Casey Means, Levels Health, on maximizing human potential

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In this episode of The Pulse Podcast, we interview Casey Means, Chief Medical Officer and Co-Founder of Levels Health. Casey Means is a Stanford-trained physician and Chief Medical Officer and Co-Founder of Levels Health and an Associate Editor of the International Journal of Disease Reversal and Prevention. Her mission to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech-enabled tools. Furthermore, she is an award winning biomedical researcher, with past research positions at NIH, Stanford and NYU.

In August of 2019, Casey co-founded Levels, a metabolic health company that empowers individuals to radically optimize their health and wellbeing by providing real-time continuous glucose biofeedback coupled with machine learning driven insights to inform personalized diet and lifestyle choices. Levels recently raised $12M of seed funding from Andreessen Horowitz and angel investors including Marc Randolph (co-founder and first CEO of Netflix), Dick Costolo (former CEO of Twitter), Michael Arrington (founder of TechCrunch) and Matt Dellavedova (NBA player on Cleveland Cavaliers).

Podcast Recording

Start — 10:00: Casey’s background

• Casey’s inspiration for improving metabolic health: Casey’s passion for metabolic health started when she was training as a surgeon. After completing her medical school training at Stanford, Casey spent four years in Oregon training as a head and neck surgeon, and a lot of the conditions she treated were rooted in chronic inflammation. Traditionally, Casey shares that doctors frequently use steroids to treat inflammatory conditions, without addressing the triggers and root causes of inflammation. We rarely step back and ask what is causing all this inflammation in the first place? What can we do to minimize this chronic inflammation? Given that metabolic dysfunction and dysregulated blood sugar are key driver of chronic inflammation, Casey became focused clinically on working to help patients improve their metabolic health through deep diagnostic workups and comprehensive, personalized dietary and lifestyle plans.
• Building her own medical practice: Casey left her surgical career and started her own practice, and was working with patients to deeply understand their health and improve their daily choices and health behaviors to optimize metabolic and overall health. She was seeing rapid, profound results in her patients with this high touch, but could only help about 20 patients a week at most, at a high cost to patients. She wanted to find a way to scale these interventions so she could help more people with the personalized behavior changes necessary for improved health. She stepped back again, and thought about how to scale her approach with digital tools.
• Meeting her co-founders: Casey put her thoughts into a slide deck as a proposal for her business idea and passed it to her close network and family. Her brother, Calley, happened to hear through his network that a company — Levels — was being conceptualized in a similar area, and connected Casey to her eventual co-founder, Josh. Casey’s main takeaway for physician entrepreneurs was the importance of stepping back to look at your clinical practice — examine what the failure points in the system are, what is inefficient about your day to day work, what could be scaled, and what could a digital product do better than a human. After reflection, the next step is putting your thoughts down on paper and sharing it: putting your stake in the ground. That’s how you end up connecting with individuals who can support and collaborate on your vision. If you don’t write it down or share your perspective, it will be harder to create the dynamic relationships necessary for innovation.

10:00–13:00: Diving into Levels

• What is Levels? You can think of Levels as a Fitbit for glucose, helping health-seeking individuals understand and optimize their metabolic health. The Levels systems involve a wearable sensor called a continuous glucose monitor (CGM) that you wear on your arm, paired with a mobile app that helps users interpret that continuous data stream. The goal is for users to stabilize their glucose through personalized lifestyle and nutritional choices. When glucose is dysregulated, many symptoms and disease can arise. When glucose is stable and less variable in the short term, it can lead to improved mental clarity, memory, endurance, sleep, and many other aspects of health. Over the long term, keeping glucose in stable and healthy range can reduce the risk of obesity, diabetes, heart disease, dementia, infertility, erectile dysfunction, and more. . With Levels, customers can understand their glucose response to dietary choices, and have tools to optimize their choices for better glucose control.
• How technology can scale glucose data interpretation: A digital tool can bring in other data streams, like heart rate, exercise, sleep, stress data, and merge it with a glucose data stream, and create really intelligent insights for people. This type of multivariate data integration is something that a human brain just can’t do. Levels helps people merge different data streams, and then use higher level analytics to make it very interpretable. A Levels users can eat a chocolate bar and within an hour see what the effects on their glucose are. This automated interpretation also takes some of the cognitive load off the physician, who won’t have to do that high-tough data interpretation on individual meals for the patient.

Levels mobile app (Source: Techcrunch)

13:00–15:00: Science behind metabolic health tracking

• How do you wear it? The wearable is the size of two stacked quarters, and it’s stuck with an adhesive to the back of your arm. Sticking out of that sensor is a four millimeter probe that’s a hair like filament that actually goes under the skin. The device is painlessly attached with an applicator, and that filament stays just under the skin. (*Editor’s note: it really was painless even though it looked a bit intimidating!)
• How does it measure your glucose? The device is measuring glucose from the fluid that is around cells called interstitial fluid. Blood sugar is in the blood, but it seeps out of the bloodstream into this interstitial fluid. Because it is not measuring blood glucose, there can be a 15 minute delay between glucose readings you’d see in the blood, and what you’d see in the interstitial fluid. Then there’s actually a chemical reaction that is happening on the sensor, where there’s an enzyme called glucose oxidase stuck to the sensor filament that converts the glucose into a byproduct that gives off hydrogen peroxide. And then that can be measured through an electrical signal that then registers your glucose levels. And then that is transmitted to the smartphone as the data, so it’s a little laboratory right on your arm.
• What affects your glucose? Many things contribute to our glucose levels, including the food we eat, the timing of our meals, how much or how little sleep we get, how much or how little physical activity we get, stress levels, our microbiome, our micronutrient status, our genetics, what medications we are on, and more.

Editor’s note: The Levels team actually let me beta test their product 2 weeks before our recording! I got to experience first-hand how eye opening their feedback loops was in understanding what I ate, how much I slept, and how exercise affected the stability of my metrics. I highly recommend the Levels program to those who are curious about how your body directly reacts to how we treat ourselves everyday.

15:00–18:00: How is glucose impacted beyond the food we eat?

• Food: While a healthy diet that minimizes glucose spikes is necessary for long term metabolic health, it’s not actually sufficient. Without thinking holistically about health behaviors, you could be eating great but still see problems with the metabolism. You need to have these other things dialed in, below, to really have the sustained optimized cellular function that leads to metabolic health.
• Stress: When our body is stressed, it releases the hormone cortisol and other catecholamine hormones. Cortisol tells the liver, which stores some glucose, to dump glucose into the bloodstream and feed the muscles during times of stress. In recent history, our stressors are usually physiological and rarely physical, so we actually don’t need this sugar for the muscles, so stress can cause a maladaptive elevated blood sugar level which doesn’t actually serve our needs. In our current lives, we are under a lot of low grade, chronic stress from all the pain points of life — emails, honking, lack of sleep, text messages, etc. All of these things can actually register in our body as little cortisol spikes. Getting stress managed under control is absolutely critical for optimal metabolic health.
• Sleep: Sleep is very similar to stress, because when we lose a night of sleep or have poor sleep quality, our cortisol levels increase. A lack of sleep also makes us more insulin resistant ( insulin is the hormone that’s required to get glucose to be taken up into cells out of the bloodstream, so if our bodies are insulin resistant, this process is diminished and glucose stays elevated in the blood). . Sleep deprivation also impacts our satiety hormones, such as ghrelin and leptin that make us either hungry or full, so lack of sleep can cause people to reach for higher carb or higher fat foods the next day because of that hormone imbalance.
• Exercise: Muscles are a huge glucose sink in the body, taking glucose out of the bloodstream to be used for energy, and when we use our muscles, they can actually take up glucose independent of insulin. When we exercise, we can soak up extra glucose and get it out of the bloodstream.

18:00–20:00: What does it all mean for our body?

• How does glucose damage our body? When we have these high glucose spikes, it can generate inflammation, oxidative stress, and advanced glycation end products (AGEs). Oxidative stress refers to an imbalance of reactive molecules in the body that can cause damage. Glycation is a process where sugar in the blood sticks to things like proteins and fats in the body, and these can lead to dysfunction, akin to “body rusting”.
• How do we prevent this damage? Your goal should be to keep glucose and insulin as stable as possible and in a healthy low range. Insulin resistance occurs when insulin is elevated over time. Over time, insulin resistance can make the body dysfunctional in terms of how you’re able to process glucose and makes it harder to take that glucose up into the cells for energy. For people who are interested in weight loss, insulin actually blocks our ability to burn fat, so keeping insulin spikes down by limiting glucose spikes may be helpful.

21:00–25:00: The Framework for Effective Behavior Changes

• Closed looped systems:

“Behavior change is fundamentally hard because it means we have to make choices that go against things in our life that bring us pleasure and are culturally entrenched. The worst part is not knowing the exact benefit of our particular choices.”

• Body awareness:

“It’s really hard to change behavior when we’re not actually in touch with what’s going on inside of our body. Currently, we’re living in a hyper stimulating world — we’ve got our highly addictive and engaging digital world, we’ve got hyper palatable foods surrounding us that are focused on getting you to your bliss point (an actual term in food science). So it’s very hard to actually understand how we really feel inside, which is a prerequisite for behavior change.”

• Accountability:

“You can’t change what you can’t measure. When you have the data in front of you in real time, it makes it so much easier to stay on track. I think that part of the reason we’ve seen a lot of just huge traction on social media and people posting about their glucose levels is because people love sharing with other people their surprises, their wins, and their successes, and they want other people to both support them and also hold them accountable.”

Casey believes that if we can close the loop between an action and a reaction, we can set the foundation for effective behavior change. Levels is focused on how we can make tools that get you in touch with what’s going on inside your body. For example, their most interesting customer feedback has been on meal sequencing, adapting pre- and post-workout regimens and the ketogenic / low-carb diet.

33:00–34:00 The future of Levels

• Laser focused on their vision: The Levels team’s Northstar is to reverse the trend of metabolic dysfunction in this country right now. 88% of Americans have evidence of metabolic dysfunction. A study out of UNC last year showed that 88% of Americans have at least one biomarker of their metabolism not being functional. Only 12% of people are optimally metabolically healthy. Casey is excited that their team is approaching this problem from a bottom-up way, giving individuals access their own data to make choices that will improve metabolic health.
• GTM strategy: Casey shares that their scaling strategy is to expand our market from our early adopters (athletes, biohackers, longevity enthusiasts, Silicon Valley), and then bring that to a much wider and accessible market.

Ok, now how do I sign up? Currently Levels Health is still in beta and they have more than 54,000 people on their waitlist. Sign up for their waitlist here. In our podcast recording, we talk about the specifics of the one month experience and it’s like for the user. The company expects customers will be able to purchase Levels starting in early 2021.

34:00–35:00: Advice to first time healthcare entrepreneurs

• The importance of customer obsession: Casey and the founding team’s first hire, Mike Didonato, came in as Head of Customer Success. This was critical. She shares that Mike is an absolute powerhouse, and is obsessed with making the customer experience as positive as possible.
• The Levels team has released 400 versions of our app in the past seven months based on customer feedback!

“If you’re not just laser focused on your customer, and making them as happy as possible, I think you’re dead. You’re building something for the customers, you have to talk to them every single day, know how they’re feeling, and know what they’re thinking.”