Dhru Purohit Show - The Top 3 Lab Tests to Determine If Your Metabolic Health is Optimal with Dr. Casey Means

Episode Date: June 27, 2022

This episode is brought to you by Pendulum and InsideTracker. The word “metabolism” gets tossed around quite a bit, usually in the context of weight loss.  It’s important to realize that our metabolic health is so much more than that—it’s the way our 37 trillion cells create energy so that we can do all the things we want to do in life, big and small.  With that in mind, it’s pretty alarming to note that nine of the 10 leading causes of death in the US are directly caused or worsened by poor blood sugar control and declines in other metabolic markers. Chronic diseases like diabetes, heart disease, stroke, Alzheimer’s, cancer, and more are all linked in one way or another to various metabolic dysfunctions.  On today’s mini-episode, Dhru sits down with Dr. Casey Means to talk about the best ways to dial in our metabolic health and take back control of how we feel and how we age.  Dr. Casey Means is a Stanford-trained physician, Chief Medical Officer and Cofounder of the metabolic health company Levels, an associate editor of the International Journal of Disease Reversal and Prevention, and a lecturer at Stanford University.  In this episode we dive into:   -Optimal triglyceride levels and understanding the triglyceride/HDL ratio -Optimal fasting insulin levels -Optimal HA1C levels Listen to the full episode here. For more on Dr. Casey Means, follow her on Instagram @drcaseyskitchen and @levels, Twitter @drcaseyskitchen and @levels, and through her website, levelshealth.com. This episode is brought to you by Pendulum and InsideTracker. Pendulum is the first company to figure out how to harness the amazing benefits of Akkermansia in a probiotic capsule. To receive 20% off your first purchase of Pendulum’s Akkermansia probiotic supplement, go to Pendulumlife.com and use code DHRU20. InsideTracker provides detailed nutrition and lifestyle guidance based on your individual needs. Right now, they’re offering my podcast community 20% off. Just go to insidetracker.com/DHRU to get your discount and try it out for yourself. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hi everyone, Drew Prode here on today's podcast episode. We have none other than Dr. Casey means, one of my friends and one of the top experts that we've had on the podcast when it comes to all things metabolic health. And we're talking with Casey about a few important subjects. So if you've ever wondered what her top three lab tests are to determine if you're metabolically healthy and if your health results show up as optimal, if you've ever wondered, what the triglyceride to LDL ratio is and why it's such an important predictor of cardiovascular disease. If you've ever wondered what fasting insulin is and what does an optimal fasting insulin number look like. And if you've ever wondered how to improve your A1C or hemoglobin A1C, which is also not

just linked to diabetes, but linked to Alzheimer's and so many other chronic conditions, we're going to go into all those topics in today's mini-episodes. with Dr. Casey Means. If you want to learn more about Casey and her work at levels, check her link out in the show notes. And let's jump into today's topic. Tell us why big picture, we should be caring about the topic of metabolic health

and specifically getting the right blood test to determine whether or not our metabolic health is headed in the right range. And if you wouldn't mind, two-parter, it's a lot. Maybe three, three of the top lab tests. that people should be getting today if they truly care about this area of their health. Thank you so much for having me back, Drew. I'm thrilled to be here, and I will jump right in on this. So the reason we all need to care about what's going on with our metabolic lab test is because

88% of American adults have at least one biomarker of metabolic dysfunction, and we don't really, the average person doesn't really know where they stand on the spectrum of metabolic health. So it's really important to get the right labs and then understand how to interpret them and know what is optimal. So if I'm looking at all the different metabolic health tests out there, the ones that I think are really critical for everyone to know about for themselves, I'd say first would actually be a ratio of tests, triglyceride to HDL ratio. So these are two pieces of our standard cholesterol panel. And when we put them into a ratio, triglyceride to HDL ratio, it's a great surrogate marker of whether we are, insulin resistant. So that's a key one that we need to focus on that I don't think the average person is really aware of right now. And by the way, we'll talk about why, but a lot of doctors don't

talk about this ratio. They're not educated on this ratio. So we'll get into more about why that's the case and how to increase that education, but that's a great first one. The second one is fasting insulin. Another test that is not often ordered by in conventional practice, but it's one that you can ask for and it's critical because fasting insulin is. insulin rises in our bodies before our fasting glucose actually changes or goes up. And it can actually change almost a decade or even more prior to our fasting glucose budging. So it's really helpful to see a fasting insulin, to see what's going on with metabolic dysfunction earlier than our standard lab tests like glucose. And the third one I would say is hemoglobin A1C. This is a test that a lot of doctors

will order for their patients. And this is basically a three-month average of what's going on with your glucose. There's some limitations to it because it doesn't show you the variability in your glucose day to day. It's an average overtime, but it can give you a broad snapshot of where you stand in terms of your average glucose levels. We've been teasing towards these lab tests. You mentioned three of them in the beginning, and we have a bunch more that are here that we're going to walk through, but let's talk about the first one that you mentioned and why that ratio is so key. Everybody talks about HDL and LDL, but we're not hearing as much about the ratio that's out there. So give us a little background on that. I want to talk to you about a groundbreaking flagship bacterial strain

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With real-time exercise, resting heart rate, and sleep data synced within your Inside Tracker plan, you can truly wear your health on your sleeve. Right now, InsideTracker is offering my podcast community 20% off. Just go to insidetracker.com slash Drew. That's D-H-R-U to get your discount code and to try it for yourself. That's InsideTracker.com slash D-H-R-U for 20% off. I really love looking at trigly trigly straight to H-D-L ratio because what it does is it tells us two really important things. The first thing it does is it's a surrogate marker for insulin sensitivity. The average doctor, as we talked about, is not ordering a fasting insulin on their patients, which is definitely one of the best ways to look at your insulin sensitivity. But triglystory

to HDL ratio has been shown to really be a signal of what's going on with our insulin sensitivity. Almost like a little smoke detector that's there that, hey, we got to pay attention a little bit more. Something might be up. That's exactly right. And the beautiful thing is, these are two tests that are in our standard cholesterol panel. So almost every doctor is ordering that on their adult patients. So you probably already have this information. And so even if your doctor is not willing to order a fasting insulin test for you, you still can get a clue of what's going on with your insulin sensitivity.

So that's one of the first reasons I love this. The second reason I love this test is because it also gives us a signal of what's happening with our small density LDL. And so some people who listen to your podcast might have heard about this all already, but basically LDL, which we typically think of as our bad cholesterol, actually has several different components that make up that total number. One of them is the high density LDL form and one is the small density LDL form. And it's actually the small density LDL fraction of that total LDL number that is dangerous for heart disease. Yeah, I've heard it compared to like,

you know, those are like golf balls and then you have beach balls. The beach balls are big and fluffy. They're not going to damage anything. But the golf balls. are going to break a window and cause all sorts of challenges inside of the bloodstream. That's exactly right. The small density ones, you can think of like the little BBs that like can lodge themselves into the vessel wall and cause that inflammation and that plaque and that buildup. The beach ball versions, the high density LDL are going to kind of bounce around and float around in the bloodstream and aren't as much of a problem. And this triglyceride to LHDLR ratio is a surrogate marker for what's going on with small density LDL. And because our standard cholesterol panel

doesn't break it down into that fraction of high density or small density LDL, having a surrogate marker is really useful. The way that you can get your exact numbers for those fractions of LDL is to get what's called advanced lipid testing or NMR lipid testing. But again, that's not something that's typically going to be ordered in standard conventional medical practice. Right, especially if you're under a certain age, they may actually have you pay out of pocket to get it because it's not seen as something that should be run on everybody. Right. So using this super simple fraction that you can just calculate on your iPhone can tell you about insulin sensitivity, can tell you about where you stand in terms of small density LDL, which is the more dangerous type. So that's why I

love it. But your doctor is very unlikely going to mention this to you, even though there's actually a good amount of research suggesting that it's important for our, for understanding our metabolic health and maybe even one of the leading predictors along with just high triglycerides in general of a cardiac event coming down the road. That's right. Yeah. I believe that there's actually with people who have an elevated triglyceride LCHR ratio, H.DLHDLR ratio 16fold higher risk of heart disease. This is just a really important biomarker that we're not talking about. And again, part of that reason is probably because triglycerides have been largely overlooked because we haven't had a good medication for them. So triglycerides are, of course, the numerator of this test.

And what triglycerides really, to me, give a signal of in patients is kind of dietary quality. Are people eating a lot of refined foods, refined sugars, refined grains, liquid fructose, that is going to go into the body, overwhelm the system, and be converted into triglycerides. So that's really, if someone has a triglyceride level of over about 100, I'm thinking we probably need to clean up the dietary quality and specifically focus on getting rid of the refined grains, the refined sugars, and the fructose. And one quick question for you. You may know this or you may not.

But, you know, a lot of people are familiar. You know, we've talked about it a bunch, the level CGM, you know, the continuous glucose monitor and why I'm such a big fan of it. And we know that if you track or use a CGM, we can see that. that you know, your blood glucose is kind of, there'll be, there can be a big delta throughout the day that's there. When it comes to triglycerides, I was meeting a doctor recently because my, I got lab results done in September and he's like, I saw you were just in Italy and I'm sure you probably like ate a lot of different stuff and things like that, know that your triglycerides

might be a little bit higher because that trip was just like three weeks ago. Do we have any sense of how long it takes to adjust or how often that number is changing. Like if somebody wanted to swing 100 points in the right direction or the wrong direction, do we know roughly about how long that might be? Yeah, that's just a great question. It's a fairly dynamic molecule. I don't know on a day-to-day basis how big the swing can be, but I do know from my own practice that people who have fully cut out refined grains,

to like flour, you know, wheat flour, et cetera, and refined sugars, which, of course, there's like 50 names to refine sugars. And so it can be hidden in everything. But fully cutting those out dropped their triglycerides 100 points in one month. And so that is just huge in terms of, and I think that was basically dropping it from in half, essentially, from about 200 to 100. So these things can move quickly. And, of course, in the opposite direction as well, if you're in Italy and eating a bunch of

pasta, it can go up. But what I love about tests like this that can shift quite quickly is it's so motivating because you make a change and you can see the results very quickly. And that's incredible feedback. It's super inspiring for anybody who's listening or watching because there's a lot of times we feel just stuck and it's scary. You know, it's scary because you're thinking, well, maybe I had a parent that developed Alzheimer's or I had a grandfather that had a heart disease and or had a heart attack or a stroke or whatever. But there's so much. And I hope that everybody really gets that the moral of today's podcast is really you have so much more control over your health than you ever imagine. And obviously, you know, hats off to companies like levels

that are making a lot easier to take that control that's there. But there's a lot that you can do. And the best things that actually move the needle in the right direction are all the things that we're already doing sleep, lifestyle, exercise, and of course, dietary interventions. Definitely, definitely. So to kind of get down to brass tax for people who are like, what numbers should I shoot for? You know, I think really for triglycerides, which again is the numerator of the triglyceride to HDR ratio, triglycerides, if you're over 100, you should really start to be thinking about how can I cut out some of these refined sugars, grains, fructose in the diet. the standard lab panel will say if you're under 150, you're fine.

But actually, it looks like lower than that is better. So definitely shoot for lower than 100, ideally less than 70 for your triglycerides. In terms of the triglyceride to HDL ratio, for that, there is no standard guideline on what this should be. Because, again, we haven't really focused on this ratio, even though there's good research suggests it's very predictive of our metabolic health status and heart disease risk. So this is really more expert consensus, but it looks like it actually is somewhat, it may be somewhat race specific. So less than, shooting for less than 2.5 for this ratio and people of Caucasian ethnicity appears to be good and less than 1.5 for people of African American descent. So basically just, yeah, take those two numbers, throw into your calculator on your phone and see where you land.

less than 2.5 for people who are Caucasian and less than 1.5 for African-American descent, I would actually say you can go even tighter no matter, you know, what ethnic background you're coming from. And really shooting for one, a ratio of one is probably optimal. That basically means that your triglyceride level is equal to your HDL ratio. So this bad form of fat in the bloodstreamed tligosteride is low. And your HDL, which is the good cholesterol, quote unquote good cholesterol that recycles cholesterol that brings it back to liver for clearance is really high. So for all practical purposes, that might look like a triglyceride of 80 and an HDL of 80. That ratio would be one. And that's basically saying you're looking good metabolically.

Your insulin sensitivity is probably really good. If we tested your fasting insulin, it would probably be quite low. And if we tested your small density LDL, it would also probably be quite low. that's kind of what you can do with that, with that ratio to give you a snapshot of what's going on with those different features. Well, I'm excited because you have a lot of members and people that are using your app now. I'm excited for people to do this test. We'll chat a little bit about how the audience can actually do it if they want to. And then to gather that data and to start publishing some information on it. You know, what is optimal? We have a lot of people using levels that are trying to focus on optimal health. And hopefully that can give more guidance out there. Because like you said,

it's not, there's not really the strong guidance that's there for people who are looking for that right now from the standard, you know, medical institutions that are there. Let's pivot into the next test that you had mentioned, which is fasting insulin. What are we thinking about when it comes to ideal numbers for that? And again, why is it so important? Yeah. So the lab slip, depending on the lab, it's going to say different things. But a lot of them are going to say that less than 25 for fasting insulin is normal. This is totally wrong. Much lower is better.

If you survey the leading metabolic health experts in the country who have really drilled into this research, almost all of them are going to say that less than 10 is where you want to be. And several of them have an even tighter range, like 2 to 6 or 2 to 8. So if you're fasting insulin is up in that 20, range for fasting, that probably means that there's already a significant amount of insulin resistance going on. So what this test is telling us is essentially how hard the body is working and how much insulin it's having to produce to keep insulin low. Again, insulin is that hormone

that helps you take glucose out of the bloodstream into the cells. And when there's insulin resistance, which is that physiologic process that's leading us towards metabolic dysfunction, diabetes and all the associated conditions, the body is essentially resistant to that insulin is having to pump out a lot more to get that glucose out of the bloodstream into the cells. So just knowing your fasting glucose alone without knowing how hard the body's working with production of insulin to get it at that level is not that useful. Because for instance, you and I could both have a fasting glucose level of 80, which by all accounts is quite good and healthy and normal.

But if my body is more insulin resistant and therefore is having to produce a fasting insulin of 25 or 30 to keep the glucose at 80 and your body is really insulin sensitive and only and you have a fasting insulin of two to keep your blood sugar at 80, we are completely different metabolically. I'm on the road towards metabolic disease, type 2 diabetes, etc. and you're really doing great. Your pancreas is not having to work as hard to keep that glucose in that level. So that's why having insulin in conjunction with glucose is just so, so, so much more information.

And because the body is incredible and can compensate for so long by producing excess insulin to keep glucose in a more stable range before it just, that whole system of compensation breaks and fasting glucose starts rising, we're missing that window of that overconsing. compensation period, unfortunately, by not testing fasting insulin in standard practice. I had a buddy of mine, close friend of mine recently who, you know, had set some intentions for the new year and then got on a CGM with levels. And, you know, he was on his best behavior and trying to really like lean into like optimizing his blood sugar. And he was having a hard time with, you know, weight loss. And I was saying, hey, listen, like, don't be discouraged because he felt like he was doing everything right. We just need some more data that's over here. your fasting insulin, which he hadn't had.

And, you know, he didn't have any of that in his recent blood work. And he's pretty in the know, generally speaking. So we need to look at a few more markers that are out there because there could be reasons why you can't get rid of that stubborn belly fat or why you feel like, okay, now you're in your late 30s and it's so much harder for you to maybe get rid of that excess weight compared to like when you're in your late 20s. So I think that's important for people to understand that as more people are paying attention to glucose, which is great and fantastic, there's other markers that we want to be looking at,

too, that help us round out the story. Yeah, definitely. And I think one of the interesting things to remember is this is, the liver is really the center of where a lot of this is happening metabolically. And what's interesting is that, so the pancreas delivers insulin directly to the liver. And the liver, unfortunately, because of our huge amount of fructose that we're eating in our diets, which is, you know, fructose, now high fructose corn syrup is just making its way into so many of the packaged foods we're eating. It's, of course, there's a large fructose load in juice because it's essentially concentrated fruit fructose. And of course, it's filling sodas because we're eating so much of this fructose and it's overwhelming

the liver. The liver is essentially converting this excess sugar into fat. So we're getting fatty liver disease, which we talked about earlier, 45% of American adults have now. And that fatty liver disease makes the liver insulin resistant. So then the pancreas is sending insulin to the liver. And it's seeing all this insulin resistance that's caused by the fat building up because of this excess refined fructose, carbs, and sugar. And it's having to do so much more. So just kind of key point here, we got to clear the liver of the fat so that it becomes less insulin resistant so that the pancreas doesn't have to produce as much insulin to basically, you know, get the glucose out of the bloodstream.

And the way to do that is get rid of all the liquid fructose, the sodas, the juice, the high fridogic corn syrup and the packaged foods, and then minimize or eliminate the refined sugars and refined carbohydrates, all of which are going to contribute to that fatty liver disease, which is the root of our insulin resistance, which of course is the root of our pancreas having to produce more insulin, which ties back to what you were talking about with belly fat, because insulin, aside from being the hormone that takes glucose out of the bloodstream, is also a hormone that blocks us from burning fat. And so the more you've got it circulating around the body, the more it's basically telling your body, hold on to that fat, don't burn it. We've got tons of glucose

around for energy. We don't need to tap into our fat stores. So it's definitely a helpful test to get if you are dealing with that stubborn fat. Another really interesting thing is that if your fasting insulin is quite high, meaning that you are quite insulin resistant, you may not tolerate carbohydrates as well, even healthy carbohydrates like vegetables or beans or lentils or something like that because your body is just less able to process the glucose that's in those foods. And I've seen this with patients and with members in the levels community where they've started out with a high insulin level somewhere around 30, 35, and really healthy foods like

tomatoes or even too many greens like broccoli or chickpeas or lentils, spiking them through the roof because they were quite insulin resistant. But after focusing on foods that keep their glucose down, eliminating their fine sugars, fructose grains, over time, that insulin started coming down. And I'm thinking about a specific levels member whose insulin came down from 30 to 5 after learning how to reduce blood sugar spikes with the continuous glucose monitor. And when their glucose, when their insulin was down at 5, they could start to incorporate much more of those healthy carbohydrates without the huge glucose spikes because their body was so much more insulin sensitive.

So using these lab tests and then these tools to understand our diet together can sometimes really help us progress along this spectrum and actually be able to incorporate these healthy cohab carbohydrates in a way that's not causing all this sort of erratic glucose. So just so that people are aware, just because something spiking you now does not necessarily mean it will in the future. But a lot of that is dependent on our insulin sensitivity. Just another reason why when people want to debate about what's the ideal diet for people, it's also kind of like what's the ideal diet for you right now and then a little while later that could change. And so that's just such an important part of the story.

and getting out of the polarization, it's like away from polarization and more towards personalization, right? Because in the personalization, the truth will start to reveal itself, but you need the data to be able to do that. I've shared multiple times in this podcast that I went towards more what would be seen as a ketogenic diet. And this was about three years ago, and I did it for about two years. And generally speaking, I've had other members of my family that have done this, my brother-in-law, the cardiologist down in San Diego, he did it and his lipids and plant-rich. You know, we're talking about clean keto just for everybody who's like listening. We're not talking about eating a bunch of bacon and that's it.

We're talking about still a ton of plant food. That's the base of the diet, all the rich polyphenol sources and phytonutrients and other things, all the low starch, healthy vegetables and even still some fruit that are part of that too. and then some targeted plant protein and other things, but a big cut on the refined sugars and carbs and other things like that. His lipids all headed in the right direction, including his NMR testing. And mine went completely in the other direction.

And it's just another reminder. And I've been digging into this and making some changes and other stuff. And I personally cannot handle larger amounts of saturated. fat. So even though I love MCT oil, would be adding it to my coffee every single morning and using coconut oil on a regular basis as some of the fats that I was using in more of my keto approach, I was switched more towards avocado oil and olive oil. And just doing that, my lipids are already heading in the right direction. All these tests that we're talking about here, you know, I just went actually this morning to get them, you know, redone. And my lipoprotein A,

which was also, like, like, super high. And, and my lipoprotein A, which was also like super high. And it started coming down significantly. So I felt really good. I started to have a little bit of GI disruption. And that's when one of the doctors of my network said, you know, you should really get these, you should go back for your physical, get all these tests done and see, are you having some challenges with this way of eating? It may not work for you right now because of a combination reason. So I felt okay, minus some small things. But if I didn't intervene now, who knows what of what have happened like 20 years from now. So this is why test, don't guess, and figure out what actually is the right diet for you. Let's jump into A1C. Yeah, so A1C is this three-month average

signal of what's going on with your glucose. So what it's measuring, so it's hemoglobin A1C. So we have hemoglobin as part of our red blood cells circulating in our bloodstream. And those hemoglobin molecules basically get sugar stuck to them because there's also sugar circulating in the bloodstream. And depending on what the concentration of sugar is in your bloodstream, more sugar is going to stick to the hemoglobin. So this is actually measuring how much glucose is stuck to the red blood cells. Of course, if there's a higher amount of glucose, your percentage of hemoglobin that have sugar stuck to them is going to be higher. So that's glycated hemoglobin. And that's what hemoglobin A1C is measuring. That's why it's measured as a percentage because it's percentage of glymoglobin that's

glycated hemoglobin. So we want this to, if you just go to the doctor and you're an adult, they're going to order a hemoglobin I would see. And basically, if it's less than 5.7, they're going to say you're totally normal. If it's between 5.7 and 6.4, that's considered pre-diabetes. And if it's 6.5 or above, that's considered type 2 diabetes. Probably more likely less than 5.5% or even less than 5% is where you want to shoot for in terms of average glucose. So not just less than 5.7, but actually a tighter range,

depending on who you talk to or what research you look at, less than 5.5 or less than 5. But essentially, lower is better, as it is for almost all these tests, except for HDL, where higher is better. But that's email going to and see. And I think this is a really important test for everyone to have because it is just a big general snapshot of kind of where you are in terms of glucose. It is not a, it has a lot of limitations for sure. One limitation of it is that it doesn't show you glycemic variability. It's not showing you what's going on with the ups and down swings in your glucose day to day, which of course are very important.

We know that glycemic variability, whether you're more flat and stable or more spiky, is an independent risk factor for developing type 2 diabetes, heart disease, and other cardiometabolic problems. So we want to keep that spikiness down. And hemoglobin A1C is not telling us anything about that. But it's telling us what our average glucose levels are over time. So it's useful in that sense. And if you're below 5.5, below 5, you can have a sense that you're kind of in a good,

good category. It's also got limitations because everyone's red blood cells actually last different amounts of times. Some people's red blood cells last 90 days. Others last more like 120 days. And so based on how long your red blood cells last, that can kind of impact. this reading, ethnicity and certain genetic variants can actually impact the shape of our hemoglobin and how propensity for glycation. So there's little factors there, but more as a

general snapshot, it can give you a picture of kind of where you're at on the spectrum. What I love about this is that all these numbers together paint a story. And sure, okay, they might be variation in this and there might be ethnicity variation in that. And there might be, you know, components that play in. But if all your markers are not in the optimal range and you pay attention to your health and you really feel like you're making an investment in your health and you feel like you're eating a diet or doing a philosophy or an approach on health that you would be hoping that is making you healthier, but your labs are in the wrong category or not in the optimal range, that's a good indication to have a little bit of like, you know, taking a step back,

saying, hey, like, this is what the data says. Am I open to changing my approach a little bit? And that's where we drop down ideology and we step into just a sense of, well, what's actually going to help me feel better.