Introduction:
Coming up on this episode of the Doctor’s Farmacy.
Dr. Casey Means:
Foods that are commonly touted as healthy or that we perceive to be healthy, may actually be generating shockingly high glucose spikes.
Dr. Mark Hyman:
Welcome to Doctor’s Farmacy. I’m Dr. Mark Hyman, that’s farmacy with an F, a place for conversations that matter. And today, this conversation matters so much because it’s about the one thing that ends up being the root cause of almost all the things it causes to suffer as we age. Heart disease, cancer, diabetes, dementia, kidney failure, high blood pressure, all the bad stuff. And what is that thing? It’s your blood sugar and we are going to be talking with one of the world’s experts on blood sugar who has more insights and data, actual hard data about what is going on with your blood sugar and how to manage it, how to regulate it, how to actually dive into the science of your own biology. None other than Dr. Casey Means. Welcome Casey.
Dr. Casey Means:
Thank you so much, Mark. I’m so thrilled to be here.
Dr. Mark Hyman:
Casey, you’re pretty awesome. We did another podcast with you about blood sugar too. Casey is a Stanford educated physician. She’s a Chief Medical Officer and co-founder of the metabolic health company Levels, and an Associate Editor of the International Journal of Disease and Reversal and Prevention, which is awesome. She lectures at Stanford University and her mission is to maximize human potential and reverse the epidemic of preventable chronic disease, all that nasty stuff I talked about at the beginning by empowering individuals with tools that can facilitate a deep understanding of our bodies and informed personalized and sustainable dietary and lifestyle choices. Dr. Means’ perspective has been featured all over the frigging place. The New York Times, Wall Street Journal, Men’s Health, Forbes, Business Insider, TechCrunch, on and on and on. I’m so happy to have you Casey today because you are breaking ground with a company that is changing how we think about our bodies, that is giving us a window into our biology that we’ve never had before and particularly our blood sugar and all things, blood sugar, and why that’s so important. Thanks for joining us.
Dr. Casey Means:
Thank you so much, Mark. I’m so excited about this conversation.
Dr. Mark Hyman:
The big thing is that we are facing this pandemic of COVID for sure. The reason we are dying like flies in America, more than any other country, probably three or four times the death rates per capita is because we are so freaking unhealthy and that poor health is related to poor metabolic health, and essentially what that means when we say metabolic health is, imbalances in your blood sugar, which causes high blood pressure, high cholesterol and abnormal blood sugar. The hallmarks of this poor metabolic health that now affect almost 9 out of 10 Americans.
Dr. Mark Hyman:
They’re the things that are getting worse and worse and worse. We’re seeing obesity, heart disease, cancer go up, dementia rising it, we’re not winning the battle. We are seeing more and more chronic disease every day, more and more obesity. We’re better and better at taking care of problems. We have better and better medication, better surgical techniques, better advances in our science and we’re failing so badly because we’re barking up the wrong under the tree, and that’s because we’re not looking upstream for the problem. Tell us about the foods, that are driving all these problems, places we should be looking at in terms of our diet and our lifestyle.
Dr. Casey Means:
Well, I think that summary was so phenomenal. We are dealing with two epidemics that are so interrelated right now. We’re dealing with the metabolic disease epidemic, which is the leading driver of mortality in the Western world now. We like to call all these different metabolic diseases by different names, which may make them artificially seem like they have less impact, but really like you said, the root cause is a problem with metabolism. When we talk about obesity, diabetes, heart disease, stroke, Alzheimer’s dementia, fatty liver disease, we know that all of these are related to dysregulated blood sugar. And in fact, 9 of the 10 leading causes of death in the United States are in some way, either directly caused by or worsened and accelerated by dysregulated blood sugar. To get to this question of what are the foods we need to avoid in order to prevent these diseases.
Dr. Casey Means:
One of the biggest things we need to do is, keep our blood sugar in a stable and healthy range throughout the entirety of our lifetimes, and we have the power to do that by making smart choices about our foods and of course also pulling the other levers that impact our blood sugar, which is of course, exercise, sleep, stress management, optimizing our microbiome, avoidance of environmental toxins that hurt our metabolic pathways. I would say that the foods that drive these cardio metabolic diseases are foods that disrupt ourselves from doing what they need to do to function optimally and that then lead to insulin resistance. The physiologic process that ultimately creates the dysregulated blood sugar. These foods that are highly processed that have the ultra refined ingredients. These are the foods that make up the vast majority of the calories we consume in this country.
Dr. Casey Means:
They have the ultra refined wheat flour, the processed sugar, which of course has more than 50 names on the packages, so it’s so hard to tell which of the foods actually have processed sugar, but the answer is most of the ones that are packaged in a store. These are the foods with fructose and high fructose corn syrup, they’re refined seed oils like sunflower corn, soybean oil. These are the foods that when we eat them in these super high concentrations that our bodies have never seen before in evolutionary history until about the past 50 or 100 years, they completely rec havoc on our core fundamental processes that allow ourselves to function properly, which is our metabolism and they disrupt our homeostasis.
Dr. Casey Means:
Those are the types of foods that you certainly want to avoid in order to prevent these diseases and the unfortunate thing is that, these ingredients sneak into so many different foods, often foods that are marketed as healthy. We really are in a tough position right now because the reality is that the average American wants to be healthy and is putting in work to try to be healthy. We see that 50% of American adults go on a diet every year, trying to lose weight. Of course, 72% of Americans right now are overweight or obese, but half the country is making the commitment, and reporting that in a survey saying that they’re trying to lose weight and yet every year we are getting sicker, we are getting fatter, we are getting more anxious. There’s clearly an effort outcome mismatch and that’s where I think the future-
Dr. Mark Hyman:
Effort, outcome, mismatch, that’s a good way to talk about it.
Dr. Casey Means:
That is where I think tools that can empower people with information to actually make choices that actually impact the physiology that leads to chronic disease and weight gain is really going to shape and change the future of healthcare and really create this patient empowered more decentralized form of healthcare, where we don’t just outsource our judgment to other people, to the food companies, to healthcare systems that give very generic recommendations to anyone. We actually are able to have the judgment about our bodies for ourselves and I think that’s pretty cool.
Dr. Mark Hyman:
That’s huge. It’s all about empowering people, democratizing healthcare, democratizing medicine, giving people their own health data, helping them learn about it, be their own autonomous health creating units, because as we know, 80% of health doesn’t happen in the doctor’s office and maybe 20% does and I think that’s an exaggeration. Health happens where we live. It happens in our homes, in our kitchens and our schools, and our workplaces, and our grocery stores, and our restaurants, that’s where health happens. And if we don’t focus on those factors and learning how to be, not just waiting to go to the doctor to get fixed, but actually being in charge of our own health, being the CEO of our own health, we’re not going to be able to actually break out of this horrible situation. It’s terrifying to me, just sitting on the front lines of it, like you are, it just seems like one of those conversations, that’s just not really happening.
Dr. Mark Hyman:
Nobody’s really saying, “Hey, we’re in a crisis.” Everybody’s upset about COVID, but way more people die every year from bad food than die from COVID or get sick from COVID and it’s causing so much more suffering, so much more healthcare costs, so much more crippling of our economy. One of the things that’s so exciting about the work you’re doing Casey, is that you’re not using these large randomized control trials and large observational trials and things that are the conventional way of looking at people, you’re looking at what we call N-of-1 studies. In a sense, we’re looking at how does each individual respond as their own control group, because you basically slap on this, glucose monitor that measures your blood sugar continuously called Levels, you put it on your arm and you leave it there and your sugar is just being tracked.
Dr. Mark Hyman:
You get to actually witness what your body does in response to particular food or sugar, and you’ve got data from 50 million glucose readings, which is insane when you think about that amount of data that you’re collecting and people are using this technology and we’re learning so many things that are so surprising. We know for example that no two people respond the same to exactly the same food. For example, in Israel, they did a large study. They looked at the microbiome and they found that there were differences in people’s blood sugar response, depending on what bacteria were growing in their microbiome, in their gut, which is like, “What? That doesn’t even make sense.”
Dr. Mark Hyman:
It depends on your genetics, depends on your overall metabolic health, it depends on so many different factors, your toxin load, all these modify your individual responses. When you’ve got these 15 million glucose readings from the Levels app, that continuous glucose monitor, what are the surprising things that you found, these are non diabetics, it’s not like you’re a diabetic, although probably I bet you’re picking up diabetic people like 90% of people with prediabetes have never been diagnosed. I bet you’re picking up a lot of that. What are you learning? What are you seeing? What is surprising?
Dr. Casey Means:
It has been so incredible to start to see some trends emerge from this huge anonymized aggregated day data set, really the first of its kind in the world. Like you mentioned, we have 51 million glucose data points and this is just amongst our closed beta program, 16,000 people who have gone through our closed beta program. We have almost 200,000 people on our wait list, so you can imagine that 51 million data points is going to get a lot larger when we start opening to more people. Those 51 million glucose data points paired with 1.3 million food logs, so we can start to see for the first time ever, how specific foods across a population are affecting glucose and creating this population data of a closed loop biofeedback. You mentioned the individualized aspect of this, that is so true and that paper that you referenced personalized nutrition by prediction of glycemic responses that was done about five years ago and Israel showed how variable it is, person to person.
Dr. Casey Means:
We could both of course eat the exact same cookie and you and I could have a very different glucose response based on several factors like our microbiome, our underlying insulin resistance, et cetera. That’s a really important aspect is for the individual, what data they can get to really, truly personalize their own data based on glucose response, because of course, and we talked about this a lot in our last episode, a more stable glucose level with more gentle rolling hills after meals, avoiding the huge spikes and valleys that we see after eating large amounts of carbohydrates and sugar. That’s what we want. We want the gentle rolling hills, the low glucose response. You can start to see that in yourself and shape your diet very quickly. On the population level, then we get to see something interesting as well that actually can benefit anyone, not just the people who have a sensor on, because this becomes a database that really informs the nutrition industry, like we’ve never been able to before, where we start the radical transparency about what food is actually doing to people’s bodies.
Dr. Casey Means:
I personally think in five years, it’s going to seem incredibly outdated, incredibly quaint to walk into the grocery store and choose foods based on what the box says, based on interests that are not aligned with your thriving and wellbeing. They’re aligned with taking you to your bliss point, making you dependent for it, making your dopaminergic reward systems want to keep coming back, but it’s not aligned necessarily with your health. We’re going to start to see this huge new way of choosing foods. I can imagine a person with polycystic ovarian syndrome, for instance, a condition that we know is directly related to insulin resistance and studies have shown that low carb diets, a healthy Mediterranean ketogenic diet for just 12 weeks can actually reverse PCOS. This was a study done just a couple of years ago.
Dr. Casey Means:
There’s people and women are very savvy with their research and they’re going out and they’re reading the books, they’re reading these papers and they know they need to keep their glucose and insulin under control. They know that just being prescribed a birth control pill and Metformin is not the answer to their long term health. They’re looking for tools and you can imagine that woman, her doctor says to her, “Oh, you don’t have diabetes. You don’t need to worry about blood sugar. You have PCOS. It’s very different.” They know though, they’ve read, they do their research. People are very smart, very informed. They know they’re going to work to keep their blood sugar down, because they know that in the research that shows that it will help.
Dr. Casey Means:
They go to the grocery store now with this app, with something that they can actually look up every food they’re buying and see exactly across tens of thousands of people, what it’s doing to people’s blood sugar. You go into the non-dairy milk aisle, and you’ve got 15 different options. You’ve got oat milk, you’ve got almond milk, you’ve got cashew milk, blah, blah, blah, and it’s like, what the heck are you supposed to get? And you think you’re making a good choice because you’re buying an unsweetened, non-diary milk, but the reality is from our data set, that there are some of those that give you a monumental spike, even if they’re unsweetened oat milk, and then there’s others that actually have virtually no glucose response. That person now, can take their health into their own hand, make a consumer decision, not based on marketing, that’s going to serve their goals.
Dr. Casey Means:
And I am so excited for that world because people are going start, I think demanding from food companies to actually create products that are not creating a huge amount of glycemic variability or these ups and down spikes and you can’t hide from that data. I’m really thrilled of what that’s going to do. Circling back to your main question of some of the theme that we’ve seen, I think one of the first things that’s really interesting is our demographics actually. Aside from glucose data, actually 52% of our beta members are women and this is so different than what you hear in the mainstream media. There’s a New York Times article about Levels that talks about how this is for the worried well, and the biohacker guy, and the longevity crazy, and it’s like, that is not the reality.
Dr. Casey Means:
The reality is, this is mostly women in their ages of 30 to 40. Very similar to the demographic I was talking about with people who are at high risk for things like PCOS and their primary reason for wanting to use a CGM, what they report to us is weight loss, followed by finding their optimal diet. The 48% who are men, their number one goal is optimal diet as well. People are clearly interested in finding what actually works for them. If you go back to what you’re talking about with COVID, the CDC just announced yesterday, finally admitted that 75% of the people dying of COVID have four or more of these largely preventable cardiometabolic comorbidities. People know. They know now and now it’s finally coming out in the mainstream media that we’ve got to get the blood sugar under control.
Dr. Casey Means:
That’s one thing we’re seeing, is really interesting demographics. This is not the worried well, this is not for the celebrity, rich and famous, this is for people who want to just figure out their diet and lose weight, which is great. The second thing we’ve seen a lot of is that foods that are commonly touted as healthy or that we perceive to be healthy, may actually be generating shockingly high glucose spikes. I think we particularly see this around breakfast-
Dr. Mark Hyman:
Like what?
Dr. Casey Means:
Like breakfast foods, we certainly see snacks, common snacks, drinks, common take out foods, and we can certainly dive into the details on those. But it’s amazing how some of these things that we just think are totally normal to just eat on a Friday night or whatever, or grab for breakfast or serve in school lunches at schools are actually causing these huge, huge glucose spikes.
Dr. Casey Means:
I think another thing that’s been really interesting is showing people combinations and alternatives of foods that they can do that will do better. For instance, combinations, we see a lot of people log something like an apple and then they’ll log an apple with peanut butter and yogurt. And that peanut butter and yogurt is adding of course, fat and protein. Sometimes they’ll put some chia seeds on that, that’s some fiber and we’ve definitely seen that when carbohydrates, naked carbohydrates, like a fruit are paired with fat, protein, and fiber, people do better. In terms of alternatives, we’ve seen some really interesting things. We just published an article on Chipotle. We see people logging all sorts of things at Chipotle, some of them disaster for glucose, some of them virtually no glucose response, like an average of seven milligrams per deciliter, very low.
Dr. Casey Means:
The really minimal glucose spiking things, is the keto bowl. This is a salad that has protein, fajita veggies, guacamole, salsa, virtually no glucose spike, tons of nutrients. Burritos, on the other hand with that take tortilla, send people on average through the roof. People start learning if I’m going to go to McDonald’s, if I’m going to go to Chipotle, if I’m going to go to Sweetgreen, what should I order, that’s going to give me the best bang for my buck in terms of blood sugar? I think the last thing I would just-
Dr. Mark Hyman:
Everybody’s different, it doesn’t mean that what works for you, like you say, “Oh, well, I found that this scrip of my blood sugar doesn’t mean it’s going to scrip your friend’s blood sugar, right?”
Dr. Casey Means:
That’s definitely true. These are more the population based things that we’re seeing that can give you, I think, a general just stalt of where you should start and then of course it’s about actually trying it for yourself and seeing what actually works for you. There may be that person out there that doesn’t spike to a huge flower tortilla, but for most people, knowing that getting the keto bowl is going to have totally stable blood sugar on average for the population, they can at least go in there and get that and see what it does to them. I think it nudges people in the right direction. The last big insight that I think we’re seeing is around, this is so simple, but it’s profound is walking.
Dr. Casey Means:
We have seen that a simple walk after eating, significantly reduces glucose responses. We actually did an experiment with our members where we sent people a 12 ounce can of Coke, two of them, and we said, “Hey, if you want to do this, drink this Coke on one day and then on the next day, drink the Coke and take a walk right after you drink it.” And we actually saw across this population that, of the people who can be both aspects of the experiment, the median Delta of the glucose rise was 33% lower if you just took a walk, so that was going from an average of 162 milligram per deciliter, peak to 132. Over the course of your lifetime, if you’re doing this every day, that’s a huge difference.
Dr. Mark Hyman:
How soon do you have to walk after you eat?
Dr. Casey Means:
There’s a lot of research that looks into this, and it really comes down to the sooner, the better. If anytime you walk after a meal, even if it’s an hour or two, do it, that’s fantastic. But because our glucose to tends to peak within an hour after a meal, what I would recommend to people is, after a meal finish the conversation, 15, 20 minutes, get up with the family, take a spin around the block, put the dishes in the sink, go take a nice stroll around the block and then come back. And if you don’t want to walk outside because it’s cold, put on some great music and have a dance party in the kitchen, or do a few squats. It’s really just about moving, but these are significant effects. That’s the general layout of some of the things that have been so interesting to me from looking at this huge data set.
Dr. Mark Hyman:
That’s just so fascinating. It’s like we just have this one-size-fits all approach in traditional medicine and it’s just so far from that. Do you also learn about, for example, what would be things we should never eat? Like one of those things we just never eat.
Dr. Casey Means:
Well, I’ll go off of just what we’re learning in our data set because we could obviously, you and I could talk about this forever about general principals, but-
Dr. Mark Hyman:
I think getting the specific data is just so fascinating. That’s why I want to get in there.
Dr. Casey Means:
Absolutely. Of the categories of things that at this point, based on what we’ve learned, I would not really eat anymore would be certain candies, which I’ll go into each of these in more detail, certain cereals, soda for sure, fast food, and lots of common takeout. When we look at candy, this is actually really interesting, the worst food in our entire data set of 51 million glucose data point is?
Dr. Mark Hyman:
I want to hear this, drum rolls please.
Dr. Casey Means:
Skittles.
Dr. Mark Hyman:
Skittles? Wow.
Dr. Casey Means:
Not surprising because it’s a refined carbohydrate, obviously there’s refined sugar in there, but it’s also a naked carb. It doesn’t actually have fat, protein, and fiber like a Snickers bar at least has some fat and some protein, the Skittles are just like naked carbs, so the Skittles have an 80-
Dr. Mark Hyman:
Naked carbs. I love that term. I never heard that. I love that.
Dr. Casey Means:
They’re just on their own, and you can think of fat, protein, and fibers as kind of clothing, the carbs. Skittles have an average glucose rise in our dataset of 83 milligrams per deciliter. That’s certainly going to take you out. It’s way more than a Coca-Cola and you are going to almost inevitably crash after that type of spike. Because of course, when you spike that high, you release all this insulin to soak up that glucose out of the bloodstream and that huge surge of insulin can overshoot. The body responds in an exaggerated way. You take up all that glucose and then people often dip to below their baseline and have that reactive hypoglycemia after the spike, which is when they feel shaky, tired, lethargic-
Dr. Mark Hyman:
Goes up and then down.
Dr. Casey Means:
Exactly. The beauty of achieving more of the gentle rolling hills is that you don’t end up having that reactive hypoglycemia that can make you feel really crappy. That post-meal slump that people are often like, “Oh I just need a cup of coffee or something.” It’s like, “No. It’s the Skittles.” Skittles have a huge… The other candies that are in the worst part of our data set are Sour Patch Kids, Caramel Corn, Twizzlers, and Jelly Beans. You notice they all are similar. They’re all these not chocolatey, no protein, no fat, just straight congealed sugar basically. Those are the candies.
Dr. Mark Hyman:
We used to have those things when I was a kid, it was like this powdered stuff [licky-made 00:24:46] or something, I forget what it’s called. You’d put a stick and lick your sugar.
Dr. Casey Means:
Yes. And the stick was made of sugar too. Wasn’t it like a candy stick?
Dr. Mark Hyman:
I don’t remember seeing that anymore. I don’t really look for it, but I was like, that was my main go-to thing, when I was six, seven years old, want the licky-made, the sugar was like a fentanyl lollipop.
Dr. Casey Means:
We use sugar as a pain management tool in hospitals. This is abhorrent, but when children undergo circumcision in the hospital in their first days of life, what do they give them for pain medication? This little dropper called a Sweeties, which is just sugar water. That is the analgesic. It’s exactly like you said, it literally is like a fentanyl lollipop. That’s candy, so get rid of the Skittles. A Snickers bar literally has half the glucose spike of Skittles, so it’s pretty amazing then it’s cereal. Oh my gosh. Get the cereal out of the house.
Dr. Mark Hyman:
You mentioned takeout and other things too, right?
Dr. Casey Means:
Just to tell about the cereals, Cinnamon Toast Crunch, Honey Nut Cheerios, Lucky Charms, about 60 or above on glucose responses.
Dr. Mark Hyman:
Wait, wait, wait. Honey Nut Cheerios, we think honey is good, not as good and Cheerios are good. So, it’s actually just a wolf in sheep’s clothes. It sounds like.
Dr. Casey Means:
After Cinnamon Toast Crunch, is the worst.
Dr. Mark Hyman:
Oh my God. Worse than Fruit Loop or Pebbles or Coco Puffs or any of that?
Dr. Casey Means:
I haven’t checked those precisely in our data set, but when you look at just the top 50 worse foods that people log, all three of those. These kids are going to school after having these spikes and crashes and Mark, a lot of them are probably eating a glass of OJ on the side, these are isolated food logs.
Dr. Mark Hyman:
Casey, I just break in for a minute. I remember when I was filming the movie Fed Up, and one of the scenes was where the mother was trying to get her kids to lose weight and her family lose weight. And she’s like, “Well, what I’ve really focused on is healthy breakfast cereals.” And she pulls out these cereals that are marketed as pro health foods. Kellogg who invented breakfast cereal as a breakfast food, which wasn’t a thing. These are basically dessert for breakfast. It’s 75% sugar and that is having a soda with breakfast. I think people need to get that cereal and starch for breakfast is a huge no-no, and if you can do one thing to change your biology quickly, is get rid of any starch or sugar for breakfast.
Dr. Casey Means:
Yes. You said that it’s like eating sugar for breakfast, I will up the ante here, it’s much worse than eating dessert for breakfast. Peach Pie has an average glucose spike of 46 milligrams to deciliter, Cinnamon Toast Crunch is 59, and they both have of course the refined seed oils and the flour it’s worse. So-
Dr. Mark Hyman:
Give me the Peach Pie. I love Peach Pie.
Dr. Casey Means:
I know. Exactly. You mentioned, getting rid of the breakfast foods that have the refined starches, this has been one of the most fascinating things we’ve seen because, all the common American breakfast foods are in the worst 100 foods that score and just to run through them really quick. We’re talking about, this isn’t our worst 50 foods, Egg McMuffin, Bagel with cream cheese, French toast, Pop tarts, cereal, English muffin, Blueberry scones, Cinnamon roll, Cheerios, Croissant, toast with jam. Those are all above a 40 milligram per deciliter spike. That’s a big spike.
Dr. Mark Hyman:
Which is a lot.
Dr. Casey Means:
It’s a lot. If you look at then the best foods in our data set, like very little glucose spike, you also see a handful of breakfast foods, and so these are the ones we want to eat.
Dr. Mark Hyman:
Like what?
Dr. Casey Means:
We see frittata, we see avocado and egg, avocado and greens, chia pudding, Greek yogurt and berries, and we actually see this… A lot of people log this. I think because Kelly LeVeque is close in our network, but we get a lot of logs for the Fab 4 Smoothie, which is a smoothie that she has popularized, which is really balanced. It has very minimal fruit, a lot of protein, fiber, fat, and greens, and all of those that I just mentioned, all score below 20 milligrams to deciliters. It’s basically Mark, it’s the pegan and diet.
Dr. Casey Means:
People can read your book and… It’s the beautiful nutrient dense foods that none of those have refined carbs and I think people sometimes assume that, “Oh, if I’m going to have a keto breakfast or a low car breakfast, I need to eat the animal products.” That’s not true. Half of those things I just mentioned, don’t have animal products. The Fab 4 Smoothie, the chia pudding, you could do non-dairy yogurt with some berries, some avocado and so, that’s just something important to remember, that breakfast is this one’s straightforward. Don’t eat those first things, eat those things.
Dr. Mark Hyman:
Fat and protein for breakfast, get rid of the starch and sugar.
Dr. Casey Means:
Yes.
Dr. Mark Hyman:
Very important. I think it’s super [inaudible 00:29:56]. I used in my sugar detox book, I create a smoothie, which essentially, nuts and seeds, was raw nuts, almonds, walnuts, pecans, hemp seeds, chia seeds, flax seeds, putting in cranberries, which is actually very low glycemic, the lemon, maybe some berries, unsweetened macadamia milk or whatever. And it’s basically and greens you can put in there in avocado and it’s basically a protein and fat smoothie. It tastes delicious and it’s not all the typical… Oh my God. Like things like Ensure, Boost, all these meal replacement things. Most traditional smoothies are full of sugar, artificial sweeteners, highly processed protein powders. It’s so good to get just real food, so I love that real food smoothie.
Dr. Mark Hyman:
I want to ask you a couple more questions. There are a bunch of things you learn just because this is such a new area. We’re just learning about in real time, what happens to real people in a continuous glucose monitoring setting, which people have to realize this is not technology, it’s been around for a long time. It’s relatively recent, and it’s even more recent that it’s being used at scale by non-diabetics. That’s huge thing. We’re just learning stuff that we just never had insight into before and Levels is capturing that data and making sense of it and has so many beautiful lessons, and for anybody listening, Levels is going to be launching. It’s a great technology to actually see what’s going on with your own biology.
Dr. Mark Hyman:
I was super surprised too, and shocked and I’ll just give you a little anecdote to what happened to me. But the first night we got it, I used it and I was at my friends and we had this big dinner. We ordered all the healthiest food from this regenerative farm and lamb, and all these veggies and it was so healthy and non sugar. There was no starch. It was amazing. And we ate so much food. We just ate a huge volume of healthy food and we both were going to bed, checking our sugar and texting each other like, “What happened? Our sugar’s like 160. This is freaking me out. What’s up?” Any big meal also can cause a spike. A few things you learn, one is what are the surprising things you learn that actually spike your blood sugar, that are surprising to you and what foods might not actually spike your blood sugar, but you still should get rid of?
Dr. Casey Means:
This is such a great question. You asked for some surprising foods that spike blood sugar. I want to preface this answer by saying that some of these foods, it’s not necessarily that you should avoid them completely, because they’re actually nutrient dense whole foods. It’s that it’s good to be aware of how they’re affecting you so that you can figure out how to eat the food in some different way. Maybe eat a smaller portion, maybe pair it more with fat, protein, and fiber, maybe take a walk afterwards. The intention is not to hear these foods and then say, “Oh, I can’t eat that again. It’s not a good food.”
Dr. Casey Means:
This brings me to one of the first ones, which is certain fruits. There are certain fruits that spike people on average a lot more than others. The ones that we see in the data set are banana, which is maybe not that surprise, but grapes. Grapes have an average glucose spike of over 40 milligrams to deciliter, whereas like a Mandarin orange for instance is like 20. It’s a very big difference. We also see, even within fruits, like different types of oranges, a Mandarin orange has a low spike, a Sumo orange is almost double that. Those Sumo oranges are so unbelievably delicious and it also could be a size thing, but chop up those oranges, put them in some yogurt and add some Zen basal seeds or chia seeds or something with tons of fiber. It’s going to potentially blunt that spike.
Dr. Casey Means:
Fruit juice is not a huge surprise, like orange juice, huge spike average of 40 milligrams to deciliters. I would say of course, avoid liquid sugar, which I would consider juices to be liquid sugar, but certain fruits do have more of a spike than others, for sure. The next one corn on the cob. Average glucose spike of 46 milligrams to deciliter, which is the same-
Dr. Mark Hyman:
What if you lather it in butter?
Dr. Casey Means:
Well maybe doing some grass-fed-
Dr. Mark Hyman:
[crosstalk 00:34:08] What if you have it with your-
Dr. Casey Means:
Yeah, I think it’s a good point.
Dr. Mark Hyman:
Grass-fed beef with it as before.
Dr. Casey Means:
Or grass-fed some really nice butter, some ghee. I actually put corn now. I only use corn really now within recipes because I know that if I eat corn alone, it’s going to spike me. For instance, I make these really great hearts of Palm crab cakes. They’re crabs crab cakes and they have some corn in there. They don’t spike me. I eat it with an avocado relish. There’s lots of other stuff going on. I just have figured out how to balance it to not spike me.
Dr. Casey Means:
We also see big spikes to some foods that are totally marketed as low carb. I hate to throw some certain brands under the bus, but SmartSweets. They market themselves as having significantly less sugar than other candy, but they have a higher glucose spike on average than a cinnamon roll. That’s where marketing people are like, “Oh, I’m going to eat the low carb candy.” You got to test it on yourself. This one was interesting. The fasting mimicking diet has become really popular. And actually, this one in our top 10 worst scoring food, so right next to Skittles is?
Dr. Mark Hyman:
You mean the fast mimicking diet, the ProLon diet?
Dr. Casey Means:
The tomato soup has an average glucose spike of 53 milligrams per deciliter. I don’t quite know what-
Dr. Mark Hyman:
It wasn’t the whole program?
Dr. Casey Means:
No. This is an individual food.
Dr. Mark Hyman:
It was one of the soups? I need to talk to Valter Longo and tell him to swap out that soup. You should just send it to him.
Dr. Casey Means:
I will. I’m going to. I’ll send in the episode. We have not met personally, but the thing is their results of the data of that program are profound and it is clearly evidence based that it is extremely effective for improving cardiometabolic biomarkers. What I would say though, is that there’s probably a way to even more tweak that program if the ingredients were slightly modified. I don’t think that glucose spike in the context of basically eating 500 calories a day, for five days is really going to hurt people, but we want to reduce glycemic variability, and it’s probably pretty simple to swap out some ingredients there. That’s good information to have and I think the last thing I’d mentioned that has really blown me away is the energy bars. We probably have over 50 different types of energy bars logged in the data set, ranging from Quest bars, Bulletproof bars, Clif bars, Luna bars, all of these and the spectrum is profound. We see that-
Dr. Casey Means:
[crosstalk 00:36:56] Like, “What bars should I eat?” It’s such a big question. What protein bar, what bar do I have, what’s good? And people are eating stuff and I’m like, arghhhhh.
Dr. Casey Means:
Totally. They’re walking into Whole Foods and you go to that aisle with all the bars and it’s just colors, galore, beautiful packaging, all these claims on every box. Each one has a different thing. It’s like, “Oh, this has no sugar alcohol, this has high protein, et cetera, et cetera, this one’s organic.” How the heck do you know what to choose? Well, in the future, we can look it up like this and figure it out. For instance, like Clif bars have a spike around 42 milligrams to deciliter. That’s almost 10 points higher than a Snickers bar. I’m I used to eat those.
Dr. Mark Hyman:
I used to live on those things.
Dr. Casey Means:
Yeah. GoMacro bars have a spike of around 44 milligrams to deciliter, and then you look at some of these others, like Bulletproof bars are very low, a perfect Keto bars. This is all just your anecdotal data. This is obviously not controlled trials, but what I get excited about is that, that person in that aisle who has made the commitment to try to lose weight, to try to be healthier, is not at the mercy of the food marketing of what the box says. They actually have some agency now in the face of unfortunately industries that are not necessarily aligned with our long term health. Those are some of the surprising ones that we see.
Dr. Mark Hyman:
I bet. A lot of people are trying to design products that are good, but they never had this tool before. Now they can reformulate maybe think about it and I think that’s the key. We have to stay current with what’s true and I think your work and getting this data is going to be so important to helping us be empowered around making the right choices in general, but also for us. You also mentioned things that don’t spike your blood sugar, but actually we should still get rid of. Why is that?
Dr. Casey Means:
This is such an important question because I want to be very clear. Glucose is not the only biomarker that you need to orient your diet around. Right now, it’s the only continuous biomarker that we have, that can give us closed loop biofeedback on nutrition. We don’t have anything else that we can put on our bodies and see exactly how food’s affecting us. Of course, both you and I would probably love to see an inflammatory monitor, an oxidative stress monitor. These things that also affect our health.
Dr. Mark Hyman:
Insulin, you told me you were in insulin.
Dr. Casey Means:
Of course. That’s what gets into the things that won’t spike glucose, but you still should avoid for optimal metabolic health. The first and the biggest one is fructose. Fructose alone will not spike blood sugar or insulin, but we know from the mechanisms of how insulin was resistance develops, that it directly contributes to insulin resistance through a really interesting pathway.
Dr. Casey Means:
Fructose is broken down into a byproduct called uric acid, which goes into the mitochondria, the seed of our metabolism in the cell and generates oxidative stress. This damaging free radical activity that actually causes the mitochondria to become dysfunctional and process glucose less effectively and shunt glucose to fat storage, so then you start getting fatty liver disease because of fructose and that fatty liver disease causes liver insulin resistance, which then makes you less able to stabilize and regulate your blood sugar. Fructose has this really interesting side pathway that ultimately leads to more instability in glucose, but will not show up on a CGM if eat in isolation. Now, of course-
Dr. Mark Hyman:
It’s a really important thing. I just want us to stop there because you said something super important. If you for example, eat a sugary soda with high fructose corn syrup, you’ll get a mixture of glucose and sucrose, but if you have pure fructose, which is like a GABA for example, that’s just pure fructose and that actually turns out to be pretty bad for you. If you’re eating fructose in the matrix of a fruit, it’s probably not as bad. It’s actually can be okay to have it in a complex of a meal and we’ll talk about food pairing in a minute, but the idea that you can be eating certain food, fructose, for example processed food is mostly fructose, like they use high fructose corns every week, but it could be 75% fructose.
Dr. Mark Hyman:
That isn’t going to spike your blood sugar, like you said, but it’s going to create a cascade of events that actually makes you more likely to get diabetic by increasing the uric acid liver or the insulin resistance. And the uric acid story is a very fascinating one and David Perlmutter just wrote a book about it called Drop Acid, which is not what you think it’s about. It’s about the uric acid blood that’s causing so many these issues and fructose is a huge culprit, so I just want to pause there.
Dr. Casey Means:
It’s so important. Going off of what else should we be thinking about? I would love to see a uric acid continuous monitor because then all of a sudden, if we could measure both those things, then we start to see a more holistic view of how food is affecting us. Because ultimately our mission at Levels is to help people know how food affects their bodies so we can reverse the metabolic disease epidemic. But right now, there’s still some blind spots. Like you mentioned, David Perlmutter is coming out with a book called Drop Acid about how fruits is affecting our health. We also in February are getting another book by Rick Johnson from University of Colorado, that’s called Nature Wants Us to Be Fat, which is also all about uric acid. I think we’re going to be starting to talk a lot more about that come February, which is awesome because fructose is absolutely killing us.
Dr. Casey Means:
There’s just absolutely really no two buts about that and like you said, it’s not the fructose that comes in fruit, which is in a complex of fiber in a whole foods, slower to digest and smaller quantities. It’s the refined liquid versions that go into our processed foods and that we find in juice that we should really avoid because what happens is, the liver knows how to process fructose and it knows how to just produce some small amounts of uric acid that our body knows how to handle, it’s when we overwhelm those pathways in a short period of time that we get the uric acid skyrocketing and create that oxidative stress. It’s really a lot about pacing and they’ve even done research showing that if you drink a Coca-Cola slower, like over the course of an hour or two hours versus in five minutes, it actually has less of a damaging effect on liver because you have to think, we’re just made up of a ton of cells that are trying their hardest to process this stuff.
Dr. Casey Means:
If you can process and clear process and clear, it’s better than if you just jam it down your throat and overwhelm enzymatic, all these enzymes in the body that are trying so hard to get through it. And then you end up creating an excess of these damaging byproducts that ultimately lead to organ dysfunction. Fructose is a big one. The second big one I would mention is the pro-oxidative stress inducing foods that come from more like refined fats. It’s like the seed oils that we talked about. Again, the name of the game is in many ways, oxidative stress, which is this process that damages our mitochondria. You want to avoid those refined seed oils that are in everything that’s packaged and you really be vigilant about looking at labels and trying to opt for things that only have oils like avocado oil, olive oil, coconut oil, ghee, butter that are less prone to oxidation.
Dr. Mark Hyman:
Are you saying this based on your data from Levels around the refined seed oils or just in a general way?
Dr. Casey Means:
Not saying that based on our data set. These ones for this question, not talking about our data set, the thing is the data set is that what we’re seeing is the realtime response to different foods, but the next layer of this onion, when we have lots and lots of people using this type of technology over long periods of time, is we think will start to see the longer term, the lagging effects of how these other products like fructose and refined seed oils and excess alcohol over the longer term lead to glucose instability.
Dr. Casey Means:
A lot of that, we just don’t have much knowledge about because we haven’t been looking at pre disease very much in our medical system. We don’t really study healthy people and how they go from healthy to pre disease to disease because that’s not the way that our healthcare system works. We wait until disease and symptoms emerges and then we react and that’s a problem. I think we’re going to see a shift here and starting to understand, but this is more based on what we just know from the mechanisms, the fructose and the seed oils.
Dr. Mark Hyman:
Amazing. I have a question about another aspect, which is not exactly what we’re eating, it’s dealing with more complex nuances around what do we eat with what, when we eat, the timing of eating, what we eat first, second, third, this is really interesting. I remember talking to an endocrinologist at Harvard a while back, he said, “We’re finding, if you have a glass of wine at the beginning of meal, it messes up your metabolic health, but if you eat it like halfway through or drink it halfway through or have it after it doesn’t, or if you eat a piece of bread before dinner, it’s a disaster, but you have it halfway through the meal, it doesn’t spike your blood sugar as much.” Tell us about what you’re learning about, what you should eat with what to minimize the spikes and blood sugar and two, what you should eat first, second, third, and three, how does time restricted eating affect all this blood sugar stuff?
Dr. Casey Means:
Well, I think the alcohol example is really interesting and it’s an important one to mention, especially both in relation to your last question and this one. Alcohol is really interesting because straight alcohol, like spirits, no mixers that have sugar actually, often cause people to see a decrease in their blood sugar on their continuous glucose monitor.
Dr. Mark Hyman:
You mean like tequila, not wine?
Dr. Casey Means:
Wine actually fits in there as well. So wine tequila, other hard alcohol, that’s not mixed with anything. People often see that it blends their glucose response and this is a well known phenomenon. The way that alcohol acts on the liver is that it actually stops us from doing what’s called glucogenesis, which it inhibits that process where… And that’s where we make glucose in the liver from other substrates. It’s one of the pathways that our body uses to make sure our glucose never gets too low, but when you block that, it can make glucose, just look artificially a little bit lower because that’s one of the streams of glucose going into the body. Food is another one, but you’re turning it off. That’s an interesting thing where, it will not spike your glucose and I wouldn’t say it should be avoided completely, but in excess, it should be avoided because over time, two or more drinks a day is associated epidemiologically with worse metabolic outcomes.
Dr. Casey Means:
Interestingly, if you look at the risk of alcohol and metabolic disease, it’s actually a J shaped curve. Meaning that if you drink no alcohol, people actually are in a slightly higher risk for developing metabolic disease, very minorly higher, but one drink seems to be associated with the the lowest amount of future development of cardio metabolic disease. And then after one, it goes up, so it’s a J shaped curve. This is not to say you should drink for your metabolic health, but it is an interesting thing, that you do see in the literature. That’s the case with alcohol. It won’t spike your glucose, but in excess should be avoided. And another interesting thing about alcohol is that it of course disrupts the microbiome and can create some transient leaky gut.
Dr. Casey Means:
Conventional wine is filled with pesticides and food additives that we know can impact the gut. And like we talked about earlier in the episode, gut health and microbiome diversity is one of the predictors of your response to different foods in terms of glucose response. It gets complex. If we could also track our microbiome, this also might help us understand our diets a little bit more. We want to certainly be thinking about microbiome and about environmental toxins when we’re eating, even though some of those things are not necessarily going to spike your glucose in real time. Eating pesticides is not going to spike your glucose, but over time it can create the toxic damage to ourselves that ultimately does lead to insulin resistance. And we know that certainly with several of these chemicals in our environment, like persistent organic pollutants, that of course are not going to spike glucose immediately, but which over the long term create cellular dysfunction.
Dr. Casey Means:
Getting back to your question about how to pair foods and to time them, and sequence them, the key point is balance. You want to eat carbohydrates with fat, protein, and fiber. That is generally going to blunt the glucose spike by slowing digestion and fiber actually can sometimes block the amount of sugar you even absorb from the gut. They’ve looked at studies, I think with nuts for instance, which have a good amount of fiber and the calories that are on the bag may not be the calories that you actually end up absorbing because fiber blunts some of that absorption. I think of fiber as a total magical life hack and I end up adding chia seeds and I love this other type of seed called Zen basal seeds, which actually have more fiber than chia, just sprinkle it on stuff. It’s like a little super power.
Dr. Mark Hyman:
You could even take a spoon of Metamucil in glass of water and drink that. I’ve actually studied that, it helps PGX. Another one Polyglycoplex, which is from Konjac root, a Japanese fiber, the Shirataki miracle noodles. That stuff is amazing and that can be powerful, and you give it before meal, I’ve had people lose 40 pounds like that, just adding that to their diet because it’s stops a spike in insulin, stops a spike in glucose. Pretty amazing
Dr. Casey Means:
It is amazing. The Shirataki noodles that you mentioned, which I think generally have like Konjac root in them and some tofu. This root, Konjac root has so much fiber. It’s actually eating this food has been shown to improve metabolic outcomes and reverse obesity. And you think about like, you could either eat like white pasta with refined white flour with very few nutrients, or you could eat some Konjac root, which has tons of fiber and nutrients. That’s the type of swap that a lot of our members are like, It’s changing their lives. I still get to eat my pesto pasta, but-
Dr. Mark Hyman:
And they taste pretty good. They’re actually called Konjac.
Dr. Casey Means:
I’m sorry.
Dr. Mark Hyman:
It sounds like cognac and it’s not the cognac you drink. I was corrected by David Bouley, who was a friend of mine, who’s a chef. I was like, “Cognac?” He was like, No, no, no, it’s Konjac.”
Dr. Casey Means:
I’m so happy to know this because I eat them constantly. I have a recurring subscription to new pasta, which is the brand that makes these [inaudible 00:52:35], the only ingredient I think is Konjac. The last point I’ll touch on is the sequencing that you talked about, which is how to order your foods, in what order to eat them, to get the best glucose response. This has actually been studied in a lot of peer reviewed data as well. If you eat protein and fat before your carbs, people tend to have significantly lower glucose response to those subsequent carbs.
Dr. Casey Means:
It’s the opposite of what we do in the restaurant where we get the tortilla chip and the bread roll before our salad and our main course, we should do it exactly the opposite. We should be eating the roughage of the salad, put some good fiber in our bellies, if you’re looking at a plate that has chicken breast, a bunch of greens and asparagus and mashed potatoes, the way to do it is eat your salad before the entree, then eat the chicken, and eat the vegetables, wait two or three, four minutes, and then eat the mashed potatoes. That will likely have a better response, than if you ate the potatoes first and then everything else. I think about that now, when I’m thinking about how to approach my plate or how to serve food at a dinner party, just simple shifts in ordering can make a big difference. It also can be satiating. You eat that protein and that fat, which is more satiating first, you may end up finding that you don’t want as many of the rolls or the tortilla chips or the mashed potatoes after eating those things first.
Dr. Mark Hyman:
Amazing. I think what you’re saying is so important and it speaks to something people really don’t talk about enough, which is this idea of glycemic load. The glycemic index, you’re talking about does a particular food spike your sugar. If you eat that food in isolation, this is what you’ll see. But when you look at how we actually eat, we eat food in a food matrix. We eat protein, fat fiber. In fact, there are very few foods that are just pure, whatever. Protein like meat is pretty much protein and just all those pure fat and sugar is pure sugar, but often when we eat like nuts or seeds or even vegetables, vegetables have fat, they have carbohydrate, they have protein.
Dr. Mark Hyman:
It’s interesting to look at how do you design a way of eating that is actually creating a meal that can include foods you think are maybe forbidden, but actually you can add them in small amounts in ways that their effect is blunted because they’re in this food matrix of protein, fat, and fiber. And protein, fat, and fiber are your friends for regulating your blood sugar. That’s the bottom line here.
Dr. Casey Means:
Absolutely. One of the things that I love to do is, while I’m cooking, I’ll have some of these foods that you just mentioned out on the counter for people to graze on. Things that I know don’t spike glucose, but which have those fat protein, and fiber. Some of my favorite things is having an assortment of nuts. We see that pili nuts and pistachios and walnuts and macadamia nuts are some of the best ones that we see. Then I’ll have some olives, which very little glucose spike, lots of fat, delicious, and some flax crackers or some seed crackers, which have so fiber and maybe have some like a sardine dip or something, which has some fat, some protein, some omega threes.
Dr. Casey Means:
A little bit of a really healthy charcuterie that is going to make people, when we get to the meal, not necessarily want to dive in to whatever carb is on the plate. So really simple, delicious stuff. Another one I love to add is coconut chips, the little dried coconut, they have virtually no glucose response and have a good amount of fat in them. Those are certainly some pre meal stuff you could try or even things you can pack in your bag to have snacks throughout the day that have a low glucose response.
Dr. Mark Hyman:
That’s great. There’s a lot of tips. I created a video once called How To Never be in a Food Emergency, and it’s a goofy video, you can find on my website, but essentially I put all the snack foods that I choose to travel with, so I don’t get in a food emergency and everything from olives, you can find packages or nuts or seeds or canned fish salmon, grass-fed beef jerkies for example, and I have all this stuff. It’s all stuff that is the opposite of people’s typical snack foods. Snack foods aren’t necessarily bad. I don’t really snack. I don’t think we should be snacking. I don’t think we should be eating after dinner. I think snack culture is just ridiculous and it’s actually a driving force because how do we produce an extra 5 to 700 calories a day per person in America? What are we going to do? The food manufacturers want to sell that, the farmers want to sell that, so we’re pumping in all this extra food and the marketplace, most of the farm roast snack foods.
Dr. Mark Hyman:
It’s a disaster, but if you’re going to be on the road, you might need to eat. And I can tell you, I carry a day or two of food in my bag all the time, so I never get in a food emergency. I’m never in an airport or somewhere where I’m like starving to death and I have to make a bad choice, because I’m just like everybody else, if I’m hungry, I’m moving like I’m going to die because I haven’t eaten something, which is what your body basically does. It’s like limbic response, the fight or flight mechanism is your reptile brain. You’re not going to make a rational choice. I make sure I keep all that stuff with me all the time and it’s great to learn from you, what are the things that are the most effective, so that’s really great. I want to ask a couple more questions before we close, unless you have a comment to make about that.
Dr. Casey Means:
Oh, I was just going to say one of the beautiful things about keeping your blood sugar more stable over time and I’m sure I imagine you’ve noticed this in your own life, I certainly have is that, when you keep that blood sugar down and you get on top of your insulin levels, you end up being more metabolically flexible and actually that can really diminish that craving and hunger that we feel all throughout the day to have those snacks. It’s the spikes and the crashes that lead to this dependence on glucose where our body is more biologically equipped to process glucose than fat. So by actually keeping glucose more stable, keeping our insulin levels under better control, we tap into fat burning much more effectively, and we all have several weeks worth of fat, even a lean person on their body that can help us stay satiated and not so viscerally hungry in between meals and not so dependent on glucose.
Dr. Casey Means:
That’s one of the other things that I really love about this technology is that, it trains people to manage hunger and manage their cravings and that is really what one of the side benefits of metabolic flexibility is, is not having that desperate feeling of like I have to snack and I’ve definitely had times in my life when I know I’ve been less metabolically flexible because I’m always looking out for, where’s the Hershey kiss, where’s the snack, what if I don’t have food with me? That’s not really a great place to be in and so it’s very liberating to be able to go longer between meals.
Dr. Casey Means:
It was at a talk by Dr. Terry Walls at a conference just a few weeks ago and she takes it to the extreme, which is that she’s so metabolically flexible that when she travels, because obviously airports are just a disaster land for getting healthy food, unless you bring your own, she just doesn’t eat on travel days. Those are her extended fasting days and she’s trained her body to be so metabolically flexible over time that, she can tap into her fat stores during those travel and not have that panic. That’s definitely one of the things that motivates me is I keep my glucose more stable, is I know I’m becoming more metabolically flexible and therefore I’m becoming a little bit more free from the dependency on always having a glucose hit.
Dr. Mark Hyman:
That’s amazing. I agree. I find that I’m never in a state of emergency with food. I know what to eat when, and I have my way of balancing my blood sugar and I never get these crazy swings. A few days ago, I really missed the boat or was with friends. We have some… My schedule gets disrupted. I will get hungry or hang like everybody else, but I really learned how to actually regulate this. It’s so great because you’re not like stuck on this vicious cycle of looping on high and low sugars and insulin and ending up craving foods you shouldn’t crave. It’s really quite amazing, how if you just learn a little bit about your biology, you can fix this problem.
Dr. Mark Hyman:
Another thing I wanted talk about was, what are you finding instead of this whole conversation about what’s normal blood sugar, because the way we learned in medical school is if your blood sugar is a hundred or less, you’re okay. Actually, when I was in medical school, it was like 110 or 115. Now they’ve lowered it to 100, but we’re actually learning that maybe that’s even 100 is not that great. Tell us about what we’re learning about the spectrum of blood sugar, fasting, and even after eating food, what’s that tell us about what we should be having as our blood sugar, as opposed to what we think of as normal?
Dr. Casey Means:
Well, I have to admit a lot of what I’ve learned about this comes from you. Reading the Blood Sugar Solution, I think when I was in medical school, one of my favorite books of all time, everyone should read it. But it’s a wake up call because that book is based on the research and it was not what I was learning at Stanford Medical School. That if a patient walks into the office, and their glucose is 99, that bill of health, it’s under a hundred. You’re totally fine. You don’t need to think about this. That is false. There was a paper in the Lancet from I think two years ago that showed that fasting glucose is really a very lagging indicator of metabolic dysfunction and therefore probably not the best screening tool for us to use, to identify people who are on their way to big problems and this conversation-
Dr. Mark Hyman:
What does lagging indicator mean?
Dr. Casey Means:
Meaning that it’s not going to change until the train is really off the rails.
Dr. Mark Hyman:
The time your blood sugar goes up, it’s already way too late. It could be decades of metabolic poor health before your fasting blood sugar ever goes up.
Dr. Casey Means:
And this paper was conservative, I would say, based on the methods and showed that it was about 13 years before your fasting blood glucose start showing problems that you probably had underlying insulin resistance. The body is so amazing. We put all these stresses on it, like repeated glucose spikes. Each one of those glucose spikes is telling your pancreas, it’s stressing your pancreas and telling it to create that insulin surge that takes the glucose out of the bloodstream. And as that happens repeatedly over and over again, and as your liver insulin resistance develops because you’re eating so much fructose, these things are working together to basically make you less sensitive to insulin, to create insulin resistance, which is the body’s protective way of saying, “Whoa, too much glucose coming around. We can’t get this all into the cell. We can’t process it fast enough block.” But the body is smart and adaptive, and the pancreas says, “Well, we got to get that blood sugar out of the bloodstream. I’m just going to produce more insulin to keep driving that glucose into the cells.”
Dr. Casey Means:
You’re having this rising insulin, keeping that fasting glucose at a seemingly normal level, while you march down this trajectory of worsen insulin resistance. Of course we do not check fasting insulin in conventional medical practice. The ADA guidelines do not recommend checking it in virtually any patients, even if you have diabetes. And so we miss this window where the body’s working so hard to overcompensate while our fasting glucose remains low, and only when that process really starts breaking down, do we start to see that fasting glucose creeping up where those compensatory mechanisms have essentially gone off course.
Dr. Casey Means:
We really want to keep our fasting glucose in that lower normal range, more from 70 to 85. There’s large studies, New England Journal of Medicine has shown that people in the lowest quartile or quintile, I forget the exact data, but in the lowest range of normal blood sugar, so more in that like seventies have a much lower risk of future diabetes development than someone who’s in the high normal range and yet for many of these people, their doctor is telling all of those people in that category that they’re normal. The cool thing about continuous glucose monitoring is that as you become more insulin resistance, you tend to have a more unstable post meal level of glucose, like you spike higher to the same food.
Dr. Casey Means:
And so seeing, where you are in terms of your responses to foods can be a little bit of an early indicator of whether you’re moving down the spectrum of insulin resistance and Michael Schneider at Stanford has done amazing work showing that we get more 24-hour continuous glucose variability as we march down that spectrum of insulin resistance, even in the face of a normal fasting glucose. The second thing of course, and I’m just obviously preaching of the choir here is, ask your doctor to order a fasting insulin test. You want to make sure that fasting insulin is in a low and healthy range, which is assigned to you that your body is not having to do all this extra work and overcompensation in the face of silent insulin resistance that’s developing.
Dr. Mark Hyman:
I think it is so important. I remember a patient who was… I think I might have mentioned on this podcast before because she was so striking to me. She was classic shape of apple, which is big belly, skinny arms and legs, classic pre diabetic and some resistant, I thought I’m going to look at her blood sugar, she’s going to be diabetic. And she had perfectly normal blood sugar. We even did a glucose tolerance test and her blood sugar never went over 110 and it was 80 fasting, maybe 100, 105 after sugar load, like drinking two Coca-Colas and she was perfect. We also checked her insulin, which most doctors never do. And her fasting insulin was 50 and it should be less than five, ideally two or less.
Dr. Mark Hyman:
Anything over 10 is like, yikes and she was 50. And then her post glucose challenge insulin was like 200, 300. It was just off the chart. And I barely seen these spikes that high. And honestly, I think we probably would see it in the culture much more because my patients already come in, they’re pretty health conscious. They’re health focused. They’re not eating fast food. They’re not drinking tons of soda. I see a lot of problems. But when I’ve had these virginal patients who are just eating a typical American diet, it’s shocking to see the Levels and you often will miss things. If you check the hemoglobin A1C, if you check fasting blood sugar, which is what typically doctors do, you’re going to miss a lot of cases of people who are really in the metabolic health crisis. I think what your point is really, really important.
Dr. Casey Means:
Well, and that example, we’ve seen several times in our members so far. We actually just recently launched a new offering for our members, which is a metabolic health lab panel that tests insulin, because so many people were telling us, “My doctor wants to order this for me.” We have a way now where we send a phlebotomist to the patient’s house and they order a cholesterol, they get a cholesterol panel, a fasting glucose, a fasting, insulin, inflammation markers, et cetera, so that you can start to see that type of thing. We had an amazing member. I will mention her by name because we actually recorded a podcast with for the Levels podcast, a whole new level, her name, Betsy McLoughlin.
Dr. Casey Means:
She’s actually an incredible business woman. She was a CEO of Hot Topic, which is a huge clothing company. She’s on the board of Good American and Bark and all these companies, she’s a huge powerhouse, but she struggled with weight for 40 years. She had some great functional medicine doctors and they ordered fasting insulin and her fasting insulin was like 35 fasting. They didn’t do the two hour insulin tests like you were talking about, but it was way too high. We want it somewhere between like two and six or so our fasting insulin. She couldn’t get the weight off. She put Levels, she put a CGM on, she basically cut out these foods that spiked her above 120, and in about a year she lost 81 pounds and her insulin dropped from over 30 to 5.
Dr. Casey Means:
She became profoundly more insulin sensitive, her liver numbers all improved, her fasting glucose levels improved. Over time she was actually able to reintroduce a lot of foods that originally spiked her because she had regained insulin sensitivity and she now tolerate those foods. It was a really inspiring example of how just having that personal data about what works for you can be the game changer in a lifelong struggle and how avoiding the foods that are creating the liver fat, clear the fat out of the liver by avoiding the fructose, minimize the glucose spikes that are generating those repeated insulin surges, and you’ll start to see your body perk up again to that insulin signal because it’s requiring less of it to function normally.
Dr. Mark Hyman:
That’s so amazing, so you’re saying we should never have our sugar over 120 after we eat? We check our Levels monitor, we should never go for 120, is that right or what’s your cutoff? 110?
Dr. Casey Means:
This is not yet agreed upon by the medical or scientific bodies that be again, because we have not done longitudinal studies that show that certain post Neal levels ultimately lead to disease. We are actually doing a lot of that research right now. We’re working closely with Sarah Gottfried at Thomas Jeff university, Gerald Shelman at Yale, several people to actually look at what should our glucose be after meals, but from everything I’ve seen in the literature, it really shouldn’t go above 110 to 120. I’d be curious to hear your threshold.
Dr. Mark Hyman:
I think we don’t know yet. It’s really up in the air and I agree. I don’t think probably should go over 110. I agree. I think a lot of people do, but it’s interesting. This has been such an incredible conversation, Casey, your work is so important. I really love having you on the podcast and actually you offering to people who are listening to the audience, a BEIC program to get over the wait list, which is cool. There’s 120,000 people on the wait list, so if you want to skip the line, go in, try early, go to levels.links/hymans. It’s going to be in the show notes levels.link/hyman, and you can get into the beta test.
Dr. Mark Hyman:
It’s super fun. I’ve done it. It’s really interesting learning about your biology. Casey your work is so important. We’re probably going to have you back on when you learn more and more about this and everybody should check it out. If you love this podcast, please share with your friends and family on social media, leave a comment. What have you learned about your managing your own blood sugar? Maybe you’ll try these CGMs, subscribe wherever you hear your podcast and we’ll see you next week on the doctor’s Farmacy.
Closing:
Hi everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medicine practitioner, you can visit ifm.org and search their, find a practitioner database. It’s important that you have someone in your corner who’s trained, who’s a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.
