Dhru Purohit Show - The Top Lab Tests to Determine Whether or Not You’re Actually Healthy with Dr. Casey Means

Episode Date: February 24, 2022

This episode is brought to you by Cozy Earth 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 ten 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.  Today on The Dhru Purohit Podcast, Dhru talks to Dr. Casey Means 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 Co-founder of 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:    -The top three lab tests to determine if your metabolic health is optimal (6:25) -The cholesterol panel and heart disease risk (22:52)  -Why triglycerides are so important to look at when it comes to metabolic health (25:53) -Optimal triglyceride levels and understanding the triglyceride/HDL ratio (32:57)  -Optimal fasting insulin levels (35:50)  -How long it takes to adjust numbers on lab tests (46:27)  -Optimal hemoglobin A1c levels (52:18) -Inflammation and C-reactive protein (1:04:36) -How exercise impacts glucose and insulin response (1:18:29) -Recommended yearly lab tests and optimal levels (1:33:00) For more on Dr. Casey Means, follow her on Instagram @drcaseyskitchen and @levels, Twitter @drcaseyskitchen and @levels, and through her website https://www.levelshealth.com. Sign up to Levels Metabolic Fitness Program (a yearly membership to Levels is required for access to the Metabolic Health Panel) at levels.link/dhru. This episode is brought to you by Cozy Earth and InsideTracker. Cozy Earth are the most comfortable, temperature-regulating, and non-toxic sheets on the market. Right now, get 40% off your Cozy Earth sheets. Just head over to cozyearth.com and use code DHRU. InsideTracker provides detailed nutrition and lifestyle guidance based on your individual needs. Right now, they’re offering my podcast community 25% 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

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. Welcome to the Drew Proet podcast. Each week, we explore the inner workings of the brain and the body with one of the brightest minds in wellness, medicine, and mindset. This week's guest is Dr. Casey means. Did you know when you go in for your routine checkup with your doctor and your blood work comes back and it shows normal and your doctor gives you a pat on the back and says, I'll see you next year, many of the things that are in the normal range are actually not optimal.

Why is that? Well, when you look out at the population, most of the population is sick. Sick is normal. Pre-diabetes is normal. Chronic inflammation is normal. Terrible lipids are normal. Now, this isn't your doctor's fault. There's been an explosion of research over the last decade.

And if your doctor went to medical school a little while to go and doesn't keep up with the latest findings, they may not know what optimal looks like. Today, we have Dr. Casey Means on the podcast, Stanford trained physician, chief medical officer and co-founder of metabolic health company levels, and associate. editor of the International Journal of Disease Reversal and Prevention and a lecturer at Stanford University on the podcast to walk us through optimal labs when it comes to our cardiometabolic panel. Well, what does that look like? Well, we're talking about everything from your total cholesterol, which by the way is not as important as we give it attention to, LDL, triglycerides,

fasting insulin, glucose, hemoglomin A1C, C-reactive protein, and so much more. We're going to walk you through all those and more, as I mentioned, and the more is actually the ratios. The ratios are key. Your total cholesterol to HDL ratio is so key. Your triglycerides to HDL ratio is super key, but most doctors, again, they're well-intentioned. They don't know about the importance of these ratios. We're going to walk you through all that and more on today's episode.

Stay tuned. Casey, welcome back to the podcast. It's a pleasure and an honor to have you here. We're going to jump right in. Today we're talking about optimal lab ranges specifically in the category of metabolic health and the metabolic health panel. Tell us why big picture, we should be caring about the topic of metabolic health and specifically getting the right blood test to do.

determine whether or not our metabolic health is head 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, H.JL 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 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 today. It's an average over time, but it can give you a broad snapshot of where you stand in terms of your average glucose levels. So the first time you were on the podcast, we did a deep

dive into glucose and how it plays into metabolic health. And the, The long and short of it is that when we have an elevated blood glucose level that increases the risk factor of so many different things that we'd experience in life, give us a couple of those things and extend elevated blood glucose to poor metabolic health panel. If you have a poor metabolic health panel, your lab results come back. And partly is this is about, is your doctor ordering the right lab results? But let's say it comes back.

They're not in the optimal ranges, which we're going to talk about what those ranges are. are generally, what are you more likely to have happened? What kind of diseases that we all know and have heard about are we more likely to develop in our life and what kind of symptoms would be people having when they have poor metabolic health? Yeah. So the first thing that might be helpful to define for people is kind of just briefly touching on what is metabolic health. Metabolic health is really this process of how we make energy in the body. Every single one of our 37 trillion cells in the body needs energy to find. function properly. And right now we are in an energy crisis in the United States where again,

88% of Americans are not processing energy properly. And the reason for this is because our modern Western diet and lifestyle is totally hijacking the processing the body for which we just make and process and use energy. And that's a problem. And so metabolic health is sort of the term for what's going on in this fundamental pathway that drives life in the body and which right now is in crisis in the average American body because of the way that we're eating, chronic overnutrition, especially refined carbohydrates and sugars, of our sedentary lifestyles, of our chronic low-gauge stress, and of our poor sleep. These things are taking over these systems that are fundamental for every cell to function properly. So now going to glucose. So glucose is one of the energy

substrates in the body. Our body takes in glucose and it converts it to an energy currency that we can use in the body, namely a molecule called ATP. And that's done in the mitochondria. Takes in glucose converts it to something we can use. And that process right now is broken for many of us. And that leads to essentially erratic glucose patterns. We see our fasting glucose going up. We see more variability in our glucose day to day. So more ups and down swings when in reality we want more gentle rolling hills. When our mitochondria are working great, we see more of that kind of flat and stable glucose in a healthy and normal range. But that's not what we're seeing in most Americans today.

We see this overtly in the rates of prediabetes and type 2 diabetes in our country, with 128 million Americans having overt glucose dysregulation, pre-diabetes or type 2 diabetes. And we also know that nine of the 10 leading causes of death in the United States right now are either directly caused by poor blood sugar control or are worse. by poor blood sugar control. So this is things like, of course, type 2 diabetes, but also heart disease, stroke, Alzheimer's dementia, which of course is now being called type 3 diabetes, cancer, many other conditions.

And so it's really important for us to understand what's going on with our glucose and then understand the metabolic context around that. So that's where other lab tests can be really, really helpful. other lab tests that give us a signal about what's going on with the energy story in our body. So that's what we're talking about when we talk about a metabolic lab panel. So this is looking at other tests that deal with energy. So this is things like our cholesterol panel, which is looking at total cholesterol, HGLL, LDL, and triglycerides, different forms of transporting energy substrates in the body.

It's looking at things like fasting insulin, which is, of course, the hormone that allows you to take up glucose out of the bloodstream, it's looking at things like inflammatory markers like CRP, which inflammation and metabolic health are closely intertwined with erratic glucose and poor metabolic health driving inflammation, but inflammation also making blood sugar worse. And so it's really taking all of these things into context so we can get a full story about what's going on with how we're making, processing, and storing energy in the body. And it's so important for us to know this for ourselves and learn how to have our own judgment about these tests because it is so fundamental to our health and to the chronic epidemics, the epidemics of chronic disease that we're facing

in the country right now. Well, I'm excited because we have a bunch of tests that we're going to walk through and we're going to talk about why they matter and big picture how people can think about them. But to add to the foundation before we jump into those tests, I think it's important to talk about, you know, a lot of people go to their yearly physical. If they're fortunate enough, you know, they have insurance, they have a doctor, everything like that. They go to their yearly physical. And they typically get the answer of, hey, everything looks good, little pat on the back, maybe some cases of, you know, maybe lose a little bit.

little weight, exercise more, and then you're on your weight, right? But they don't feel good, or they don't feel like they used to feel, or they feel like something's off or wrong or other stuff. And sometimes the doctor might say, hey, your cholesterol's a little high. You should make some changes and some cuts. But there's not a lot more unless there's something blatantly wrong, right? That's where our medicine and industrial medical complex is great. There's something blatantly wrong where they need to really jump in, you know, they can handle that situation. and save you from, you know, a heart attack that you're having right now. So I think this episode is going to be really great because it helps people understand

that there's this area in between that we don't have to wait till we literally have heart disease to make interventions. We can start paying attention now to these labs that we're going to go through and why they matter so that we can catch things early, not just to avoid chronic disease later down the road, but to also feel good today. That's exactly right. What's so interesting about the energy story is that right now we're dealing with so many people just don't feel good. They have FLC syndrome, as Mark Hyman says, feel like crap syndrome.

You know, we feel tired. We feel anxious. We don't have the pep in our step that we want. We know something's wrong. And we're often going to the doctor and hearing, oh, your labs are normal, like nothing to worry about. We know in our gut that that's not good enough, that there's got to be something more that we can, that we can figure out about how to optimize our health. And what's interesting is that this way we're feeling today, even when we're young, maybe just not enough pep and our sweat, not enough energy, that's the same process that's

going on that will ultimately lead to chronic disease. But these symptoms, in a sense, are a gift because they're showing us that something is going, something is off right now, something is not optimal. And that is a gift because we can do something about it. But unfortunately, as you alluded to, right now in our system, we don't really take action or intervene until things are really flagrantly wrong on our lab testing. And usually when our, when the, you know, green check mark in the electronic health record that says everything's fine, moves to sort of a red X and the doctor says, oh, there's a problem. Usually that means that there's

probably actually been underlying dysfunction for a long time, but it hasn't quite met that diagnostic threshold. So there's this window of many, many years when we're otherwise healthy, maybe don't have a diagnosed disease, but don't feel our best when we can actually dig in much deeper to these lab tests and start to pick up clues of what might be going on. And so I think that's what this conversation is really about is to help people figure out what are the clues in these tests that the doctor's ordering for us that we actually can look at and start to understand if there might be some early dysfunction that we can actually do something about. And the beautiful thing is, is that with slight tweaks in our diet and our lifestyle, we can really turn these lab

tests around. We can move them into a much more optimal range. We can improve our energy now and we can set ourselves up for much better outcomes in terms of chronic disease. One more other thing I want to touch on as a medical doctor and having all the training. Now, on our last podcast episode, you talked about how your family was into wellness, right? You've been into wellness for, you know, pretty much growing up. So there was a lot of education that you had that typical doctors don't have. But tell us a little about what education you received when it comes to some of these areas that are highly impacted by lifestyle factors, especially diet. What education did you get in medical school?

And how does that impact interpretation when it comes to what's normal, right? Most of the population is normal, but most of the population is sick versus what's optimal. Yeah. So you just brought up such an important point, which is what we're being told as normal has to do with what's going on in the population. And usually a few standard deviations away from the mean is what we kind of categorize as normal. But the average American adult right now is sick. So we don't want to be just orienting around what's the average and two standard deviations from that mean. And, you know, an example of this is that like our what's normal for, for instance, liver function tests. have actually creeped up over the past 30 or 40 years because the average American now has liver disease. I mean, 45% of American adults now have fatty liver disease. And that's going to show up on your liver function tests. And so do you want to be, you know, two standard deviations from the mean of that? No, you want to be in a much, much better range. So unfortunately, with training, you know, we're really taught to see sort of black and white. You're either normal or

you are in the diagnostic disease state. But that's not the way biology works. Biology is a spectrum. And we're always moving back and forth on this spectrum based on what's happening in our lives, how we're living, how we're eating, and what our lifestyles are. And so, you know, so just putting yourself in a bucket of normal, abnormal, that's the first thing we should move away from. We should stop thinking that we're fine if we're just in the quote unquote normal bucket and that there's a problem if we're in the abnormal bucket, we should start to really begin to look at things as spectrums and where we are on the spectrum of health. And that's something that I don't think is emphasized in conventional medical training because a lot of it's about triaging and you need to

focus on who's the person I really need to focus the most energy on. And that's the person who's in the diagnosable disease state. But we need to do more than that. And now knowing that most of the the symptoms that are facing people today and diseases are actually diseases that develop over over decades. That whole window of pre-disease is where we need to focus energy and where we don't in our conventional medical practice right now. And so because of that reality and because of the way the system is set up, the onus is actually on us to stop outsourcing our judgment to other people who are focused more on, you know, the black and white, no disease or disease state and to actually start understanding for ourselves what some of these biomarkers

are pre-disease are so that we can take action and have agency in our own lives. So that's where education is really important. And on the topic of education, I love the levels blog. We have a link to in the show notes because one of the things you guys highlight there is the incredible amount of research that's constantly coming out that supports why we want to be paying attention to some of these things. For example, people were not talking about fasting insulin as much, even though we've had the ability to run that test for quite a long time. It's gotten a little bit more popular, but still a lot of people aren't necessarily looking at that. Forget even just optimal or not optimal. So my guess, and this is just a guess, but a good chunk of the research on what we

know when it comes to metabolic health and what these lab numbers really should look like is probably come out in the last 10 to 15 years. So that means that if you're a medical doctor, well-intentioned, I have many medical doctors in my family, my brother-in-law is a cardiologist, and they're doing the best job that they can. They have so much to keep up with. But if you're a medical doctor, you know, first of all, they're not getting that much education on nutrition in the first place. You talked about that on your podcast episode with a guest recently. But the second component is that if they graduated school quite a bit ago, they may not be aware of the latest research. So I hope that the doctors are listening, which they are, too,

because they're trying to dial in their own health as well. Definitely. And I think another thing about the physicians, I think your point is absolutely right on. Everyone here is well-intentioned, but the system is set up in a certain way that really drives training. And one of the big systems issues that we face is that it's a very pharmaceutical-centric system. Medications have been life-saving in many cases. We think about things like antibiotics. They've absolutely extended life for many conditions. But because we are so focused on what do we have in our toolbox that we can give to someone that's simple and easy, we really lean on medications. And so that's actually really driven how we've interpreted lab tests, actually. So Rob Lustig, Dr. Rob Lustig talks about this

quite a bit, which is that if you actually look at the cholesterol panel, we focus so much on LDL. A lot of people know, oh, LDL is the bad cholesterol. And it's a very nuanced topic, but the odds ratio for LDL and risk of heart disease is about 1.3. And it's actually 1.8 for triglycerides. But we hear a lot less about triglycerides. People aren't running around saying, oh, triglycerides is the bad, you know, part of the cholesterol panel. You just don't hear it talked about it much. Right. A lot of people know their HDL and their LDL, and I'll ask them, what was? your triglysterides and they're like, I don't know, I have to go back and look. And you kind of wonder why. And I think there's good evidence to just as part of the reason why

we've had so much of a focus on LDL is because we had a medication for LDL early. And tell everybody what that medication is. Statins. Right. And so we did not have a great medication for triglystorides. We now do have medication, strikylisides, but they have quite a bit of side effects, fibrates, and aren't used as much. And so what's interesting, though, is that triglycerides, they have an higher odds ratio for increased risk of heart disease, but they didn't have a medication, and so we don't hear about them as much. And they are such an important indicator for what's happening in our metabolic health, how our diets impacting our health, and are so easy to change with dietary interventions. I've had patients who have just gotten off for signs

sugar and refined carbs, and in a month have dropped their triglycerides by about 100 points. And so we really start need to start orienting around less about which lab tests are important because of how we can intervene with medications and actually focus on which ones are the best signal for what's going on in our metabolic health and which ones do we have evidence-based dietary and lifestyle avenues to get them in a better place. I'm one of those people. I definitely have a family history genetically influenced that predisposes me towards higher overall. markers of cholesterol and triglycerides that are there partially, right? And so when I went to my physician in high school and he saw that my triglycerides were off

the charts and he was like, this is just something that you're going to have to watch out for and be there. And I dropped almost 100 points. I dropped almost 100 points by getting off of, at the time I was vegetarian, that's not the reason that I was there. I was eating junk food, right? Even though it was vegetarian and you can eat junk food that's very. vegetarian, you can eat keto junk food, you can eat any kind of junk food that's out there.

And by moving towards actually, truly what at the time, I was doing more of a plant-based diet, eating more vegetables, cutting out all these processed carbohydrates, cutting out all the processed sugars, my triglycerides completely changed. So I think that's a perfect jump off. 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 really love looking at trigly trigly story to HDL 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 triglyceride 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

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 that, 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 LHGLRHDL 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 fractal, you 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. all 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 L-GD-R ratio, H-DL-R ratio 16-fold 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 trilicerides 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, 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 this swing can be. But I do know from my own practice that people who have fully cut out refined grains 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 triglysteroids 100 points in one month. And so that is just huge in terms of, and I think that was basically.

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 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 tacks for people who are like, what number should I shoot for? You know, I think really for triglycerides, which again is the numerator of the triglyceride-HDR ratio, So 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, and 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-2-HDL ratio, for that, there is. 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 1.4.4. 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. So that's kind of what you can do 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 haven't even tighter range like 2 to 6 or 2 to 8. So if you're if your 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, towards diabetes and all the associated conditions, the body's

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, Fasting, or type 2 diabetes, et cetera, 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 overcompensation 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 in, 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 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 essentially concentrated fruitstose. And of course, it's filling soda. 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-fidogos corn syrup and the packaged foods and then minimize or eliminate the refined sugars and their 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 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 you're 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 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 in 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 fats. So even though I love MCT oil, I 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 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, sorry, lipoprotein B 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. of a combination of reason. So I felt okay, minus some small things, but if I didn't intervene now, who knows 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. Absolutely. And I think it's another testament to why actually testing maybe on a more frequent basis can be really helpful. Because if you make a dietary intervention, if you wait until maybe a year, until you retest some of these

things, you may not actually be able to create that kind of one-to-one relationship between the intervention and what actually happened. So for many people, like, for instance, if you're cutting out, adding more saturated fat or adding more plants or cutting out refined sugars and grains, retesting after one to two months on some of these metabolic health tests can be a great indicator of whether you're moving in the direction and can be extremely motivating. So the more we can tighten up those feedback loops, I think, the better. And of course, the continuous glucose monitor is kind of the ultimate in the biofeedback loop because it's just that really instant feedback on each thing you're eating. But that's only part of the picture, of course. And some of these

other lab tests that we're talking about give you a bit more of that comprehensive picture. But we'd definitely encourage people to think about, you know, using there's so many amazing tools now, like direct-to-consumer lab testing, where you can actually order these yourself, do the test at home, and really get more of that tighter feedback loop between a dietary intervention and what's actually happening in your body. Before we jump into A1C and why that was listed as number three in your top three that we start off at the top of the episode. And then we got a bunch more to cover after that, all high-quality information.

You guys are offering this metabolic health panel to folks, in addition to the continuous glucose monitor, people can get that. Maybe just mention how can people sign up for it and what does that look like and where do they go to get their blood drawn? Yeah. So in an effort to get this type of information to more people on their terms and their timeline, we're now offering as part of the levels membership, not just access to continuous glucose monitors and of course the level software that helps you understand what's going on with your glucose levels, but we're also offering this metabolic health panel, which is a blood test that gives you a lot of these tests that we've been about. So it's your full cholesterol panel, so total cholesterol, HDL, LDL, and triglycerides,

high sensitive ECRP, which is an inflammatory marker because of course we know that inflammation and metabolic health are very tightly linked. Your hemoglobin A1C, which is that three-month marker of average glucose, fasting insulin, which honestly I'm kind of most excited about this test because it is very hard to get through, you know, just the standard primary care physician. They're just not used to ordering this, but it gives you so, so much information. And just one thing on that, I'm going to interrupt for you. I was telling a buddy of mine to go get his fasting insulin. And he came back and he was like, I'm getting pushed back from my doctor in terms of a little

I just moved to a new town. I want to get it done. He's a new doctor. And it's kind of like, who are you to tell me to do my job and why we should be ordering this? And not everybody's like that, but it's just, again, friction inside of the medical system. Exactly. So we're trying to make this as frictionless as possible.

And, you know, there's research that suggests that it takes 17 years between when we understand things in the scientific literature and when it makes it to clinical practice. And unfortunately, we're in the middle of that window right now where we know fasting insulin is so important as a biomarker of pre-dise of these diseases that are affecting monumental numbers of Americans. We don't really have access to that biomarker. So Levels is making that possible. So on top of that, the last one people have access to is fasting glucose. So that's the metabolic health panel. And essentially, you can get this to levels membership. A phlebotomist will actually come to your house, draw your blood at home, and then the

levels will show up in the levels app. And it'll actually show you not just what the standard ranges are for those tests, like what's on the lab slip, but what are the optimal ranges for those? So what is the consensus expert opinion of where we should really be shooting and how to interpret these in a more comprehensive way? So this is just really allowing you to be more of the CEO of your own health. This is allowing you to not have to outsource all the judgment about what's going on inside your body and let you really start to take some ownership.

And the cool thing is you can order these as frequently as you want. You could get them once a year. You could do them every month if you want. You could do this panel three months after starting a dietary intervention. You can start to see how what you're learning on your continuous glucose monitor is impacting these other metabolic labs. So it's really up to you. And so that's a new offering that we have with levels that I think is going to give people a lot more context on what's going on with their continuous glucose numbers.

And I'm thrilled to see how people respond to it. Yeah, I'm super thrilled. And I've been very vocal in my newsletter online, on social and on the podcast. I'm an investor in levels. I really believe in you guys. You're one of my favorite health communicators. And that's why I have you on the podcast, not just to promote the company, but really just to, educate the audience that's there. And I love the idea of democratizing medicine. And, you know,

this test is 179. Yeah. Right. It's still, you know, people are going to pay for it. But like, I've run these tests before. It's been more expensive when I've gone sometimes and how to pay them out of pocket and even trying to convince your doctor and other things like that are there. So I would rather deal with the friction list component. And, you know, I think it's an investment in your health, but it's a beautiful thing to be able to do and have access to. And we have a link in the show notes. If anybody wants to sign up, we've got a lot more things to cover here. So we're going to jump back in.

But if you are listening, you can go to levels. Dot link slash Drew, DHRU, and you can get access to all these labs. 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 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 A1C. 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 we 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 female going to 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, you know, 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 lasts 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 a variation in this, and there might be ethnicity variation in that, and there might be 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 and 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? And last time you on the podcast, we had a discussion a little bit about this that you can do any diet incorrectly. Now, diet gets all the attention. We don't talk enough about, you know, these other categories, sleep and working out.

Although it's getting a little bit more attention. But diet typically gets the most amount of attention. And it causes a lot of debate because people get very animated about their approach. And there's a lot of layers that go into it. There's planetary layers. There's animal welfare. There's a lot of layers. and everybody has a different feeling or a different interpretation of what that means.

There's people who eat meat that only eat meat that they hunt. And they feel like that's actually the most ethical thing that you can do. And then there's people who, you know, on the other side of the spectrum that feel that, you know, again, everybody has their own idea of what's right and wrong. But when you get your labs, if you're not heading in the right direction, especially if you test over time, it's just more information of let's step out of what my feelings are are about what should be done and actually step into what's going to help us head in the right direction.

That's exactly right. I mean, data cuts through so much of this noise about the diet wars because the reality is the body is this incredible complex system with many redundant pathways. Also, each body is different. Of course, genetically, microbiome, everyone responds to foods differently. You know, you and I could eat the exact same piece of bread and have totally different glucose responses to it. So everyone's different. We're also different day to day as our own bodies, like we were talking about with the insulin story. Insulin could be 30 and three months later,

be five. And so you're going to respond to food differently in those two different states. I really like to think of the body as this incredible dynamic entity that is kind of like a shape shifter. It's different literally day to day based on how you're living and what you're doing and what you're putting into it. Based on the amount of sleep you got the night before, the amount of cognitive stress you're under, what you ate the day before, whether you moved your body a lot or a little,

it's a different body. Even the thoughts that we have create a whole different hormonal milieu in our body day to day. And so it's just, it kind of makes it seem totally nonsensical to say that there is like one particular diet or lifestyle for everyone. And because, I think we can pretty much, you know, say that that probably doesn't make a lot of sense.

Then it comes down to, well, how do you determine the right choices for you? And certainly, subjective feeling has a huge part about this. How do you feel? How does food make you feel? How do different lifestyle choices make you feel? And we should absolutely be tapping into that body awareness and that sense of interception or what's going on inside our bodies and can we sense it and perceive it. But the biologic data and the biomarkers can really help create a link between our choices and how we feel and what the actual results are in our body. So I love using these tests in part as a way to prove to myself that the choices that I'm making are moving me in the direction of my goals and my priorities or not and feel really, really confident with the choices I'm

making even if they are different than what some really loud voices on social media are saying or that a doctor is saying or that books are saying, if I have the data and I know how to interpret it, I can feel comfortable with my choices for my body. And I think that more access to this type of data is going to be one of the lovers that really pulls the rug out from under the Diet Wars, where we have to actually be held accountable to what the truth is inside our own bodies as opposed to food marketing, the loudest voices, or the minimal amount of information that our doctors were taught in medical school. I had another buddy that called me a few weeks ago, because I'm always talking about this

and people are looking for, you know, what's the right information out there? And I try to send them to information sources that have or doctors that really can, like, help them on their journey. But he just got told by his doctor that he has fatty liver, you know, going back to us talking about insulin and everything. And he eats a traditional South Asian very very. vegetarian diet, which, by the way, a lot of people think of it as traditional, but it had way more, like, actual plant foods in it and way less refined carbohydrates, which is what a lot of

it is made up of now, and that's kind of the diet that I grew up eating. And I remember sharing with him this story that I understood about how, you know, how do we induce fatty liver in an animal if we wanted to? And the most popular way that we, you know, unfortunately, is consumed around the world. I think it's a little bit cruel and I think a lot more people are realizing that is for gras, right? The delicacy that's there, which is the liver of the duck, right? And it's kind of a sad situation, but they force feed ducks basically corn. Corn in some cases, depending on the country and other things, other things that would be like corn meal and refined carbohydrates to basically pump the animal full of, you know, refined

carbohydrates is sugar inside of the diet. And that induces fatty liver. And so I said, listen, I know you feel very attached to this way of eating. And you can still be vegetarian in this case. That's very important to him. It's part of the tradition and everything like that. But stepping out of this what we think of as our traditional diet, which really is not that old, right? It's not like our Paleolithic ancestors were eating that way of being vegetarian, even if they were, and incorporating more healthy plant foods and maybe also cutting back on the alcohol a little bit as well too, which was a big part of his diet. So it just was a funny story and a thing for me that until he went and got tested, he didn't really know that what he was doing wasn't working

for him. I think that's such an important story because it really highlights a phenomenon that is happening in this country right now is that we are becoming human foie gras in a lot of ways. I mean, 45% of Americans with fatty liver disease now, that's what's happening to us. And, you know, it can really be linked to this excess consumption of corn products like what's happening with the yeast, but also, of course, the refined sugars, refined grains, and the fructose. And so it's really simple to reverse. And the nice thing is that it's much simpler to reverse early in the process than it is late. because when the liver has been fatty for a long period of time, that's generating a lot of

inflammation in the liver, and that can ultimately lead to scarring and actually more of an end-stage disease state where the liver permanently has structural changes. So being able to clue into a lot of this stuff early is the time to do it. And we're seeing this in kids now. And so really zeroing in on these metabolic lab tests is important for this reason. And actually one that, you know, probably out of the scope of the conversation today, but looking at your liver function test is really important too. Again, this is one where the range is very large. Some of the tests that you might hear about are AST and ALT, which are different transaminases, liver enzymes that basically rise when there's liver dysfunction. Typically, we've heard about them rising in relation to

alcoholic liver disease, but now we're seeing them rise in relation to dietary-induced liver disease. So just one take-home point for people who are looking in their labs, if you're looking at your ALT, it's probably going to say shoot for below like normal is below like the 40s. Sometimes the ranges will go into the 50s, but really shoot for below about 25. You want really optimal liver health. And that can be one, you know, slight clue of what's going on your liver. But of course, the whole picture of what's happening with your insulin, your triglystory to HL ratio, these also give us a signal, of course, of what's happening in the liver as well. So yeah, it's a great example with your friend. And we just, we all need to be focusing a lot more on

what's happening in the liver. Absolutely. Let's talk a little about inflammation and C-reactive protein. Why does this laboratory marker matter? And what could be some of the things that could be setting it off as a red flag that there's some excess inflammation going on in the body? Yeah. So CRP is one of the key markers. that we can track in the bloodstream of what's going on with inflammation. It's called an acute phase reactant. And it's a protein that's generated in the liver. And it can go up in response to infection, autoimmune disease, cardiometabolic disease, heart disease.

And it's a great signal of basically what our baseline inflammatory state is. It's also one that is frequently ordered in the doctor's office. You may actually have one on a past panel or you could ask your doctor to get a CRP. And you may actually want to ask for an HSCR. which is a high sensitive ECRP test. And based on what lab you're going to, they might say that less than 2 milligrams through liter or less than 3 is normal. We really want to shoot for less than 1 and ideally even less than 0.5.

We want that inflammation to be low because we know that chronic inflammation can drive metabolic disease. And so this is definitely a test you want to clue into and be getting every once in a while to make sure you're not creeping up. and that there's not something kind of simmering underneath the surface, like a chronic low-grade infection that you may not even be aware of. So definitely one that I include in my metabolic sort of comprehensive picture to get at least once a year.

This is one of those confusing ones because I've seen different lab reports that are out there. And when they talk about the reference ranges, you'll see the reference ranges can be like zero to like five, right? And it's like, wow, that's like a huge range that's there. you know, and again, this just goes back to the fact that more research continues to go out there or more research. In the case of CRP, there's been quite a bit of research that's, you know, a lot of people that have been talking about that, different studies that are there, but it's more recognized in terms of its importance because there's so many physicians like yourself and

functional medicine doctors that are out there who are talking about the reason that it's important in relation. My brother-in-law would often say that when it was in that lower range, even as a cardiologist, they often didn't even talk about it because there was a question of, well, what do we tell somebody to do, right? What am I going to tell somebody to do if it's still elevated, but it's in that lower end of the range? And a lot of doctors don't know. Again, well-intentioned, well-meaning, they're trying to do their best, but they weren't educated even what should they look in the direction of? They just felt like, okay, this is going on. We don't know why. But it's not so, so high that some major issues going on, but it's still elevated enough that we got to do

something, but we don't know what to do. Right. And when fat is essentially in the wrong place or there's excess fat, it's going to generate inflammation. When there's fat in the liver, you're going to get inflammation in the liver. Adipose tissue, fat tissue in its own right, can be inflammatory. And different cell types in the inflammatory pathways like macrophages can basically take up resonance in this tissue and create these inflammatory programs, secrete their inflammatory chemicals that cause this threat sense in the body that we do not want over time. So clearing out that excess fat from the liver, from the visceral fat, this can actually help our CRP come down.

As cardiometabolic disease improves, CRP will improve. So anything you're doing to improve metabolic health will actually, usually parallel with CRP declining. And I think generally speaking, we can also think about general anti-inflinflation. dietary and lifestyle strategies. Of course, a lot of the refined processed foods they were eating, they generate inflammation in the body, whereas a lot more of the whole foods, especially the omega-3 rich foods, like, you know, chia seeds, flax, fatty fish.

These things have these anti-inflammatory properties. Of course, there's other incredible food chemicals that can do this like turmeric, which has curcumin, which actually reduces the activation of one of our inflammatory path, which ways and up capa B. So use food as medicine when you're approaching inflammation. So thinking about really just like a comprehensive anti-inflammatory strategy is really important in our diets. Another one to think about is our microbiome, of course, because the microbiome secretes short chain fatty acids, which go into our bloodstream and can have also an anti-inflammatory effect. So we want to keep our microbiome on point, which of course means feeding it what it needs to

thrive in the right populations. These are high fiber foods, the nut, seeds, beans, legumes that are going to let the microbiome do what it needs to do to produce anti-inflammatory chemicals. And so there's so much there, but CRP can kind of give you like that general sense of what's going on. And if it's elevated, you definitely want to take action. You want to take stock of your diet. Is it pro-inflammatory? Are there anti-inflammatory components? Do I have excess fat in the wrong places. Do I have underlying stealth infection that I need to, you know, dig into more. Is there some sort of autoimmune process going on, et cetera? So that's where it can be kind of useful. And certainly if it's elevated, there's absolutely

dietary lifestyle things that you can do to move it in the right direction. That's a beautiful thing about all these things, is that my business partner, Dr. Hyman, you were just on his podcast. You've been on there a couple times now. I love those episodes. he always say like, it's not like there's one diet that's there for brain health. And then there's another diet that's there for cardiovascular health. And there's another diet that's good for your microbiome. The beautiful thing is we're covering all these individually as indications, as smoke detectors that we want to be paying attention to because sometimes one might be elevated and one might

be a little bit more normal, but it's still worth paying attention to. But generally, the same intervention overall is going to be beneficial. And those are a list of all the things that you just shared there. It's an important reminder because sometimes people obsess about one of these areas, but your overall approach that's going to bring you into well-being, especially dietary-wise, anti-inflammatory diet, you know, a lot of the healthy Mediterranean fats that we've talked about, avocados, avocado oils, olives, olive oils, other things like that, cutting out the refined carbohydrates, the refined sugars inside of the diet, especially the liquid sugars, which are getting a lot of attention right now, even things like fruit juices, which people thought. just really quickly, how could something like fruit juice, which a lot of people thought was healthy, how could that be something now that we're reconsidering and that it might be driving? Because even people who think that they're eating a healthy, quote unquote, diet, if they still have a large amount of some of these refined carbohydrates in there and they have

large amounts of fruit juice in their diet, their panel could come back looking super wonky. So talk about, let's talk about fruit juice in particular. How is that that that could be influencing some of these things? Right. So fruit obviously has many wonderful qualities to it. Fruit is filled with antioxidants. Many fruits have a lot of fiber. There's tens of thousands of phytochemicals in fruit that are wonderful little molecular, you know, chemicals that can help ourselves function properly. Fruit can be a great food to have. But juice is not fruit. juice is a ultra-concentrated form of fruit, of which many of the positive things have been removed. So I think we really need to first associate that juice is not fruit.

It is a concentrated, essentially liquid form of sugar with some of the benefits of fruit, but you're much better off eating a whole piece of fruit. Juice, the issue with juice is that we're getting essentially like pharmacologic doses of this fructose that's in fruit, because again, it's concentrated. And the thing about the body is that it has an amazing capacity to process things and get rid of them. Like, it can process toxins in the liver. It can process medications.

It can process sugar and take it out of the bloodstream into cells. It can process fructose in a totally healthy way. But the cells only have a certain capacity for this amount of processing. And when you overload the cells in a short period of time with huge amounts of almost anything, there will be dysfunction. And that's what juice is doing because it's a huge fructose load that's usually drank really quickly. So you have this set amount of cells with a set amount of capacity and you're overwhelming it. So you're going to get dysfunction. You're going to get byproducts that are damaging. And in the case of fruit, what's happening is actually quite an

interesting story. When fructose is broken down in the liver, it's broken down into a byproduct through a complex pathway, but eventually uric acid is one of the byproducts that is made. And uric acid, normally the body can handle a certain amount of uric acid and dispose of it, but when you have such a big fructose load, your uric acid rises in the cells. And what that does is it actually goes to the mitochondria and it causes oxidative stress. It causes that oxidative damage that overloads the capacity of the body to essentially count. So you get oxidative stress in the mitochondria, our little energy factories. And what that does is it essentially blocks the mitochondria from doing their job, which is converting glucose into ATP,

and instead shunts glucose into fat because so fructose creates excess uric acid. Your acid damages the mitochondria. The mitochondria can't do their job well in producing ATP from glucose. The glucose gets shunted to fat storage. And now you've got fat in your liver. What's interesting, is that if you eat like the amount of fruit that's in, or amount of fructose that's in like a one piece of whole fruit, this doesn't happen. Your body converts it to uric acid. The body manages the uric acid.

It doesn't overload the mitochondria. Everything's smooth sailing. You're not converting the glucose to fat. Things are good. But it's when you overload it really quickly that we have a problem. There's actually interesting research that's been done that shows if you actually drink a Coca-Cola slower, like over the course of several hours versus just pound it in like five minutes, it's a very different effect on the liver. Because in the slower version,

your body's kind of constituously able to process and not get overwhelmed. But when you're slamming it, you're, of course, going to overwhelm the capacity of these cells. So that's really kind of one of the reasons we don't want to drink liquid sugar. It happens too fast. It overwhelms the systems. It out- outpaces the cell's capacity. And then we get dysfunction and storage of excess in ways that we don't want that create organ damage. Yeah, and we're, you know, teasing out fruit juice here for a moment, but we're really talking about any liquid sugar. Right.

But fruit juice in particular, because a lot of people, and especially parents, right, think that they're doing, again, the best thing that they can for their child, at least they're not drinking a soda, and everything exists on a spectrum, right? Everything exists on a spectrum. But as we get updated information, we take a look at things and we say, well, is there a better way to go about this? and reevaluating the total concentration of maybe fruit juice in our diet or any liquid calories. I posted something the other day saying that I've dialed in and kind of made homemade latte.

I used to enjoy kind of like walking to the coffee shop, other stuff. But I'd see back in the day, I never really drank oat milk a ton, but I'd have it occasionally. I saw that oat milk would send my blood sugar like off the charts. but then even most almond milks that are out there are sweetened. But you can make it at home. You can make a little coffee, a little latte at home. There's plenty of brands that are out there that are unsweetened, have no fillers inside of them like Carragian, which has some, you know, suspect, potentially suspect impact

on the gut microbiome and other things like that. But you can get a clean almond milk. You can make a latte at home. And it's like enjoyable. And mine scored like a nine out of ten on my levels, which is a good. thing, by the way. It scores your meals and helps you understand its impact on your blood sugar. So, yeah, as we get more information, we start to reevaluate and then we make adjustments. And we do it without freaking out and with data, right? We don't want to obsess about any one

particular thing or any one particular food or thinking this one thing is going to be the downfall of us, or this one area is going to totally throw off our help. When we improve our baseline, our ability to have flexibility every so often if we so choose to increases. And that's not just when it comes to diet, although that's a big part of it. I would say that the biggest takeaway that I had from wearing the levels CGM is that I could be eating the same diet this week as, let's say, two weeks from now. But if I don't get in my three workouts a week, my blood sugar is completely different than when I do work out. When I do work out, my blood sugar response is so much better. And I have enough of my metabolic health panels that have been taken at different times

that just by including a 30-minute high-intensity workout for me, that feels good, my overall panels are so much better, even though I've been eating basically the same, you know, between those two panels that are there. Definitely. And it's so good to figure. out those personalized insights for yourself. I mean, the thing about the exercise is it changes everything, right? Muscle is a huge glucose sink. It pulls glucose out of the bloodstream and uses it and disposes of it. It also clears out the liver of excess fat and stored glucose

in the form of glycogen because you're putting the body under a stress where it needs more energy. It pulls it out of its stores and the liver is one of the big stores. And so it really can change the game, like you said, week to week and be able to see those impacts. I mean, I imagine that was motivating to you to keep on doing those three workouts. That was been one of the most motivating things for me for working out. That's been the most motivating thing because there's just this confirmation that not only does it matter so much, but it's being reflected. And I think that that's actually more important because there could be a lot of variables

while if somebody's motivation was say, you know, to lose a little weight, right? Okay, great. That's fine. Anybody can have the motivations that they want to have and that's up to them to have those motivations. You know, depending, because we're talking about these labs, it's way bigger than just one marker. Your fasting, insulin could be really high because you've been eating a particular way or living a particular way for so long that we need a little bit more length of time for your body to get that number lower, which then will impact the ability that you put on weight, especially belly fat that's there. But when you see that some of these these markers that change on a more regular basis are improving,

it's that confirmation that you're heading in the right direction. You guys were so kind enough to send level CGM to my friend, Dr. Rungan Chatterjee, who's been using it over the last month since January, beginning of January, he said, this is the biggest habit and behavior reminder that I've ever had. and I eat like really clean. Like this is just such a reminder of what works and doesn't work. And I think they've built a really great system. Anyways, a little, a little love that I wanted to throw in your guys' direction.

Let's get back to the lab test. And I think there was one, one test that we didn't get a chance to cover. HDL. HDL. Yeah. So this is one of the ones you'll see in sort of a metabolic lab panel. It's one of the four things that tests in a cholesterol panel. And this is typically thought of as the good cholesterol.

This is one of the forms of kind of the cholesterol packets that floats around in the bloodstream that brings cholesterol back to the liver, helps recycle it, helps get rid of it. And so it's taking it away from the blood vessel walls and moving it away from sites where it can be harmful. So we want HGL to be higher. I think it's the only test we're talking about today where higher is better. And typically, you'll see that on a lab slip that it says anything above like about 45, milligrams to deciliter is normal. It'll sometimes be broken down by gender, like above 40 for women or above 50 for men is where you want to shoot for, but around 45. But the reality is we probably actually want it to be much higher, like above 60, maybe in the 80s or 90s or up close to 100. This is, if you're just on the edge of like 45, 46, your doctor will probably say to you, great, that's normal. Your HGL is normal. You're good cholesterol. is in the normal range. But I think as we've kind of learned from today, you need to think about this in the big picture context. Here's an example. We talked about the importance of triglyceride

H.GL ratio, surrogate marker of insulin sensitivity of small density LDL, the harmful LDL. Well, imagine a situation in which the standard lab range says that triglyceride less than 150 is normal and HGL above 45 is normal. So you might have a triglyceride of 149 and an HDL of 46. And you And your doctor says to you, great, your cholesterol panel is totally normal. Keep doing what you're doing. Keep doing what you're doing. Well, that's going to be a triglyceride HDR ratio of three to one of three. You know, yeah, or about that.

That's way too high. That pretty much indicates like full-fledged there is a metabolic problem. But each test in its own right is sort of falling into the quote-unquote normal range. So that's why you've got to look at these things in constant. What we really want is for those numbers to come much closer together. Triglycerides, low end of normal. HGL, high end of normal. The ratio closer to one.

That's going to be a much better signal that you're in a better place on the metabolic spectrum. But unfortunately, it may be missed by your doctor who's kind of just looking at the electronic health record and looking for those green check marks that you are generally falling into the normal range. All this goes back to we got to be the CEO of our own help. okay to have people. You know, when you're an actual CEO, you hire people that are smarter than you in different topics, but you're synthesizing that information and trying to make the right decision

for everybody's best interest that's inside of the company and the shareholders and other stuff. When you are the CEO of your health, it doesn't mean that you know every in and out about these lab markers. It doesn't mean that you think that just because you have data that you went to medical school, right? It doesn't mean any of that. What it means is that you are, choosing the right people and pulling in the right inputs to help you synthesize the information so that you can make a decision of what direction and what actions you want to continue and what actions you maybe want to pull back from. And so you can't do your job as well as a CEO if you don't have all the right inputs and the right team that's there. And so far that information

has been highly protected in terms of, you know, right now, most of, people know, you cannot just go and order these tests for yourself, right? Most testing, actually, I would say, you know, there's been so much controversy about Theranos and as there should have been, but one good thing that came out of the whole Theranos situation, as I understand it, was they were instrumental in passing a law in Arizona that allowed people to order their lab results directly, right? So that's silver lining, the tiny little silver lining from the whole Theranos situation. Tiny silver lining from the Lernerner, tiny silver lining from the lab results. the whole there in a situation. But in the instance for you guys, you guys have figured out the

hack. You've partnered with another company and there's supervising doctors that are part of the situation that allow people to have it. But there's really no reason why people shouldn't have access to it and then guidance that's out there to help them interpret it. And they can even order these tests and they go and review there with a doctor. They should. Maybe you can send your doctor this podcast. If they're open minded and they want to listen to it, they might learn something and start to begin to optimize their own health that's there. Absolutely. And I would definitely second that that this is information for you to bring to your doctor and start a conversation. You know, this is just just giving you access to the information. But one thing that's really blows my mind is that in only one state in the United States, do patients own their health records outright? I believe it's New Hampshire. But only one. In a lot of states, the hospital or the physician, actually own the data. That's your data from your body. You know, and it's, it's so interesting to me

because you think about other parts of our lives where access to this information, access to information is really critical. Like, for instance, our car, our car now has dozens of sensors all over it, you know, for tire pressure, for the windshield wiper fluid, for the oil. It's constantly sensing what's going on in the system and giving you all this information so that you can then have a sense of what's going on with the car and pull in the mechanic if you need them. Obviously, if something is wrong, similar with our finances. We obviously have access to the information about what's in our debit account and what our credit score is. And then we have a financial advisor who might advise us about these numbers. But the way we're practicing medicine right now is as if you did not have

access to your debit account balance, to your credit score, to when your credit card payment is due, if you didn't have access to see how much mileage is left until empty on your car, whether your oil needs to be changed, none of it. You don't get to have it unless you, you know, submit a form and have someone give that information to you. Imagine if just to know how much gas was left in your car, you had to like submit an official form to, to a, the, you know, the company to give you that information. That's kind of what's happening with our health.

Like we, in many cases, can't easily access it, transfer it, give it. to other people to look at. That's insane. We think that health is some sort of different thing. And it's a very almost, almost paternalistic. I don't really love that word. But, you know, it's sort of an authoritarian view of things of like, we, this is too serious and it's too complex. And it is, it's going to be a problem if you are trying to interpret us for yourself. I would like to throw out that system. You know, we all deserve access to our own health information. excellent information to feel comfortable looking at it. Of course, we're not going to be the financial advisor or the mechanic. We're not going to be experts in it. Of course, unless we had advanced training

in this, but we should at least have some baseline understanding of what we're looking at, what it means, whether there's a problem, and when to ask for more assistance and help. And, you know, this is all just a legacy of a system that minimizes lifestyle interventions. because even if somebody said, okay, there's the medical industrial complex and there's big pharma, but it came with good intentions. Let's say somebody gave the benefit of doubt and said that. Okay. That a lot of these things, you know, you want your doctor to be able to decide what drug

or what other component. But we know now there are so many things we can do on a lifestyle level to be able to influence these things. So having that information, many people who are listening to this podcast might be well more aware of the lifestyle interventions that can influence these panels that we talked about than even their doctor themselves. And I think about, I was watching a documentary about the history and the evolution of medicine. And Freakonomics also did a really good series on this called Bad Medicine.

It has like part one, part two, part three. We'll link to in the show notes. But in the 1950s, because there was very limited things that you could do for a patient that had cancer, the standard of care at that time, I think it was late 40s, early 50s was it was up to the doctor to decide whether or not they wanted to tell the patient if they even had cancer. And part of that directive came on, well, we don't want people to be suicidal if they know that they have cancer because there's not a lot of we can do and maybe they'll have a mental health crisis, right? Maybe they'll be so depressed they won't want to make progress on other stuff.

And again, we can't really do much anyway. So it's up to you to decide. Do you want to tell the patient? And sometimes even doctors would tell the family, but say don't tell the patient, right? right, because there's not much we can do. I mean, we're a little bit in that place right now where a lot of times a doctor will see that you are very clearly on your weight of diabetes. You're in that pre-diabetic area.

It's like, well, everybody is, right? Everybody's a little fat. Everybody's a little bit pre-diabetic. Everybody's blood sugar is fucked up. Everybody's this is that and whatever. And people aren't going to eat healthy. And people aren't going to eat healthy. I mean, that's crazy.

How could you tell somebody to lose weight or eat healthy or other stuff? again, that's their limited knowledge and awareness of what's possible. So just keep doing your thing and maybe one day we'll hope for a drug that can fix the situation. We don't have to live in that world anymore and we can be a big part of changing things around and that starts with you having access to the information that you need to optimize your health, feel good. So that, let's remember the whole reason why, when you feel good, you can give love and

attention to all the things that matter in your life. and you can be an incredible citizen who looks out for other people, looks out for your family, and makes a difference in only the way that you were designed to make a difference on this planet. So that's why we're doing this all. There's no goal to be just healthy for healthy sake. We have plans and we have goals. We want to make a difference.

We want to be at our grandkids' wedding. We want to be there to run around and whatever it might be. Everybody has their own version of goals. But that's the reason why all this stuff matters. So that was my little rant. I'm so glad you brought it back to that, that the basics there. Like this is not just about getting some A grade on a lab slip, right? This is about actually being able to embody our core passion, our core truth,

what we want to bring into the world and to be able to be a force of light and good in this world. And it's easier to do if you feel good and if your cells are functioning properly. And so it comes back to that. And I really appreciate you bringing it, bringing it back to that. And the opposite of that is when you feel bad, you take your hurt out on everybody else, right? Whether it's emotionally, physically, other stuff, you're just driven by poor motivations. And I really think that a lot of what we're dealing with today in the world, not that it's an easy fix. It's not.

It's going to take generations of people like you and other experts that have been on this podcast that are educating people and creating companies and solutions to help them in that direction. But when you feel bad, you're not a good citizen for the world. world and you add in more hurt to the world because you're hurting yourself. So my heart goes out to everybody that's in that category. And I appreciate everybody who's listening today that is trying to step out of that place if they are in that place. Casey, remind us again, maybe take us through a little bit of a recap, if you could. You know, we covered a lot of information, but it's always nice to get a little bit of a recap. And then we'll close up with some

concluding thoughts. Absolutely. So I'd say in terms of a recap, The first thing I'd say is, um, one, you know, like you said, start to think of your involvement with your lab results as you being the CEO of your health. I love that. And make sure that you're really looking at your lab tests, um, and giving them a critical eye, you know, really looking at them yourself and not just take everything at face value. I would say in terms of some of the bare bones, basic metabolic tests that we want to be looking at at least every year, maybe more frequently. We're talking about fasting glucose, ideally fasting insulin,

hemoglobin A1C, a full cholesterol panel, which includes total cholesterol, LDL, HGLycerides, CRP to look at inflammation. Make sure you are looking at your triglyceride to HGL ratio, which you're going to have to calculate for yourself. And certainly if you can get some liver function tests in there as well, AST, A-L-T, that's great as well. But make sure you're looking at these and looking at them as a whole story.

to get into totally just the specifics really quickly I'll run through them for CRP. We want to make sure generally it's less than one, ideally less than 0.5. LDL, which we typically think of as bad cholesterol, this one's a little bit more complex because on our standard lab panel, we can't see what the sub fractions of LDL are. So the number itself is sort of tough to know what to do with it. We are most care about small density LDL. But once you see your LDL number, first of all, if it's less than about 100, that's great. that probably means that it's low enough that the small density LDL probably wouldn't even

be high enough for it to be a huge problem. So less than 100 is a good sign, ideally less than 70. But once you've got your LDL number, immediately go to your triglyceride HDL calculation, which can be sort of a surrogate marker for your small density LDL fraction. You want your triglyceridyl HDL ratio to be as low as possible, ideally like one or less. but some research suggests that it may be somewhat ethnicity or race specific. So less than 2.5 to 1 in people of Caucasian descent, less than 1.5 to 1 in people of African American descent. Aside from the triglyceride to H.Glyceride, you want to just, of course, zero in on your triglycerides. Most lab panels are going to say less than 150 is normal.

You want to definitely be tighter than that. Less than 100. ideally even lower, maybe even like less than 70. For HDL, higher is better. Ideally, shoot for above 60, but getting up into the 70s, 80s, 90s is great. And then fasting insulin, ask your doctor for it. Maybe share some of the pearls that you might have learned from this episode with your doctor to kind of encourage them to order this for you.

It's actually a really cheap test. It's like $15. And somewhere between 2 and 6, 2 and 8 is, I'd, deal definitely want to be probably less than 10. So that's kind of like the really quick wrap up of kind of what we've talked about. But the key point I would also say is that none of this is medical advice. People should definitely talk to their doctors about the interpretation of these results. And these are just sort of like general things to kind of create a framework for which you should be thinking about when you look at your lab tests. Oh, that's beautiful. And Levels has made

it's super easy. Again, you know, I'm such a big fan. It's why I invest in the company. It's why myself and Dr. Mark Hyman are advisors. We believe in getting access to all this information that's there. And the test is only 179 bucks, which is super affordable, right? If you're going to be looking at, you know, a few meals out can easily end up adding up to that thing. And you get access to all that information that's there and you can sign up levels.com. and the link is in the show notes for anybody who's watching or wants to come back and pull it up a little bit later on. What is some of your hope now? I mean, this is just recently launched, right?

What is some of your hope that of what having access to this information will do for people who already have the CGM or might be using a CGM from levels right now? Like what are your hope in terms of that? And then the larger implications of just everybody having access to this. So my two big hopes are first that for people using a continuous glucose monitor, this can really help them figure out whether the changes they're making based on the CGM data are leading to shifts in these bigger sort of lagging indicators of metabolic health. So for instance, you can imagine if you see on the continuous glucose monitor that Cheerios are spiking your glucose through the roof, which they do for most people,

We can pretty clearly know that that's going to be an excess of glucose in the bloodstream, that the body's going to have to process, and that may be feeding into a high triglyceride level. And maybe if you shift your breakfast to something that does not have a huge glucose load like chia pudding or eggs and avocado over the course of a few months, you might see your triglycerides drop hugely. And so that type of feedback between what you're learning and implementing based on CGM data and how it's actually fitting into your body. bigger metabolic health metrics is really exciting to me.

So it gives people like another layer of closed loop biofeedback about some of these markers that we know are associated with long-term disease risk. I think more broadly, one of the things I'm excited about is getting back to this idea of like the diet wars and there's a one-size-fits-all diet for everyone. Having these, this picture and control over when you order it and when you get these labs done allows you to do dietary interventions in your own life, your own n-of-one experiment, and actually see how it's moving the needle on your lab work. So one thing someone could do is, let's say they, for instance, they pick up the Pagan diet,

you know, Mark Hyman's latest book, which is an incredible, very like sort of healthy Mediterranean-type style diet, very low and refined carbohydrates and sugars. try it for two months, get a baseline of this metabolic health panel, and do it after two months, and watch the numbers change. That is incredibly motivating to keep up some of these lifestyle habits. But for another person, you know, they might be going on a totally different dietary strategy, like all Whole Foods plant base or carnivore. Well, they can actually see for themselves how that intervention shifted their metabolic health panel. So, you know, if the carnivore diet keeps the numbers, in a really great range, good for you. Continue it. If the Whole Food plant-based diet does it,

good for you. Continue it. If Pagan diet does it, that's great. But at least have the data, so we're not just out there yelling about what we think works, but actually focusing on what does work for our bodies. So I'd say those are the two things I'm really excited about. Those are a beautiful thing to want to wish for the world. And for anybody who wants to step out of that polarization of even the dietary space, which I'm very much in that category. I don't even like doing episodes where people are arguing about the best approach because I've been on all sides of it. And I also know that something has worked perfectly for somebody else and it's worked terribly for me. Not to mention all the other aspects of our life that sometimes somebody is a new mom or

dad, right? And they have a period of their life where eating a different way is easier to keep up. There's periods of our life where even though we know that, you know, alcohol is generally not, you know, a supportive thing that's there. I was on the phone with the first. friend of mine just a couple weeks ago with another doctor that I connected them to. And they were like, look, just being super honest, like right now giving up that evening glass of red wine that I have, like a half glass, not like those big glasses, it's just really tough for me, right? It's just really tough for me after having two kids and dealing with a lot of stress that's there. And a doctor is going to meet them where they're out and say, okay, well, let's work on all these other things.

Or they're going to order this panel and say, well, I know you can't do it now, but I just want to show you that if you don't change things, here's where your panel is headed towards. So Casey, that was a great recap, and I'm excited that we have another podcast in the books with tons of free information. Again,

if you want to do these tests, you can sign up with levels. It's only $179. The link is in the show notes below. But even if you don't sign up, I hope you got a ton of value today of tests that you can go and tell your doctor to order for you if they haven't ordered it

and get some indication of some questions you should start asking, especially if your numbers come back, wonky. Dr. Casey Means, thank you for being back on the podcast and delivering, as always. I super appreciate who you are in the world. Thank you so much, Drew.