucose goes between about 85 and 100 mg/dL. And then, it goes up even higher as you go into the prediabetes range, and the Type 2 diabetes range. But we’re basically telling those people who are on the upswing, the early upswing of that curve for future risk, that they’re totally normal, when actually I’d much rather be at the nadir of that curve.
It’s actually important to mention that it is a J-shaped curve. So below 70 mg/dL, you actually see an uptick of future risk of various cardio-metabolic diseases, which I think is really interesting. And so that’s why I said, when some people ask, well, is lower better like, should we shoot for 60 mg/dL? And in the current research that exists, there are quite a few J-shaped curves where at the lower range, it actually goes up. And the certain authors have speculated on why and the thought is maybe that as you get towards those lower glucose levels for fasting, it’s almost like a stress signal to the body that may be releasing catecholamines and actually creating more of stress vigilant physiology in the body, which can also hurt mitochondrial function. But I’m just saying this more of conjecture, I don’t know for sure. But I think that if someone is metabolically flexible, and is actually really adept at – their bodies are really primed for fat oxidation – and they can use other substrates for ATP production, other than glucose, I actually think you’d probably find that people with a fasting glucose lower than 70, are not going to have increased risk of mortality, because we see a lot of people on a ketogenic diet or a higher fat diet who tend to fall into those lower ranges for fasting glucose. And I’m not getting a signal from knowing who these patients are or what their other better metabolic biomarkers are, that they’re probably at higher risk.
So I think if you take someone who’s not metabolically flexible, really dependent on glucose oxidation for ATP production, and all of a sudden throw them into a glucose level of 60, that could be a stressor on the body. But I would guess that for someone who’s really metabolically flexible, that it’s actually probably not so. But based on what the literature says I would say 70-85 mg/dL is probably going to be associated with the lowest risk of future chronic diseases in terms of fasting glucose, and that’s certainly what I shoot for.
One last thing I’ll note is that if you are checking your fasting glucose every day either with a finger prick or continuous glucose monitor, a lot of people will find that it bounces around aggressively day to day so if I am just completely on point with all my health vectors, so I’m lifting I’m walking I’m doing zone two I’m getting quality consistent sleep I’m you know eating a whole foods low glycemic diet getting my protein not eating late at night, my fasting glucose could easily be 70 mg/dL. If I have a publishing deadline, I am not exercising, I’ve only walked 7000 steps the day before, I maybe ate really late at night, I could easily bump up to 90 for my fasting glucose. So it’s really fun to see how much the health behaviors translate into the more optimal fasting glucose range. Because of course, if you extrapolate that over the course of a lifetime, that’s the difference between developing, you’re moving down the spectrum of problems or not. And so nothing has been really more motivating to me than seeing how much fasting glucose can really bounce around, and just making sure that I’m doing the various things that keep it in that lower end of normal, so that I can hopefully stay there for the rest of my life.
Dr. Gabrielle Lyon [0:25:33]
I love how you said the lower end of normal. It’s interesting, I often wonder about ketogenic diets and beta cell dysfunction over time. I don’t know if you’ve read about that. But oftentimes, if insulin is not stimulated over a period of time, I believe that there is some disruption to those pancreatic beta cells. So perhaps adding some kind of carbohydrate in rather than chronically doing a ketogenic diet may be of some benefit to allow for, if an individual goes off of a ketogenic diet, that the body still is able to manage and mitigate blood glucose levels from carbohydrate load. Would you say that that’s accurate?
Dr. Casey Means [0:26:13]
I think so. I think that it really comes down to metabolic flexibility. You can become metabolically inflexible because you’re too carb dominant, but also, because you’re too fat dominant. And so I think this is where the concepts around carb cycling come in. And I would say I don’t think we really know in terms of, from a fasting blood sugar perspective, exactly what optimal means if you are on a more extreme diet. But yes, I would say that it’s like with all biological systems, like ultra-rigidity, tends to be less favorable than a more harmonious interplay between different poles. So that plays to the idea of giving your body the ability of work various pathways and actually focusing on metabolic flexibility.
Dr. Gabrielle Lyon [0:27:18]
I love that, very important. There is something to be said for inclusion of all kinds of foods over periods of time. And we’re seeing that in the evidence whether it is if someone is following a carnivore style diet, there is clearly benefit to fiber and phytonutrients. We know that there are multiple low molecular weight molecules like creatine and searing all kinds of things that you can’t get from one or the other group. When it comes to foods over that now, how large is, are you able to say, how large the dataset is for Levels?
Dr. Casey Means [0:27:56]
Well, in terms of people who have used the program, it’s been somewhere around 50,000 people. In terms of people who join the Levels program, you can opt in to an IRB-approved research study. And that number I actually don’t have off the top of my head, but there is a subset of that that has actually entered a research study where we can actually look at the data.
Dr. Gabrielle Lyon [0:28:24]
Incredible and before we talk about the foods that relate to blood sugar, I think that it’s important to mention postprandial meaning after-feeding glucose disposal. So what is the body in a, I hate to say, healthy sedentary but a sedentary individual. What does that kind of look like? To maintain blood sugar at 85 mg/dL? We are looking at 2 g/hr for the brain. Organs are about 2 g/hr, muscles is around 2 to 3 g/hr. I know most people are shocked by that, but muscle is not extremely metabolically active. Glycogen deposition in the liver is about 30g. There is some gluconeogenesis; we don’t really know what that number is. But basically, based on the literature calculations, sedentary individuals can dispose of around 20g per two hours and 30g over two hours. Ultimately, it ends up being 50g post-meal; 50g total post-meal disposal ends up being about 50g over two hrs.
Dr. Casey Means [0:29:42]
Oh, that’s so interesting.
Dr. Gabrielle Lyon [0:29:44]
Yes. So here’s why I’m bringing this up. Because oftentimes, when we talk about what does it look like for designing a meal and keeping blood sugar regulation steady, I always tell my patients, and I wrote about this in my book, between 40 to 50 g max, if not related to exercise, because you have to be able because the numbers for glucose disposal, typically, it’s 50g over two hours, takes about two hours. So I just wanted to lay that out there as people are struggling, I’m sure that they are going to be playing with blood glucose monitors, and seeing. So I want to see if that literature data actually makes sense with what you are seeing.
Dr. Casey Means [0:30:35]
Yeah, it’s so interesting. So 50g over two hours does feel right. There’s so much variability to it, of course, because assuming, is that in an insulin sensitive individual?
Dr. Gabrielle Lyon [0:30:50]
Normal motion sensitive individual, baseline glucose disposal in a sedentary individual, you would not want to go over 50g per meal, and assuming that they would be able to dispose of that.
Dr. Casey Means [0:31:02]
Yeah. What’s especially interesting is thatthe average American now is not insulin sensitive. I would say probably most are not. But when you look at the data, so they have done several observational studies in people without diabeteswhere you basically justthrow on a glucose monitor on a population of like nondiabetics, so presumably, insulin sensitive people, and you give them various standardized meals, or let them just walk around and eat normally, and these studies range from like 3 days to 30 days. When you look at that, typically, people tend to peak around 60 or so minutes after eating, and then come back down to normal by about 2 hours. Although I would say that for the most insulin sensitive people, they tend to come down probably faster than 2 hours, they go up and come down, before you actually reach the two-hour mark. But if someone is going up after a meal, and kind of floating above the baseline after two hours, to me that would be a very strong signal that this person was having issues clearing glucose from the bloodstream, and probably has some underlying insulin resistance. That kind of pattern of a wide mountain spike would be concerning to me, versus a more straight up, straight down. I would say anecdotally, from Levels data, 45 minutes to an hour is about when people tend to peak and then come back down and be down to baseline before about 60 minutes. We haven’t fully analyzed or published all that data.
But I would say it matches up pretty closely with the observational studies you see in healthy populations. But you know, it’s interesting, I think, something we focus about so much I think in the glucose, metabolic health, CGM conversation is the inputs, how much glucose is actually going in, in the meal, which is such an important part of how it’s balanced and how quickly it’s being absorbed. Of course, fiber, protein, fat is going to change the dynamics of how quickly the glucose is being absorbed. But I think what has been so profound to me looking at the literature is actually the other side of that coin. So how is it getting sucked out of the bloodstream, and that, of course, comes down to insulin sensitivity and muscle. And that’s where I think so much of the research is just so fascinating.
We have done some research with our Levels population showing how just walking after a meal has a very significant impact on blood sugar levels. We gave members an experiment to do, where they drink a 12-ounce can of Coke, and just were sedentary after the can of Coke. And then we gave them a 12-ounce can of Coke the next day, ideally, under very similar circumstances, like similar sleep, similar stress levels, etc. And then they just had to take a brisk walk after the Coke. And we actually saw that the glucose peak went from 162 mg/dL on average to 132 mg/dL on average. So just taking a simple walk after the meal, activating the muscles to pull the glucose out and actually process it, had a fairly robust response on that peak glucose level and that represented about an 18% decrease in peak glucose levels. So I think if you extrapolate that over the course of a lifetime, the simple act of just taking a walk after a meal can be very, very, very powerful, as this, as you talk about so much like this incredible glucose sink and there’s insulin-independent mechanisms of getting glucose out of the bloodstream with muscle activation. And so it’s almost like a freebie.
So that’s, of all the things we’ve learned, I think one of the biggest ones is: take a short walk after a meal, 10,15, 20 minutes, ideally after every meal. And it’s essentially like getting the best bang for your buck from a meal. So I would say yes, certainly walking, it’s so simple, but hordes of research literature, I think support that walking a lot throughout the day, that low level movement and that constant stimulation of AMPK and these different pathways is very important for keeping the body constitutively moving through glucose, as opposed to just chunking it in one exercise block, which is going to be very different physiology than low grade movement throughout the entire day.I really like to think about it as you can either constantly be triggering these pathways to keep working, keep bringing GLUT4 to the cell membrane all throughout the day, or you can chunk it.Ideally, we’d have intense exercise in a chunk, but also this low-grade movement throughout the day. I think that’s one of like the biggest takeaways I’ve seen from both the Levels data, but also the general research literature about walking.
Dr. Gabrielle Lyon [0:36:21]
That’s very valuable, that’s very valuable for anyone listening. Because regardless of where you’re starting, everybody can move. And whether it’s walking or push-ups or squats, it is post-meal disposal, leveraging skeletal muscle – very critical, independent of insulin. So what Casey is saying is that you can move blood glucose out of the bloodstream, into skeletal muscle, independent of insulin. And that is incredible, because we know that muscle accounts for 70+% glucose disposal.
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There’s a few things that I really want to talk about. I’m curiousif there are very particular foods that surprised you. I’m curious about what you’re seeing with alcohol. Again, I know that it’s very difficult because typically individuals are not drinking a Coke, right? Or if you are, shame on you. I’m kidding. But do you? Are there certain foods that you see that surprised you? For example, a banana or any food in particular that surprised you with its increase in glucose?
Dr. Casey Means [0:40:33]
Yeah, I think the foods that have been most surprising to me are breakfast foods. To be honest, I think that one of the biggest deltas we see between a healthy response and an unhealthy response really happens with breakfast, because so many American breakfast foods are so heavy on refined carbohydrates and refined sugar. And some of the breakfast food responses are the highest we see in our entire data set. And it’s often when certain words are mentioned in the log, because of course, it’s hard to parse this data because people are eating lots of different things together. So it’s not like it’s clean data. But generally speaking, when you have words that are within the log, like, juice, doughnut, pastry, toast, croissant, muffin, bagel, cereal, cereal is like a real disaster in terms of glucose response in the data set, cereal of almost all kinds, even the ones that kind of masquerade as like healthy tend to have some of these very large glucose responses.
But then on the flip side, some of the more balanced breakfast that we see logged, so phrases like eggs and avocado, even like eggs and greens, frittata, chia pudding, almond butter, these are types of words that when you see the patterns of those words tend to be some of the lowest glucose responses. So it just feels based on what we’re seeing, there’s this huge opportunity with breakfasts to really, and one thing I hope is that some of this as these Levels data becomes more organized and we can hopefully get more of it out there, that it’ll really help push culture forward.
I mean, we all know that refined grains and sugars are not good. But when you see these significant patterns of logs that include these terms being really huge spikers and the ones that are much more balanced, having such low glucose responses, it really shows you how much it can really set you up for success if you make those latter choices. And so yeah, some of the breakfasts that have been consistently low spikers would be the things like eggs and avocado, eggs and greens, frittata, chia pudding. Often those are paired with low glycemic fruits like berries and almond butter. And then we see a lot of people, one of our advisors is Kelly Lovak, and we see a lot of people logging her smoothie, which is called the Fab Four smoothie.
Dr. Gabrielle Lyon [0:43:08]
And, look, by the way, she sent me an email yesterday.
Dr. Casey Means [0:43:11]
She’s such an amazing, but she’s really popularized this very simple recipe, which I think is emblematic of what a balanced meal can look like, which is essentially it’s very high protein, it’s very high. It’s high fat, you know, she puts like, not afraid of fat, you know, almond butter. People can use whole milk, whatever, fiber and greens. And so it’s a smoothie that’s quite well-balanced and isn’t going to just load your… and those tend to be less than 15 mg/dL spikes for breakfast, so I’d say breakfast is a huge opportunity. We also see, like in terms of some of the very, very worst things in the data set, I would say, cereal is up there, but also very specific. And then of course, soda, but very specific types of candies. So at one point, and I’m not sure if this still holds true, but the very, very, very worst food in the dataset was Skittles. And this is so not surprising, all candy is not going to be optimal for cellular biology. But these candies that are naked carbohydrates, they don’t even really have any fat or protein. You look at a Snickers bar and there’s actually some fat and protein in it to kind of maybe slow the absorption of glucose. But a Skittle or something like a lollipop or a Starburst or something like these, these are just straight sugar macronutrient Felino focused. They tend to be some of the absolute worst. And so if I were to eat candy, I would definitely push myself towards eating a more balanced candy, maybe one with nuts, or something like that, as opposed to these just straight injections of sugar into the bloodstream.
Dr. Gabrielle Lyon [0:44:57]
I like that. So basically, you’re saying if you’re going to make a bad choice, make a bad choice wisely, I can appreciate that. Also, what you are seeing in the data set and what we know in some of the literature out of Heather ladies Lab talking about combination meals – protein first, not breakfast skipping – really changes the impulse to eat later on in the day. People really care about weight loss, people care about weight loss, people care about weight loss as it relates to blood sugar regulation, not being hungry, I absolutely agree with you in terms of that first meal of the day,the data would support that that is actually the most critical. And while individuals typically have fasted for that first meal, I believe we’re going to start to see a shift, coming back to actually eating earlier on and stopping eating earlier, rather than pushing that fasting window.
Dr. Casey Means [0:45:57]
Yeah, I think that’s exactly right. And one key reason for this, of why I think breakfast is so important to get right if you are going to eat breakfast is because the research is showing that it’s the crash after a spike that is often when we see people have the most cravings for high calorie, high carbohydrate foods. So if you have a very high glucose spike the body is going to respond by releasing a lot of insulin and trying to soak all that glucose out of the bloodstream. And that can often lead to a post-meal crash, which the technical term for is reactive hypoglycemia. And there’s actually a paper that I think was published in Nature in the last couple years, that looked at the time when you’re crashing. So going below baseline, which is how a reactive hypoglycemia is defined, that is when people often have the highest cravings for carbohydrate meals and the extent of reactive hypoglycemia can actually predict how much people are going to eat later in the day.
Dr. Gabrielle Lyon [0:47:03]
And also, not to interrupt you, these are our patients who are waking up in the middle of the night to eat. [Yes.] You guys, the people that have an, it’s so interesting, binge eating disorder, night waking, and going to the kitchen and eating and not remembering it. We see this with individuals, we put a monitor on them and they’re having reactive hypoglycemia.
Dr. Casey Means [0:47:29]
Yeah, it makes total sense because that is actually a primitive fear signal for the body of, I’m starving and I need to get my glucose back up to baseline. And so in many, it’s physiologically understandable why someone would have this sense of, I need to get up out of bed to stabilize my blood sugar if it’s crashing. And the much better option, of course, is to not have the crash in the first place, which can be done through so many different ways: balancing the meals properly, like you were talking about; having protein and fat before eating carbohydrates in the meal, so sequencing the meal properly, obviously avoiding refined grains and refined sugars as much as you can, because those are going to spike the glucose; and eating if you’re going to eat carbohydrates, eat more complex carbohydrates that are paired well with fat and fiber. And so, I think we hear a lot of patients talk about how they might be dealing with hypoglycemia, like, oh, I have problems with low blood sugar. But I think what people don’t maybe understand until they put on a CGM is that the reason, one of the reasons they might be having hypoglycemia and the symptoms associated with that, like cravings and jitteriness and anxiety and a lot of subjective experiences, low energy that we know are associated with reactive hyperglycemia, is because it was preceded by a spike.
So figuring out how to modulate and smooth that out, can be really, really helpful. And I’m just double checking that paper that I was mentioning, it was in Nature Metabolism, and it was actually from April 2021. It’s called postprandial glycemic dips predict appetite and energy intake in healthy individuals. So it’s a pretty relevant title to almost anyone who’s dealing with that hunger, urge and constant urge to eat throughout the day and so stabilizing… You can imagine if you start the day with a huge spike and crash, can you imagine how much that setting up your day for basically problems because you crash then you eat something to bring it up, then you spike again and then you crash and then you’re on the roller coaster versus just keeping it more stable throughout the day.
Dr. Gabrielle Lyon [0:49:41]
Yeah, that’s very important for individuals because when you’re setting yourself up for failure, these are primitive mechanisms that are going to be deployed and we want individuals to be successful. What are some of the states in which individuals will see the variability that they may not be expecting, for example, are there changes when someone starts testosterone therapy? Are there changes when someone starts the pill? During menstruation, ovulation? You know, men, women, are there certain times where we see more flux than perhaps we anticipated?
Dr. Casey Means [0:50:23]
Great question. Yeah, I think there’s definitely several physiologic scenarios where people might see ups and downs in the absence of food changes, that can sometimes be very confusing, but most are very physiologically understandable. And many actually aren’t. It is not clear for the research that some of these spikes are actually problematic. So I think one of the ones that you’ve probably seen a lot in patients that are wearing CGMs is that when people do really intense high intensity interval training activities, where they’re getting their heart rate up to 80% or above of their max heart rate, or an elevated VO2max, although most people aren’t checking that while they’re working out all the time, so it’s more like heart rate is a proxy, or powerlifting. Basically, anything that’s the most intense exercise you can do, we often see people having a significant, very sharp glucose rise, even if they’re fasted. The reason for this is because these exercises can release catecholamines and cortisol and stress hormones. Essentially, those hormones can then tell the liver that the body is in need of extra fuel to fuel the muscles and cause glycogenolysis from the liver and release glycogen into the bloodstream very quickly to essentially fuel this exercise.
So this is one of those spikes where it’s physiologic. I have not been convinced by any research that I’ve seen that this is necessarily bad for the body over time. If you’re doing a moderate amount of HIIT training per week, there’s been some research that shows that over 150, I believe it was 152 minutes of high intensity interval training per week, actually, you could start to see sort of a decrement in the benefits in terms of like mitochondrial health and whatnot. But I don’t think there’s that many people who are doing 150 minutes of HIIT training per week. So for the average person, probably in a safe zone. And so that glucose, I think, we know that those exercises over almost immediately improve insulin sensitivity and over the long term, like are positive for overall metabolic glucose dynamics. And so even though you’re seeing that spike, it’s very different than a food spike, because it’s a feed forward, you know, you’re releasing that glucose, and then you’re processing it into ATP and actually using for energy, and you’re likely getting a lot of it out of the bloodstream through these insulin independent mechanisms. And so all of that is just very different physiology than a food related glucose spikes.
So that’s one that you see spikes in the absence of food. Another one is different phases of the menstrual cycle. So people and we know that people tend to be more insulin sensitive in the follicular phase of their cycles than in the luteal phase of their cycle, we tend to become slightly physiologically insulin resistant during the luteal phase of the cycle. And this may have something to do with the balance of estrogen and progesterone during that phase of the cycle. And so people will sometimes find that they spike higher to food in the luteal phase. They’re a little bit less carb sensitive, or I’m sorry, they’re a little bit more glucose intolerant or carb sensitive, and it’s subtle, but we definitely have heard some reports of that and that, I’m not sure if that’s something you’ve got.
Dr. Gabrielle Lyon [0:53:52]
Do you think it’s significant as it relates to body composition over time, or managing hunger? Just out of curiosity.
Dr. Casey Means [0:54:00]
I don’t know if it is, I think, I don’t have the numbers off the top of my head. But in terms of how fasting glucose changes from follicular to luteal, from what I recall from the research, it’s less than 10 mg/dL in terms of shift and fasting glucose. It’s small numbers, but there’s something there. And the way I approach it is just thinking more about how to make sure I’m supporting my glucose disposal during that phase of the cycle. So being just a little bit more dialed in with. I don’t want excess glucose sitting in my bloodstream no matter what is going on. So do I maybe take a very gentle walk after my meals, maybe for a little bit longer during that phase of the cycle? Or do I just really make sure I’m getting optimal sleep so that I’m not going to be hitting myself with insulin resistance from these other mechanisms like stress or sleep deprivation because we know both stress and sleep deprivation can acutely cause insulin resistance, like the next day. So just making sure that of all these different levers you can pull, you’re not adding more fuel to the fire, if there’s already a physiologic hormonal reason for why you might be slightly less insulin sensitive.
The other ones, I just mentioned sleep and stress, both can cause people to have changes in the dynamics of their glucose. We see a lot of members reporting that when they’re having an acute stressor like getting up and speaking in front of people or presenting at work or something like that, or having a fight with a loved one, that they often will see a glucose rise. Those are similar mechanisms of stress hormones and catecholamine release causing glycogenolysis, that I would say is probably not a healthy version of this physiology, because you’re not actually using the muscles to clear that glucose in that stressful situation, right? Like you having a fight with your partner and going back and forth, or giving a talk, you might be having that release of glucose into the bloodstream, but there’s no sink for it. It’s just so that’s where, unless you go take a walk or workout or something, you’re going to probably need to release insulin to actually clear the glucose. So that’s going to probably be one, and it makes sense. We know that chronic stress over time and chronic sleep deprivation, both are very bad for metabolic health, and then there’s certain medications that can definitely cause glucose issues, like corticosteroids. The steroids they were prescribing for so many patients in the ear, nose, and throat world, tend to cause pretty significant glucose elevations.
It’s wild, actually, to see how high and it’s something I’ve talked to a lot of my surgeon. Anesthesiologists and surgeons will actually just give IV steroids before or after a surgical procedure for several reasons. One is, because it can help with pain after surgery, it can help with just general inflammation after on the surgical site. But I think it’s something we actually need to dig deeper into as like a medical community because I think if you put CGMs on patients postoperatively and just looked at what was happening for the week after surgery with their blood sugar after giving them those IV doses of steroids we’d probably find that it’s monumentally elevated. Of course, we just don’t see that because we’re not putting these CGMs on people, but I think there’s probably some more digging we need to do into that because steroids are just profound elevators of blood sugar, whether it’s like an oral steroid course or an IV. I would say less so with certainly nasal steroids like a Flonase. And definitely almost nothing with a topical steroid. But oral and IV are pretty pronounced.
Dr. Gabrielle Lyon [0:57:59]
I’ll just mention, when I think about muscle-centric medicine, we do think about medications that create issues, oral steroids that is on it. Oral steroids induce insulin resistance. They do this by inhibiting GLUT4 transporters in the muscle. It can cause a 30-50% reduction and insulin stimulated glucose uptake, 70% reduction in insulin stimulated glycogen synthesis. That’s a problem. And we know whether the chicken or the egg, where is the actual defect? There are probably multiple areas of challenges within the body, whether it’s glycogen synthesis, whether it’s reduced insulin synthesis, any of those things, oral steroids actually contribute to many of them, nearly all have them. So from insulin resistance, inhibiting the transporters, reduction in the stimulation of glycogen synthesis, reduction of insulin synthesis, so there are issues.
Have you seen, and that’s so interesting, because as an ENT, again, one of the things that you are always prescribing not always but for an acute -itis, we give patients corticosteroids and then someone would say, okay, well, they are having an inflammatory reaction, you do need to treat it, I absolutely agree with you. That may be a time in which we change their diet. It may also be a time where we do monitor their glucose, especially if it’s cyclical, and their cyclical need, whether they’re an asthmatic, or whatever that individual is needing. Do PPIs also, are there other things that change blood sugar? You know, we can talk about GLP, GLP 1s, we can talk about Metformin, but I’m just curious from an ENT perspective, were there other things? Or had you thought of other things?
Dr. Casey Means [1:00:06]
Yeah, when you think about medications or really any substances going into the body, it’s interesting because there are some medications that are going to acutely affect blood sugar, either bringing it up or bringing it down. And that’s something you can really see on the continuous glucose monitor. And that steroids is a perfect example of that you put them on it and within hours someone’s glucose might be going floating up into the abyss, which is what it looks like, it just starts floating up and it just stays up there. Then there are other medications; people might start Metformin, and then two days later, they notice their glucose is just frame-shifted down or something like that. So there’s drugs, but then there’s all these other drugs that we prescribe in medicine that don’t necessarily have that direct impact on the blood sugar that you’re going to see on a continuous glucose monitor. But we know that they function in a way that overall can hurt the metabolic milieu in the cell through many different ways.
So there are medications that are maybe microbiome disruptors, and therefore going to change the short-chain fatty acid production imbalance in the body, which has downstream effects on metabolic regulation. There are some that are going to be direct mitochondrial disruptors. It’s amazing how many different ways medications that we prescribe can hurt the mitochondria from depleting ATP in the cell, from actually depleting a mitochondrial cofactor like Coenzyme Q10, like blocking ATP synthase, like blocking specific protein complexes in the electron transport chain. Those aren’t going to necessarily cause you to have a glucose issue the next day, but they’re going to be slowly and more insidiously, creating a foundation of metabolic issues in the cell that may, down the road, then lead to more glucose intolerance.
I think that’s a real journey that we all need to go on as a healthcare system, really thinking about all of us taking ownership of protecting the metabolic health, or the mitochondrial health of our patients, as well as the microbiome health and all the different things that interplay and make sure we’re understanding what those risks are. But some of the drugs, for instance, there’s certainly, like statins, for instance, are known to deplete Coenzyme Q10, which is one of the key cofactors related to electron transport chain. So this might underlie some of why people have side effects with this medication, like myopathy is also why supplementing Coenzyme Q10 might be helpful with people taking statins. A lot of antidepressants like fluoxetine, antipsychotic drugs, Clozapine. These are known to have mitochondrial effects.
Now actually, there was a really interesting study that came out last year that one of our medical advisors at Levels, Dr. RobertLustig, was an author about this concept of obesogens. So now that we’re starting to understand the mechanisms of how some of these medications actually hurt mitochondrial health or metabolic processes, they’re now being classed as medications called obesogens, meaning that we know that they actually causatively are related to obesity by the way they impact metabolism. So on that list would be certain antidepressants, antipsychotic drugs, there are certain antibiotics, chemotherapy agents like cisplatin, pain medications, aspirin, NSAIDS, Tylenol, some diuretics. So just a lot of medications that in some way have either direct or secondary effects on these pathways that again, can be direct mitochondrial inhibition, microbiome-related, or the way in which they impact epigenetic modifications that can then have downstream effect on metabolic pathways.
So just really something I think, no blanket statements here about what to take what not to take, but more like these are questions to probe with your doctor about what are the unintended consequences of what I’m taking so that we can have a real risk-benefit conversation because many people do end up coming off these medications, the side effects that we should be exhausting all of course non-pharmacological avenues like diet and lifestyle, in addition to of course, grabbing our prescription pad.
Dr. Gabrielle Lyon [1:04:54]
Absolutely agree with that. What else would you like to talk about? Anything really on your mind that you would love to talk about?
Dr. Casey Means [1:05:04]
Oh, it’s a great question. I mean, I feel like we could talk for hours about metabolic health. I think that one thing that I’ve been reflecting on just with this conversation, we started out talking about ENT, I think that one really interesting thing that I think people might not be aware of is that some of these conditions that are being treated in very specific parts of the body, like the head and neck, things like migraine, or sinusitis, or hearing loss, I think the average person and the average doctor has no idea how these are related to wider metabolic dynamics in the body. And I think it’s really, unfortunately, it’s something that’s really a blind spot in a lot of the surgical subspecialties. But when you actually dig into the research, you see some really interesting correlational and epidemiologic data about the risk of some of these specialized diseases, with being so much higher in people who have underlying metabolic issues.
One thing that I was really shocked by as I was looking into the research, is that if someone has high blood sugar, like Type 2 diabetes, they’re almost three times more likely to suffer from chronic sinusitis. And so that’s an area where we can really dig into a little bit and talk to people about hey, if you or people can be chronically debilitated by chronic sinusitis, and be really motivated to do whatever they can to get on top of that. And so, if there’s an avenue there of stabilizing blood sugar, improving insulin sensitivity that can actually help with that, it’s really worth talking to patients about. Similar to hearing loss, which is one of such a common complaint in geriatrics. I mean, I know you’ve trained as a geriatrician and it’s really debilitating to people. And usually, the way that we talk about it is oh, you’re getting older, and you went to too many loud concerts in your youth. But it’s actually really clear that elevating fasting glucose confers a much, much higher risk of losing your hearing, high frequency hearing, earlier in life and having a more severe case of it.
So people with elevated fasting glucose levels had 40– the prevalence of high frequency hearing loss was 42% in that population compared to 24% in people with normal fasting glucose levels. And this makes sense. Hearing is a very metabolically demanding process in the body, it’s very complex signal processing. And it’s very small parts of the body like the hair cells. Actually the cells that do hearing in the ear are called hair cells, and they’re fed by extremely, extremely small blood vessels. And so glycation, blood sugar sticking to things, endothelial dysfunction related to insulin sensitivity, nitric oxide signaling, these things in these small vessels with really high energy processing needs in parts of the body, like the ear are, of course, going to be exquisitely sensitive to metabolic function, but I’ve never heard the words blood sugar, metabolic health or hearing loss really ever be mentioned in the same conversation in the ENT world.
So that’s one area where there’s so much opportunity to empower patients, to essentially really dial in diet and lifestyle in hopes of keeping metabolic health and blood sugar levels under better control. Another one that we saw a lot in my field was people with migraines, which can be again, very debilitating, affect women more than men. And there’s a lot more coming out now around like the neuro-energetic theory of migraines. They’ve been very poorly understood, but two pathways that seem to be emerging as more, maybe mechanistic, causes are excess oxidative stress because the brain is exquisitely sensitive to excess oxidative stress and also, essentially, neuro-energetic so certain regions of the brain not having the excess energy demands for what it’s able to produce. And for a long time, there’s been interesting research showing that certain supplements actually may be helpful for migraine and it’s things like Vitamin B12, Coenzyme Q10, magnesium, lipoic acid, and actually even L-carnitin. And, when it’s always been like a question of oh, well, I wonder why? – that’s interesting. But when you look, these are all mitochondrial cofactors. They are all involved in the actual, either the electron transport chain or how we shuttle substrates into mitochondria, and so really just speaking more broadly, it’s the metabolic lens on any subspecialty, I think, just opens up such a world of opportunity for potential areas that we can empower our patients and help them dial in some of their lifestyle strategies with showing where to point the spear essentially. And because I think people, if they’re just like, oh, I need to eat healthy, and I need to exercise more, it’s maybe less compelling than helping people understand reallywhat they’re trying to achieve with this.
So I would say just for any subspecialist who might be listening, get on PubMed and start to look at some of these different links, that may not be in our guidelines, but actually might be something that you… you have to search for different things. If you’re an orthopedic surgeon, for instance, start looking at things more oxidative stress and osteoarthritis, or mitochondrial dysfunction and osteoarthritis, or things like that, that start to open up a whole set of literature that, yeah, it’s just not necessarily what we’re learning about in our conventional training or practice.
Dr. Gabrielle Lyon [1:11:15]
Well, Casey Means, you are really leading the charge. I know that the whole community is just so incredibly grateful to you. Like I was saying before we were recording, so many people just really love you. And I’m very excited to have you on the podcast. I will link where everyone can find you. I know that you have a newsletter that’s called Casey’s Kitchen. By the way, we should collaborate. Do you know that I recently launched a 30G’s recipe newsletter? This was from our mutual friend Drew Pruitt’s idea. I would love to have you on as a guest for contributing to a 30-gram G recipe. So if anyone is listening, please go sign up for your 30G’s. Casey will be one of the guest recipe providers, by the way.
Dr. Casey Means [1:12:09]
I’d love that. I am learning from you so much on Instagram about new ideas for the 30-grams meals, they’re incredibly helpful. So please keep– I’m so happy to know about the newsletter because your life really opens up and gets better when you start learning how to incorporate 30+ grams of protein in every meal. What an unlock, yeah.
Dr. Gabrielle Lyon [1:12:30]
Totally. So you guys, we can’t, I can’t wait to host you as a collaborator. So we’re definitely doing that. Now, where can people find you? I will also say Levels has an amazing blog. So please share with us.
Dr. Casey Means [1:12:42]
Thank you, we’re very proud of our blog. We invest a huge amount of energy and have many experts on the blog, essentially synthesizing the most recent research literature to be as understandable as possible. So levelshealth.com/blog and we also do post a lot about things we’re learning from the data set and what members are experiencing about how to stabilize their blood sugar levels on our Twitter and Instagram @Levels. And I am @DrCaseysKitchen on Instagram and Twitter. And yeah, I recommend signing up for the Levels newsletter and checking out the blog. There’s lots of great information there.
Dr. Gabrielle Lyon [1:13:25]
When is your book coming out, by the way?
Dr. Casey Means [1:13:28]
It comes out next May. So as you know, these publishing processes are a long time. So the book is done. But it comes out in May, so just under a year. And I’m so excited for your book coming out.
Dr. Gabrielle Lyon [1:13:41]
Thank you. Thank you. Well, it’s a total process. So I’m excited to have you back on to talk about your book that is going to be great. Dr. Casey Means, I will see you in LA very soon. Thank you so much for coming on the show.
Dr. Casey Means [1:13:53]
Thank you so much.
Dr Lyon [1:13:56]
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