February 6, 2021

From podcast: https://bengreenfieldfitness.com/podcast/self-quantification-podcasts/cgm/

[00:00:00] Introduction

[00:02:08] Podcast Sponsors

[00:04:55] Guest Introduction

[00:08:33] How Josh Became a Rocket Scientist

[00:12:07] How Josh Became Interested in Blood Glucose Management

[00:19:34] How a CGM Works, What It Measures, And How It Compares to A Blood Glucose Stick

[00:23:35] How the Levels App Calibrates with The CGMs On the Market

[00:26:40] Podcast Sponsors

[00:29:04] Gold Standard Location for Placement of the GCM On the Body

[00:31:20] How to Keep the CGM on Your Body for Long Periods of Time

[00:37:47] How to Obtain a CGM Without Faking You Have Diabetes

[00:39:10] Whether it's Necessary to Wear A CGM in Perpetuity

[00:45:00] What a “Metabolic Score” Is

[00:56:13] What an “Activity Response” Is

[01:01:00] How to Keep Blood Glucose Stable Throughout the Day and Beyond

[01:06:39] Glucose Disposal Agents That May Be Outside the Norm

[01:11:47] Josh's Personal Practices to Stabilize His Glucose Levels

[01:18:22] Final Comments

[01:20:20] End of Podcast

Ben:  On this episode of the Ben Greenfield Fitness Podcast.

Josh:  I need some objective data to drive my daily choices. What am I doing? Am I heading in a positive or negative direction? I have no reason to believe I know what I'm doing anymore.

Ben:  I thought I was God's gift to cardiovascular fitness, but I had gut issues, I had endocrine issues, like I mentioned, like rampant blood glucose issues every time I tested.

Josh:  And people are learning these–ultimately becomes an insight that they can use throughout their life going forward, but it's grounded in this personalization mechanism.

Ben:  Health, performance, nutrition, longevity, ancestral living, biohacking, and much more. My name is Ben Greenfield. Welcome to the show.

Well, in today's episode, I really, truly unpacked continuous glucose monitors in a way that I don't think it's been done before with a super smart dude. So, I'm sure you've seen–it seems like there's kind of like an echo chamber going on right now about blood glucose monitoring. And I really wanted to record for you an episode that got into the ins and outs in the practical aspects, like how these so-called CGM's work, continuous glucose monitor's work, what the really tiny filamentous needle actually measures, how you get them to stick for long periods of time, or in saunas, or in water, how to get them to stick for long periods of time.

How does the phone gather data from the sensor? Is EMF a concern? Do you have to calibrate it with a blood glucose reading? Is it available to only diabetics when it comes to insurance coverage? What do you do about things that might cause it to artificially elevate until you have a bad score like exercise, or sauna, or coffee? Are there certain herbs, or foods, or supplements, or lifestyle practices that do the best job controlling blood glucose that tend to fly under the radar? So, I get into all of this and more on today's episode. I think you're really going to dig it. And all the shownotes for everything we talk about are at BenGreenfieldFitness.com/levels because the guy I interview, he's with a company called Levels Health. That's the way I've been monitoring my own blood glucose.

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Well, folks, as I have mentioned many times before on podcasts, I've been using something called the CGM, continuous glucose monitor, at various intervals throughout my life, or probably about four years or so. Before that, I was doing the blood finger pricks to monitor my blood glucose. That was ever since I got a genetic test and noted that I had a higher than normal risk for type 2 diabetes, and also noted blood glucose levels that were a little bit concerning for me. So, I decided I just wanted to monitor it, and then I got into ketosis, and breath ketone measuring, and blood glucose measuring. And anyways, the CGMs are pretty nifty, but ultimately, I consider this whole idea of glycemic variability, right? Like having an idea of how much your blood glucose is going up and down throughout any given day along with inflammation, which is a little bit more difficult to measure than blood glucose as it typically requires a visit to a lab to be my two top key biomarkers for health and longevity.

And so, because the CGM, the continuous glucose monitors, what allows me to monitor that glycemic variability, is giving me some really valuable data on how my body responds to foods, to supplements, to exercises, to lifestyle practices, even like emotions and people. It's really weird. So, anyways, I wanted to get somebody on the show to dig into continuous glucose monitoring. And if you're like, “Oh, yeah. And I've heard like a billion podcast about how to track your blood glucose.” Don't turn this off. We're going to dive into some stuff that I guarantee other folks haven't covered when it comes to glucose monitoring because my guest is a rocket scientist. That's right, he's a rocket scientist. His name is Josh Clement. Josh, do you say Clemente or Clemente?

Josh:  Clemente.

Ben:  Clemente. I was close. Clemente sounds fancier. So, Josh is a rocket scientist, like I said. And I will allow him to unpack that for us briefly. And worked at SpaceX for six years, managing the team that designed the life support systems in their space shuttles. And he also actually, as I'll also let him share with you, found he had some pretty serious energy fluctuation spike and crash issues and got into blood glucose measuring himself and connected with this company called Levels, Levels Health, which uses the exact CGM system I've personally been using to access and understand my blood glucose in real time. So, once I found out that Levels Health had a super smart rocket scientist on staff who could answer all my, and your, burning questions about CGM, I figured I had to get him on the show.

So, that's the background. The shownotes for everything that Josh and I talk about you can find at BenGreenfieldFitness.com/levels. That's BenGreenfieldFitness.com/L-E-V-E-L-S. So, that all being said, Josh, welcome to the show, dude.

Josh:  Ben, I'm stoked to be here.

Ben:  And you have an interesting background. So, tell me about becoming a rocket scientist.

Josh:  Well, the way it starts out is you just like building things, and that was usually something like an engine attached to something with wheels that went way too fast through the woods. And that's how I grew up. It's just building machines and–

Ben:  In the woods?

Josh:  Yeah, in the woods. My parents, they were all about giving us the space to get our energy out. And so, grew up in Northern Virginia, and we had about 30 acres, and I kind of went wild there, just building crazy stuff.

Ben:  You're just like playing hooky out of school day, building stuff in the forest?

Josh:  Well, actually, my mom was my teacher. So, I was homeschooled K through 12. And so, that gave me a lot of extracurricular time to–

Ben:  No kidding.

Josh:  –just walk outdoors and build stuff.

Ben:  Oh, wow. That's so funny. I was also homeschooled K through 12. I grew up on a bunch of acreage outside of Lewiston, Idaho, where my parents also wanted us to just have free-roaming space. And so, I did not go out and build shit. I shot rattlesnakes and hiked, and maybe made some dams in the creek. So, I'm not wired up the same way you are, but that's super cool that we've got a couple of homeschoolers chatting, which means it's going to be even more geeky interview now.

Josh:  Yeah. Beware, beware, audience.

Ben:  Yeah. So, you built engines out in the forest. And how did that get into rocket scientism?

Josh:  Well, it turned into just mechanical obsession, cars, motorcycles. I had that wallpaper all over my room. I was just obsessed with them. And the way that you build machines in a career path is–well, you can either be a mechanic working through the hands-on part of it, or if you want to do more of the theory and design and developing the next generation of these machines, you get an engineering degree. And so, I don't really remember making a decision to go into engineering. It was sort of just like, “Hey, you got to apply to college now. Here's the application packet. Do so.” And I think I essentially just wrote mechanical engineering down out of almost autonomy. I never thought about it. I don't recall down selecting for. It was the only obvious path for me.

So, I went to school for engineering, continued to build machines through college. I was becoming more obsessed on the side with electric vehicles. And Tesla in particular, at this time, was one of the new names on the scene. Elon was building these electric cars that were getting everyone's attention. And so, I really wanted to go work at Tesla. Anyway, long story short, I got through school. Tesla had almost gone bankrupt. They had just gotten a loan that saved them at the last minute, but they didn't have any engineering opportunities, and the recruiter there said, “You should apply to the sister company SpaceX.”

And I had never really thought, frankly, that I had what it takes to be an aerospace engineer. I was focused on automotive stuff, but I put the application in. I worked all my connections to try and get anyone who knew anyone to say a good word for me, and they called me back, and got in the door. They really just wanted people who could build things. And actually, the majority of SpaceX's engineering team at the time were people who built what's called Formula SAE cars. So, in colleges, they have this program where you build little race cars. And so, most people there were automotive, nut cases like myself. So, I fit right in.

Ben:  Interesting, interesting. So, did you get to work a lot alongside Elon, who's obviously a super popular fellow right now? So, we might as well bring him up.

Josh:  Yeah. On and off. So, it depended on the program I was on. Once I was on that life support program towards the later half of my time there, I spent a lot of time explaining why we were making certain decisions to Elon and hearing his thought process on why that was a good or bad idea, and it was pretty interesting to get to know the way–from an outsider's perspective, the way his brain works. He's a few levels above myself in his ability to see the future and manifest it. So, it's really good learning experience.

Ben:  So, at what point along the way, as you were at SpaceX smoking weed with Elon, did you wind up getting interested in the whole idea of blood glucose management? So, that's kind of a far cry from cars.

Josh:  Well, on the side, I had played sports through most of my adolescence into college. I didn't have that sports outlet once I was getting a career going. So, I actually went and got my CrossFit Level 1 Trainer Cert. I'm now a Level 2. But at the time, CrossFit was my way of staying fit, and I always considered physical fitness to be the best proxy for health. So, at some point, and that's about four or five years into my SpaceX time, and I was hitting this crazy burnout mode where mentally and physically, it just felt like I hit a wall every single day multiple times a day, and my mood was just garbage. I was irritable. I was dragging in between meetings, frustrated, tired. I'd get shaky and just generally felt like I had a terminal illness.

And I actually told my doctor like, “Something is going on here. We have to find out what's happening under the hood because I should be healthy and I just do not feel that way.” So, this kind of energy thing was happening, and I didn't know–I wasn't sophisticated on much of human physiology at the time. And so, it was totally non-obvious to me what was behind the scenes. So, I actually read a paper by Dom D'Agostino, and this was developing a breathing system for astronauts. And so, this is an oxygen delivery system. And so, I was reading a paper about potential for seizures in a high oxygen, high-pressure environment. So, basically, divers, potentially astronauts. Anytime you're hooked up to a breathing apparatus that could potentially malfunction, there's a scenario where you could be exposed to high-pressure oxygen, which can, because of the reactivity, cause seizures.

Ben:  Yeah. I've talked with Dominic D'Agostino a little bit about that just because of all the research he did on ketosis and ketones to manage some of those issues.

Josh:  Yeah. And so, this paper that he produced, which is it was studying mice, but it showed that if they were in a ketogenic state, they could survive five times longer in the same environment without experiencing central nervous system, toxicity, and seizures. And that totally blew my mind. I mean, it was literally a wheel screeching moment for me because up until that time, I was all physical fitness workouts. That's the key to health. I was a calorie in, calorie out, absolute–

Ben:  Right. Me, too. I mean, kind of another category in which we have a similar experience. I think it was like eight years ago when I was on the tail end of my Ironman triathlon career, at least a couple of years out from finishing it up. I thought I was God's gift to cardiovascular fitness, right? I could ride my bike super-fast on the highway and looks good in spandex, and literally, was just like fit as a fiddle. But I had gut issues, I had endocrine issues, like I mentioned, like rampant blood glucose issues every time I tested, elevated insulin, just sucking down fructose and maltodextrin all day long to fuel my racing and my training.

And that's what actually initiated me to write my first book, which is called “Beyond Training,” because I took a dive into biomarker analysis and blood analysis in all these things that athletes who think they're fit, but are actually healthy on the outside and slowly dying on the inside. Don't actually take into account or look into. So, that's super interesting. You came at it from a CrossFit kind of a background, me from an endurance background or ultra-endurance background. But it's such a good point that a lot of people, especially people who are fit–and I see this a lot in the people I work with for lab and biomarker management. Particularly amongst other things, their blood glucose and their insulin is often way out of whack.

Josh:  Yeah. And I mean, it was happening to me, and I really had no idea. But that paper was the first thing that shocked me out of my stupor. I was like, “All you have to do is work out calories or calories.” I mean, obviously, there are hormonal implications to everything we eat. And that point had never come home for me until reading that study. And so, I was like, “This is crazy. I mean, I feel terrible. I feel like I have a terminal illness.” Obviously, just working out harder is not the solution. I need some objective data to drive my daily choices. What am I doing? And I heading in a positive or negative direction? I have no reason to believe I know what I'm doing anymore.

And so, that led to a ton of just research into metabolism physiology. I started pricking my finger obsessively to measure blood sugar. Couldn't make our tails of it. I then read Robb Wolf's book “Wired to Eat.” And in that book, he briefly touches on CGM technology. And I was like, “Man, that is what I need. I have got black and blue fingers and no idea what's going on. So, I just need that continuous data stream.” Asked my doctor for one. He was like, “Absolutely not. You're not diabetic. This is something that only people who have blood sugar dysregulation that's much worse than anything you've got going on should care about blood sugar levels.” That wasn't satisfactory to me, so I eventually got a CGM. And I found that, just like you had mentioned in your triathlon days, my blood sugar was absolutely out of control. I mean, it was like literally jagged peaks, deep canyons, spikes, crashes, pre-diabetic range, diabetic range after meals, hypoglycemic reactive lows where I just wanted–irritability through the roof. No energy. You just wanted to go to sleep.

All of this interoception, these feelings I had were suddenly connected to a data stream. And thinking about the hormonal implications, the insulin, what's happening behind the scenes, it was just immediately obvious to me that I needed to totally overhaul my lifestyle. I had no idea at the time what optimal should look like, but I knew it wasn't that. And so, I then turned this into a passion project, left my other projects behind, and ultimately decided what needs to happen is we need to increase accessibility of this data, this technology, and then improve the actionability of it. So, take this requirement to go study primary literature away and build the WHOOP or the Oura type experience for real-time glucose data.

Ben:  Interesting. So, a lot of people, they're familiar with the idea of measuring blood glucose, I think, on a very shallow level. And many people may even use like an Accu-Chek or some other blood glucose monitor from Walgreens or CVS to prick their finger and test their blood glucose. But what I'd love from a rocket scientist homeschooler standpoint, and I'm not going to call you Josh anymore, I'm just going to call you the rocket scientist homeschooler, how does a CGM work exactly? And what I'm specifically curious about is what it's measuring and how you would compare and contrast it to the blood glucose stick.

Josh:  So, CGMs, they are measuring glucose molecules, which is really key because it's not like an approximation or anything. They're interacting with glucose molecules. Now, the way it works is you have this patch, this typically a disc or an oval shape that you wear. It's adhesively attached to the skin, and there's these little filaments, kind of like a hair that sticks down into the skin, and it's measuring and interacting with sugar molecules in what's called the interstitial fluid. So, interstitial fluid is, it's basically a sub-solution of blood. It's kind of like filtered blood. And so, it's not exactly capillary blood, but it's very similar. And the difference is that interstitial fluid is slightly filtered and it takes a little bit longer to respond than your main bloodstream.

So, what that means is if you were to take a finger prick measurement and then compare it to a CGM in the moment, there could be a deviation, especially if things are changing quickly. So, for example–

Ben:  Right. So, basically, if you'd eaten a high carbohydrate meal and then you test using a CGM or look at your CGM because the CGM is testing the interstitial fluid, which is not directly the blood, what you may see is that if you compare that to a blood glucose reading, the blood glucose reading is going to be higher than the sensor glucose reading, at least temporarily because the interstitial fluid is catching up to the blood measurement?

Josh:  That's right. Exactly. So, it's like a phase shift. So, the patterns and trends tend to match really nicely, but they'll be offset somewhat, and this can cause some confusion because people will oftentimes got check the sensors with finger sticks, and I've done this myself. It took me awhile to recognize that, oh, there's this physiologic process happening where blood is then filtering out into the tissues towards the surface of the skin, which isn't instantaneous. So, your bloodstream changes, but then it takes a little while for that to get to–closer to the surface of the skin where that filament is. Of course, you could make the filament much longer and it could extend deeper into the body, but that could get uncomfortable, and there's a bunch of other side effects that you don't necessarily need that, given that, like we're talking about, the patterns and trends match really nicely.

Ben:  Okay. Now, quick question about that, because this might not be somebody who hasn't used blood glucose monitor, continuous glucose monitor, would understand, but a lot of them actually allow you to calibrate to your blood glucose finger prick measurement. And that's always confused me a little bit because why would you calibrate to a measurement that your sensor is lagging behind? Wouldn't that result in like an inaccurate calibration? Or what's the deal with the whole calibration thing?

Josh:  Yeah. So, historically, the calibration has mostly been a function of, like what you're saying, the desire to measure blood glucose, but with an interstitial sensor. And this is really important for people who are, for example, dealing with diabetes and need to be able to both monitor and manage very quickly. So, for someone, for example, that has type 1 diabetes where you have to use exogenous insulin to manage your glucose levels, it's pretty critical to understand as quickly as possible where you are so that you can either inject the appropriate amount of insulin. Or if necessary, if you're experiencing a low, you can get sugar into the body to re-stabilize immediately. So, the reason those calibrations existed, as far as I'm aware, was the intention of trying to get interstitial fluid readings to match blood readings as closely as possible in time. So, these calibrations actually try to estimate where your blood is based on where your historical interstitial fluid values are, if that makes sense. So, they're almost predicting the future a little bit and trying to shift in time.

So, as we get into the more wellness use case where you're not actively managing a condition, I think that that delta between blood and interstitial fluid values is going to go away. And we're just going to focus on interstitial glucose because that's really–as we mentioned, the patterns are the same and we don't need to know immediately. We just need to learn the lessons about what's happening. And a lot of us, we have this sort of interception, which I'm sure you've experienced where you feel some things, and then you see the data and you're like, “Oh, that's what that means, connecting those dots.” So, that helps as well.

Ben:  Right. Okay. So, do you need to actually calibrate when using–for example, I'm using the levels which–and we'll get into the different styles of blood glucose monitors, but I've got the FreeStyle Libre, which is the actual piece with the long filamentous, tiny hair-like needle that goes under my skin that I attached to my body, that I change out every 14 days, and that is measuring my blood glucose and then sending the reading of my blood glucose to my phone, to the Levels App on my phone. Do I need to do any calibration with the Levels App, or have you found that to be necessary?

Josh:  So, right now, the Libre–basically, there are two devices out there, two manufacturers, and the Levels App will integrate with both Abbott and the Dexcom, which is called the G6.

Ben:  Oh, it works with the Dexcom, too?

Josh:  Yeah. Well, we're rolling that out very soon.

Ben:  I was going to say, “Hook a brother up.” You know what, actually, I'm more interested in using a Dexcom, not only for accuracy reasons, but also because–and this is probably getting into the weeds, but I believe it was a conversation that I had with Dr. Mercola about whether or not these blood glucose monitors–and my audience may be one of the few audiences that you speak to who actually cares deeply about this, whether or not it produces any appreciable amount of EMF, electromagnetic fields, or non-native EMF, particularly. And while to my understanding, and correct me if I'm wrong, neither the Dexcom nor the FreeStyle rely upon an appreciable amount of Bluetooth. And do they, by the way?

Josh:  The Libre does not. The Dexcom actually does. So, the Dexcom is streaming on Bluetooth low energy. So, it's the ultra-low energy spectrum on Bluetooth, full time. So, you don't need to scan the device. Whereas the Libre, on the chip, it stores about eight hours of glucose data, and you need to scan the device with your smartphone, and it uses what's called near-field communication, which is a very, very low frequency and power band wireless transmission protocol.

Ben:  Yeah. That clarifies. So, what Dr. Mercola was saying was he's actually–and I think it was him who I had this discussion with. The low-level Bluetooth produced by the Dexcom is far less problematic than the potential wireless signal produced by the FreeStyle. So, if you're concerned about EMF or EMF hypersensitive, a lot of people would do better with the Dexcom regardless of the fact that I think the Dexcom is more accurate, and also more convenient because it's just tracking all the time.

Josh:  Yeah. I mean, it's interesting. We really like the two different form factors. Both, I think, have their place. The Dexcom's a little bit more like–it's like the Level App from the Libre in a couple different ways. It's got a slightly more complex application process right now. But as you mentioned, it's got a really great track record of accuracy, and generally, the Bluetooth streaming, especially for athletes. And if you're on the bike and you want to see your glucose in real time, whether for fueling or for just pacing yourself, you can do that without having to scan. So, lots of really interesting stuff. And that's why we're building in this flexibility to be able to work with both sensors.

And the other interesting thing is both of these technologies, the Libre and the G6, are factory calibrated. So, the Dexcom actually offers the ability. If you want to manually calibrate with a finger stick, you can do so. But both of them are actually calibrated at the factory to a known glucose concentration. So, that allows you to just apply the sensor and never have to prick your finger as long as you're not worried about, like I said, a few percent of deviation between interstitial and blood values. And so, that makes it very convenient for those of us who just want to put this thing on and forget about it, and learn from the data, and not necessarily have to carry around a finger prick kit.

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So, you've got this really tiny filamentous needle that goes under the skin. And the next question I have for you is I've been wearing my monitor on the back of my arm because I've found that to be more convenient, and it feels better. And I seem to get similar data as I do when I put it on my abs. But would you say there's like a gold standard location for the placement of the monitor?

Josh:  So, both the manufacturers have taken a slightly different approach here. The Abbott device, the Libre, was developed and tested in the back of the upper arm location. Whereas the G6 was tested in the abdominal location. I think what's necessary is that the sensor filament be in softer tissue, not directly in the–if you have thin skin area and a lot of musculature low body fat, it might go into the muscle itself, that filament, and that can cause issues with the–what I've seen with like the contraction of the muscle affecting basically like local pressure, it seems like, or something, and moving–it can seem to interfere with glucose values. I don't have enough data to [00:30:11] _____.

Ben:  That's good to know because I'm actually very low body fat and got massive guns. Not really, but I do have like lean muscular arms. And so, I wonder–and I use them a lot. I have a lot of triceps muscle contractions because I have little Pomodoro breaks I take throughout the day. In any given hour, I'm probably dropping and doing like 30 to 50 pushups. So, my triceps are just working all day long. So, I'm wondering if I might actually get a better reading from my abdominals, which are–I don't even carry much fat there, but I guess those are the top two locations, am I correct, the triceps or the abdominals?

Josh:  That's right. I've noticed, and I've tried both, I've noticed that the difference is minimal enough that it doesn't really affect me and how I'm using the data. But more importantly, I find the back of the arm much more comfortable and much more convenient. So, I usually use the back of the upper arm. I go right between like the upper tricep in the deltoid. That's the softest region right there between the tricep and deltoid for me. So, that's where I put it, both Dexcom and Abbott. I'll wear them both up there. And yeah, I just generally don't like having something on my stomach. Sitting down or anything like that becomes uncomfortable.

Ben:  Okay. Got it. And then, another usage question. How do you get yours to stick for long periods of time? And that would include like in water, in saunas, or in hot tubs. I have a trick that I've found, but before I get into that, I'm curious what you do.

Josh:  Yeah. So, there's two kinds of things that I focus on here. The first is that the adhesive is going to be very sensitive to oil and skin flaking. So, actually, most skin cells will only live about two weeks' total, and then they'll start to flake off. So, it's pretty important given that these sensors can–the Libre, for example, last for 14 days. That's like the entire lifespan of the skin cells. So, I always make sure 100% of the time that I shower and scrub the application area really well before I put a new sensor on. Anything–

Ben:  I just use an alcohol wipe. I mean, do you think that would do it, or you do a full-on shower?

Josh:  I do the full-on shower because I think that removing that–like sort of those cells on the outermost area or the outermost surface area will–the cells, by making sure that you've removed any that are already flaking, you can make sure that you're not going to end up having some skin cells starting to flake off while the sensor is under there. I also use the alcohol wipe, but mostly to sanitize it. Make sure it's fully sanitized. And then, I let it dry completely. So, I've gotten the best results by just doing that shower alcohol wipe and then application process. I have no problems getting the full two weeks out of them. The second thing though is the performance covers we're working on.

So, we've done a ton of iterations on these. Basically, they're a larger footprint than the sensor itself. And we also have this backing where there's the center disc. Essentially, that prevents the sensor from sticking to the cover, and that allows you to replace these covers numerous times without peeling the sensor out. And that's been huge for me. Pre-COVID, I was training for a triathlon and I was doing a ton of full time, and it was really important that I was able to replace that cover essentially a few times per sensor because–the cover would start to peel, but it would have protected the sensor from peeling in. And that's huge, especially for spending a ton of time in the water.

Ben:  Okay. That's actually really good to know about cleaning the skin beforehand. And I'm sorry about the triathlon, by the way. I had actually a few people I was coaching for triathlons before COVID hit and they all got canceled or else moved to, “Do your own race inside your home gym,” which nobody was too excited about.

Josh:  That was [00:33:44] _____.

Ben:  I know. I actually signed up for a kettlebell cert that keeps getting moved farther and farther forward. So, I told my wife last night, I'm like, “Okay. I'm done swinging kettlebells.” I'm like, “I want to do this cert, and then move on to something else.” So, anyways, the thing that I found is that the adhesive tape–before, I was using the Dexcom and just would go to Amazon and buy CGM adhesive tape. But then, there's also like a topical, and I found this on like a diabetic forum. I forget what it's called, but it's like a topical adhesive, almost like a glue that you can apply over the tape. Have you experimented with that much?

Josh:  Yeah. So, you can get these wipes that are called Skin Tac.

Ben:  Yeah, Skin Tac, exactly.

Josh:  S-K-I-N-T-A-C. Yup. And you can basically, after you clean the area, they're pre-sanitized. So, the adhesive is clean and you can basically rub that in the area and it will leave this little–it will basically seal the skin and help with the same issue. It works really nicely. I don't use it all the time because I've been able to get things to work without it, but definitely, a ton of people say that that works really well for them as well.

Ben:  Yeah. If you do a lot of sauna, or much hot tub, or anything like that, like hot/cold thermogenesis–like I've found the Skin Tacs actually vastly increase the amount of time that the thing stays on, or that the tape stays on. So, that's a tip I'll give to any of you, you active folks out there. I also wore my CGM a few times during Spartan races where you're just crawling on the ground, and scraping and get shit, and found that it was pretty effective for that, too. I would warn people that if you use the Skin Tac, if you can put it–like open the windows or put on outside because it does have a little bit of a chemical content and chemical smell. And initially, you don't to be huffing that stuff into your sinuses. So, do it the same way you would use paint, basically. But once you get it on, it's fine. It's not going to be toxic once it dries. And really, it's over top of the tape, so not much is getting absorbed through your skin or anything like that, unless you're like super-duper orthorexic. I don't think it's something you have to worry about.

Okay. So, the next thing, and I realize I'm just asking a lot of practical questions here, Josh, but I'm hoping this is really helpful for people who want to use a CGM and just don't know a lot of these things. I don't think get discussed enough. Everybody talks about why to measure blood glucose and why having blood glucose normalized is healthy. But I think most of my audience is kind of familiar with that, so I just want to dig in a lot of this more practical stuff. So, anyways, from an insurance standpoint, if people wanted to get one of these, I guess can you walk me through the process of getting a CGM? Because I think that confuses a lot of people thinking they have to go to their doctor and pretend to have diabetes.

Josh:  Yeah. Well, I ran into the accessibility issue myself when I was first trying to get a CGM. The mainstream perspective is that this is a device for the management of diabetes strictly and you don't really need to worry about this otherwise. But obviously, as we all know, there is huge value in, first of all, managing what you can measure. And first, you need to measure in order to manage. And of course, none of us want to just get snuck up on by metabolic dysfunction. And in fact, many of us can benefit from actively focusing on building metabolic fitness by tracking these things the way that we track heart rate or sleep quality.

So, right now, the devices that are available are all prescription only. So, they're Class 2 or Class 3 medical devices, which in the United States require prescription, and that requires a physician's order. So, traditionally, you had to have diabetes in order to get that because that was the most common use case. So, Levels is developing–our platform and package includes a physician consultation for that specific reason. So, speaking with telehealth providers who are familiar with the use case for CGM outside of diabetes management. And so, anyone who gets CGM through the Levels platform, it comes with that prescription and that allows one year of pharmacy fulfilled sensors. You're not buying some sort of grey market thing, and it also is fully forward in terms of what is needed.

Now, insurance does not yet consider the use case for the wellness use of CGM to be a coverable use, right?

Ben:  Unless you have diabetes.

Josh:  Unless you have diabetes. That's right. And so, right now, Levels, for example, is cash pay only. You're totally allowed to get access to it, but it's just not going to be covered by insurance. Certain insurance providers seem to be willing to reimburse, but that's on a case by case basis. I'm certainly optimistic that as more people adopt this, as the data set gets larger, as clinical research is conducted, showing that people who track this glucose information are improving their quantitative risk of chronic illness, it's only a matter of time until insurance companies become increasingly open to covering for really anyone.

Ben:  Right. And so, if that weren't the case and weren't covered by insurance, what's the approximate cost for someone to, say, jump in, let's say, using a platform like Levels and to start like a monthly blood glucose monitoring?

Josh:  Yeah. So, the Levels program, the first month, which includes that physician consultation, includes a series of reports, the two Libre sensors and an access to Levels software. That first month is $399, all-inclusive and it's direct to your doorstep. And then, you can get ongoing subscriptions for just the sensors after that first month, which are $199 a month.

And right now, the devices are fairly bespoke, they're expensive, obviously not being covered by insurance. The price is a little bit stiffer right now, but with time, we've seen a really dramatic improvement in the unit cost of CGM sensors just in the past two, three years. And I think that trend is going to continue, especially as market forces work, right? As you get increased adoption, demand goes up, supply goes up, we're going to get, I think, a really nice improvement over the coming years as this becomes more common and more mainstream.

Ben:  Now, do most people use theirs the entire year? And the reason I ask is kind of like ketone measurements, for example, I will dip in and out throughout the year to keep my finger on the pulse of my blood glucose. But I'll go sometimes without putting it on just because a lot of times I'm eating in a similar fashion. I'll track it for a few weeks, and then until I change my diet, or my lifestyle, or my exercise dramatically, or I'm having something going on, like let's say a sleep issue or an energy issue that I want to get more insight into, I will not wear it. I'll take a break. I'm curious if that's common, or if most people just wear these all year long.

Josh:  Well, I think there's a ton of individuality here. I'm a person who I feel–essentially, my accountability comes from what I'm measuring. So, I've made the decision that I want to maximize my every day. I want to be optimizing my lifestyle and doing whatever I can to improve my performance mentally, physically, and also my longevity. And so, having that metric is a massive accountability piece for me. So, it keeps me–

Ben:  Yeah. I agree. I wear the Oura ring, for example, and it is incredibly motivating for me because I look at my step count literally at the end of every day and I will go for a walk. I'll go for postprandial stroll after dinner if I haven't hit 15K steps. And I realized that, speaking of orthorexia, that sounds a bit anal, but it's just like my metric. And if I'm not wearing the ring, I really don't care that much. I kind of lose track, I don't move as much, I don't take as many postprandial strolls, I don't go up and down the stairs as much or take my Pomodoro breaks. But if I just know, regardless of any workout that I do that I want to hit a 15,000 step count, what gets measured gets managed I believe is the saying–you may have been homeschooled better than I was, so you might know if that's exactly how it goes.

But yeah. I mean, essentially, I have noticed that, that there's a little bit of a cognitive shift as silly as it seems. You'd think if you knew, and you had been measuring at various intervals throughout the year, that you would just make the right dietary choices anyways. I've actually found when I wear it, even when I'm at a restaurant, I just know that if I got to look at my data later, I'm just more careful. It's just a weird irrational human psychology, or maybe it's rational human psychology.

Josh:  Yeah. I think it's self-preservation. When you're faced with something that you know is detrimental, you're very unlikely as a human being to make that decision, right? It's just when we can put it out of sight and out of mind that we make those decisions that compound negatively over time. So, if you could get a live look at your lungs every time you smoke a cigarette, I think very few people would do it. It's just the fact that you can wait decades before you get that cancer diagnosis. And similarly, with metabolic dysfunction, you can eat junk for a long time and we're flying blind. We don't have feedback on that.

So, once you get the feedback loop, it's a totally different experience from somebody saying, “Oh, you shouldn't eat that,” or, “Eat healthier, workout more.” It's like, now, this is your body saying, “That's not great.” And also, on the opposite side of the coin is when you get–at least for me, when I get that positive feedback of a great day where my glucose was–I was nailing both time and range, postprandial work was awesome, and I'm seeing the benefits of exercise, focus, effort, repetition. All the things I've been doing paying off in better glucose management and correspondingly insulin management. I feel great about that. It feels just like waking up. And I use WHOOP rather than Oura, but I wake up, I check my recovery score, and I'm excited about it. And all these wearables, they should have that mechanism where it is driving better behaviors. And so, I certainly feel that generally, we just want to meet people where they are. So, if you're the type of person that wants to wear a CGM one month every quarter or continuously, that it's available, the technology, and accessibility should be such that you can do that. And that's alright if that's what you would want.

Ben:  Right. Okay. Now, I want to dig into the actual dashboard itself because when I use the FreeStyle Libre, for example, it comes with the app, the Libre link app, which is pretty bare bones. I mean, it just gives your blood glucose and the daily graph, the daily trend. You guys are doing some interesting things at Levels. And one of the first things that I see when I open up my app on my dashboard, I see something called my metabolic score. So, what's the idea behind the metabolic score?

Josh:  So, this is a metric we've been developing and certainly going through iterations on to fine-tune, but it gives you an idea directionally of how well your metabolic system performed that day. So, the idea is that taking in a number of composite background metrics. So, things like rate of change, the amount of variability, your average glucose, time, and target range. There's all this stuff going on behind the scenes. We can filter that down into a single score that shows you sort of like a grade on a test. Out of 100%, how well you perform that day. And so, the intention is that over time, you start to connect the dots between the lifestyle choices you make on specific days and the quality of that metabolic score. And the goal is to shoot for 100%, just like in most things in life, and string together streaks of really high-quality metabolic scores. And so, that's the metric that you focus on as the bottom line for how well you are functioning, how well you're treating your metabolic system, and how well it's treating you.

Ben:  Okay. Now, there are some things that actually concern me a little bit about the metabolic score because there are certain activities that I think confuse people because they cause a glucose excursion yet do not result in a problem with long term down the road, say, insulin desensitization or poor blood glucose management, because it's a transient rise typically of glucose do to your liver, releasing storage glycogen that then spikes the blood glucose in response to a metabolic stressor that's arguably healthy. And what I mean by that is many people will see their blood glucose rise even if they haven't had, let's say, sugary sports drink, or gel, or something like that beforehand during a high-intensity exercise session or weight training session. Even in a fasted state where the liver releases glycogen, and that results in an elevation in blood glucose that can often stay elevated, depending on how intense the workout is and how much epinephrine, or norepinephrine, or adrenaline was released during the workout for an hour afterwards sometimes.

And I have seen this same thing occur, and this is also primarily due to the epinephrine and norepi response. The same thing happens with sauna, with heat stress, you see–actually, I see a massive spike in blood glucose during my sauna sessions. A lot of folks will have a fasted morning cup of coffee, or like no sugar, no milk, totally black coffee. And again, because coffee causes like a mild metabolic stress, kind of surgeon energy, there's one way that it works, and it's the cortisol response in that case that can cause a rise in blood glucose. Now, all of these are not because you're consuming a food that's sugary, or because you're necessarily metabolically broken, it's the body's natural response to provide energy to you during stress. And the interesting thing is long-term exercise normalizes blood glucose and insulin sensitivity. So does hyperthermia and sauna, which I recently did a podcast on, which I talked about the benefits of cold and heat coffee arguably. You see in some studies a massive drop in risk of diabetes in response to coffee consumption, yet all of them spike blood glucose. And what I'm getting at here is if someone is regularly, like me, doing exercise, and sauna, and drinking coffee, aren't you going to see that artificially show on the Levels App that you have a poor metabolic score, when in fact, your metabolic score is just fine and probably is going to be improved by such practices?

Josh:  Yeah. I love this line because this is the core of the intelligence we're building into the Levels system. So, we're still relatively early in the process of taking CGM and turning it into a platform for non-therapeutic use case, right? And there's a ton that we're working on behind the scenes to develop intelligence to detect these sort of healthy adaptive stressors that you just touched on a great number of them and adjust accordingly to incentivize instead of de-incentivize. So, the intense exercise, for example. I see the exact same effect, those glucocorticoid hormones being released, cortisol epinephrine. My blood sugar has reached over 200 on a CrossFit workout and stayed elevated above my target range for over an hour.

And that being said, high-intensity interval training, it's associated with cardiovascular development, insulin sensitivity in the long-term. This is something we want to incentivize. And so, we've recently rolled out a strenuous exercise detection. So, by integrating with Google Fit Apple Health, we can use other wearable data like your accelerometers, your heart rate data to detect, oh, you're actually working out. This is not you eating Chick-fil-A or something. This is a high-intensity workout, and we will auto-detect that. We'll surface that and we'll actually remove that data point from your metabolic score calculation.

Ben:  Okay. This is really fantastic. Sorry to interrupt, but are you saying that if I had my Oura ring and I've checked on my iPhone that I'm okay with the powers that be at Apple having full access to all my health data with my Oura ring feeding into my Apple health that by the nature of that, the Levels App will then be able to detect via my Oura, the rise in heart rate or the rise in activity level, and account for that as being an activity that spike blood glucose and not, say, a dietary sugar consumption error that spike blood glucose?

Josh:  Exactly. Yup. That's live today. So, you have to also authorize the Levels App to access Apple Health. Once you have that setup, yeah, we're pulling in heart rate movement data and glucose info and we know–and we can auto-import that workout. And so, now, rather than you having to log it, we know exactly when it happened and we know that it was strenuous because you saw both a high threshold heart rate, which was sustained, and you saw a glucose elevation. So, we won't dock points or we won't cut out, notch out the workout timeframe if your glucose does not elevate.

Ben:  I love that.

Josh:  We're detecting this stuff. And we're getting smarter about it, and this is a constant improvement based on feedback. But yeah, that's already in place. But then you've got stuff like sauna, which you touched on. This is a little bit trickier because most thermal or most wearables don't expose thermal data. So, they don't tell you–

Ben:  Well, the Oura does it. It'll tell body temp data.

Josh:  It does. That's one of the few, and it actually doesn't–there's no Apple Health integration for that, unfortunately. So, a direct integration might be possible in the future to do something like that. It's really interesting to think about. And so, we should probably talk to the Oura folks about. But yeah. So, as more wearables start to expose thermal data, we're going to be able to do a much better job at detecting sauna. And one of the ways for now people can just–if necessary, they can just log a workout at that timeframe or something along those lines to identify that this is a stressor that's probably adaptive. For example, Dexcom has thermal couples or resistive thermal devices inside their sensors, and it's possible that we could get access to that to identify both cold and hot thermoregulation. And so, I'm optimistic we're just going to be able to continually improve all of these adaptive stressors to the point where your metabolic score is in actual depiction of how your system was stressed by these non-adaptive factors like food and legitimate lifestyle stress that should be controlled, right?

Ben:  Right, right.

Josh:  We'll get there. And I'm glad you touched on the coffee one.

Ben:  I was going to say, “What about coffee?”

Josh:  Yeah. That one is interesting. So, I'm personally super sensitive to caffeine, it seems. And I'll have like a 20-point spike on a delicious cup of black coffee every morning. I'm trying to figure out more about this. I think I really want to get some studies underway. Hopefully, we can be involved in that from the Levels side to look deeper into the caffeine mechanism. I think you're right that it's like cortisol response, but it's so individual. Some people have absolutely no movement as a result of drinking coffee. I don't know if I'm one of the lucky ones or one of the unlucky ones, but I want to learn more about that.

Ben:  It could be related to some of the CYP genes or any other genes responsible for whether you're–a lot of people are familiar with this whole idea of being a fast versus slow caffeine metabolizer. And it could just be that fast coffee oxidizers or fast caffeine metabolizers will see a more distinct rise in blood glucose. I wouldn't be surprised by that. There's all sorts of different things you could experiment with the test. It's like drink decaf and see if you see a similar blood glucose response. In which case, it might be that you have a little bit of like a coffee bean protein allergy that's mounting like a little bit of an immune response, which is very interesting because blood glucose rise after meal can theoretically, especially if it's a low glycemic index meal and you're seeing a big rise in blood glucose, indicate a cortisolic response to that meal that might be kind of like food allergy, or immune reaction based.

I've noticed that happened. Like I, on my Cyrex food allergy testing, I test allergic to very little. But interestingly, and I consider Cyrex to be one of the gold standards for food allergy testing, the one vegetable that I actually test to have an immune system response to is green beans. And the reason I found that out is because every time I'd have green beans, which were a staple in my diet for a long time–we love to have roasted green beans with dinner and green beans at Thanksgiving, I'd see a spike in blood glucose, which you would not expect from a plant legume like that. And then, once I wound up testing, it turns out I'm allergic to green beans. And now, it makes total sense why my blood glucose, in response to a vegetable that normally wouldn't spike blood glucose, becomes elevated.

So, the same thing could–some people do have coffee reactivity or coffee gluten cross-reactivity. And so, that could be a factor. Another factor could potentially be whether it's like organic versus non-organic, like mold, or fungal, or pesticide exposure. It could be whether you're a fast or a slow coffee oxidizer, like there's a lot of different ways that you could test something like that to see. But ultimately, I think it's probably nitpicking at a relatively meaningless issue because we know from most data, long-term coffee consumption actually normalizes blood glucose. So, I'm not personally too concerned about it. I think the metabolic benefits of regularly drinking coffee exceed any short-term rise in blood glucose that might result from consumption of it.

Josh:  Yeah, yeah. My opinion is if that's the last thing, the last straw, everything else has been optimized, I'm in a good place. Yeah. So, I'm going to–

Ben:  And if I got to die early from like a horrible blood glucose management issue and it strips a couple of weeks off my life, but I've got to drink a cup of coffee every morning, I'm kind of cool with that. So, you have metabolic score. Another term with which I was unfamiliar that is on the app is called an activity response. What's the activity response?

Josh:  So, activity response is a way of basically categorizing everything that you do in your day. So, we're all making decisions every day. Some people are sitting down for lunch. They want to know what to eat and why, they want to know how their body's responding to that lunch. Some of us are going into stressful meetings. Some of us are drinking coffee, exercising. All of these are activities that have metabolic implications. And none of these choices happen in a vacuum. So, actually, all of our actions compound together and create an environment or a context that our bodies are operating in.

So, an example of this is you eat a meal and you have, based on how your glucose levels change, how quickly, how high, how quickly they come back to normal. We can monitor how that is happening and make assumptions about the hormonal effects of that decision, right? So, eat a big meal, your blood sugar spikes, and then crashes back down. We can make assumptions based on what we know of the human body on whether or not that was a good meal for you and we can score that. Now, let's say you eat that same meal, and then you take a postprandial stroll. So, you finish the meal out, put the dish in the sink and you walk out the door and walk for 20 minutes. The effects of that walk, using the large muscles in the posterior chain, it can immediately supplement your metabolic system. So, those muscles are pulling glucose out of the bloodstream without the need for insulin, using it directly for energy, and helping to sort of blunt the effects of that same meal.

And so, those two things coupled together, the meal and the walk. And combined, you're going to see a different metabolic response, and that should be scored differently. And so, what the Levels App does is it detects these combinations of activities as they're happening, and surfaces them for you as insights. So, you can compare, let's say, a pizza. If you're going to indulge, you have a pizza, you sit on the couch and kind of sleep it off, and then the next day, you eat the same pizza and you go for 25-minute walk right afterward. Those two things are completely different in terms of the way your body likely responded, and you can compare those using features like our comparison function. But ultimately, the goal is to show you how your activities compound together and can affect different outcomes. So, if you are going to indulge, it's teaching you that you have some power to control your metabolic response.

Ben:  I dig it. So, I could even use like–because what I do, I'm totally into time hacking and I eat, in many cases, the same type of meals day in, day out. So, in my Levels App, my morning smoothie, I don't have to re-input all the ingredients or anything like that every time. I just click on the morning smoothie that's already saved in the Levels App. But what it can do is it can also pull in my different activities, whether I walked, whether I took a cold shower beforehand, whether I had a sauna that morning, a cup of coffee, a blood glucose disposal agent, which we'll talk about momentarily. And then, it will actually show how my blood glucose may respond differently to that meal based on how I hacked my day to one activity versus another.

Josh:  Exactly. And again, we're building more intelligence. And each wearable, so like the Oura versus other wearables, they'll all have different ways of surfacing activities. So, we're slowly developing the range of activities that can be auto-detected. but if you log, if you log a walk as a workout and those types of things where you're manually making sure that everything is covered, you can very quickly learn these deeper insights that some of them are very counterintuitive, some of them are very intuitive. But over time, you start to get the sixth sense for how you can modify to optimize, make these little micro-optimizations and get a digital receipt for it, how the Levels App show you that that work. You just ate that indulgent meal, but you walked it off.

And then, for people who are going through life changes, where one of the four levers of metabolic function, or lifestyle decisions rather, nutrition, exercise, sleep, stress, one of those is compromised. So, let's say you just had a baby and your sleep is totally blown up. Well, once you learn the connection between poor sleep and insulin resistance, acute insulin resistance, and the way that that affects glucose management, that lesson is really powerful and you can start to realize that when I'm compromised on sleep, it's even more important that I make up for it with effective combinations of activities, whether that's the nutrition I choose or the way I add postprandial locks to every meal that is further on the glycemic load spectrum. But you start to learn that it's actually–when I'm most tired, I'm most frustrated, I'm most likely to cheat on my meals, that's actually when I need to make these optimizations even more critically than otherwise.

Ben:  Yeah. And speaking of micro-optimizations, which by the way, someone needs to buy microoptimizations.com, if you haven't snagged that one yet. There are some things that I want to get into. I have discussed many times on my show before, and so this isn't going to be a newsflash for folks that the number one thing more than anything else that allows me to have stabilized blood glucose the rest of the day, even when eating an appreciable amount of carbohydrates is morning cold thermogenesis. And we're not talking like a 20-minute ice bath. We're talking about even as little as three to five minutes of relatively cool cold, like 30 to 40-degree plunge into–I have this unit called the Morozko Forge outside my office that I'll go take a dip into. And even before a meal, quick cold shower, cold brisk walk outside, et cetera, beats the pants off of just about anything.

And so, that would be one example of how to improve your insulin sensitivity or your blood glucose response. Long term, we've talked about how activities such as exercise, sauna, or even coffee might actually normalize it as well. But I'm curious, because you guys have built into the app this idea of challenges, and so if I open up my Level App, I see all sorts of different challenges that I can engage into that I assume other people would actually be also doing. So, you guys are probably getting some data here, and correct me if I'm wrong, about what type of things people are doing on a day-to-day basis that's actually causing them to have a higher metabolic score.

Is that kind of what the challenges are allowing you guys to gather data on?

Josh:  Well, the Levels dataset is large and there's a ton of various user populations inside of it. So, we're generally learning a huge amount about the implications of certain decisions. This is essentially an unstudied space. It's entirely green fields and the idea of what is optimal in terms of glucose management remains to be seen, and specifically to individuals who have different phenotypes, right? So, over time, we are learning more and more about outcomes of specific actions over longer terms. The challenges are a really good way to see individual sensitivities. And rather than just doing those behind the scenes, we're exposing that to the user because it's really valuable to understand specifically how you respond from one decision to the next. So, the challenges are–

Ben:  Okay. So, it's more of like a chance for you to compare.

Josh:  That's right. It's a way for you to compare. So, an example would be–and actually, I'll provide a little context here. The individuality of glucose response is pretty incredible. So, there is a study you're probably well-familiar with in cell that was published in 2015. It's the Weizmann Institute trial. And they–

Ben:  The day two trial in Israel?

Josh:  Yes, right. Yeah. They took 800 people without diabetes and put CGMs on. And they studied a whole host of things, but one of the most interesting lessons learned was that two people who ate the exact same two foods, in this case a banana and a cookie made with wheat flour, can have equal and opposite blood sugar responses to those two foods. So, one person spikes on the bananas, flat on the cookie, and vice versa. So, the implication there is that it's likely that they're having equal and opposite hormonal responses. So, equal and opposite insulin release. And that has all these other downstream effects.

So, those results were also supplemented or replicated by the gluco types trial at Stanford, the predict trials that are still ongoing in the U.K. And actually, the predict trial showed that that effect even continues to twins. So, you have identical twins that share 100% of DNA. They also can have very, very different glucose responses to the same choices. And that kind of flips this whole glycemic index, one-size-fits-all concept on its head, and it's really important that the individual is not comparing themselves against the average, but it's actually comparing themselves against themselves and identifying the optimal choices.

So, the challenges are grounded in that concept where you can test different foods that may be a part of your staple, they might be recommendations based on what we've seen inside the dataset. But you can see, for example, how brown rice versus white rice affects you, how a smoothie that's blended up with a lot of ingredients versus a whole fruit or a whole vegetable affects you, poor sleep versus good sleep, adjusting the meal order. So, whether you're putting carbohydrates upfront or protein upfront. And people are learning these–what ultimately becomes an insight that they can use throughout their life going forward, but it's grounded in this like personalization mechanism.

Ben:  Yeah. And I've got my Levels App out right now. I just looked at my phone and there's some cool ones in there, like vinegar versus no vinegar, or cinnamon versus no cinnamon. Those are two things that we know are our GDAs, glucose disposal agents, that would actually, when taken before a meal, in most cases, actually will allow for a lower blood glucose response to that meal, particularly like a couple teaspoons of Ceylon cinnamon. It's relatively high volume based on the studies on cinnamon, but that's easily put into a smoothie or a shot, literally like one shot of apple cider vinegar. I've experimented with both those and they do both work for me for lowering blood glucose, rice versus cauliflower rice, fresh starch versus cold starch. Like if you cook a potato, then cool it, then take it back out and reheat it, or the same with rice.

For me, personally, and for many, many people in this, again based on research, better blood glucose response. I mean, you've got everything from all that stuff to like water with a meal versus water without a meal. And so, it's pretty cool. You can begin to really identify the things that are going to be impactful for blood glucose. So, one thing I wanted to ask you about related to these challenges is if you've looked into, because I don't see them written in the challenges because now we're getting into the whole messy world of supplements, which I know is rife with a lot of bias and sometimes marketing is blown out of proportion, but have you looked into blood glucose disposal agents that go beyond kind of like the standard Ceylon cinnamon or apple cider vinegar like berberine, or bitter melon extract, or even a pharmaceutical like metformin? Have you guys gathered much data about whether any of those work or compared any of those?

Josh:  So, it's a great question. We don't yet have any sort of publishable or statistically significant result there, but for most of our users who are not managing a metabolic condition, they aren't typically taking something like metformin. Berberine and some of those others, I've tested myself. I've tried a few different blood sugar control capsules that include these sorts of supplements. And I haven't really noticed a big effect. And if there is one, it doesn't seem to be significant. And actually, just like the regular perturbations in what I'm doing tend to be much more significant.

So, I have yet to see, and it could be another situation where it's just kind of individual. And maybe someone else is seeing a dramatic result. And that's the fascinating thing about increased access to individual data is that we can start to go n of 1. If the average doesn't work really well, but for an individual, it has a massive impact on glucose, well, that's great. I mean, that's a good thing for that person to know and they should probably implement that.

For me, the biggest one is just consistent exercise and consistent sleep. Those are by far, besides my sensitivities to certain foods, which I improve portion sizing or just remove, those are the biggest levers for me. If I can manage my schedule consistently and hit those, my glucose is significantly better, and those are my levers.

Ben:  Yeah. For me, outside of anything in the realm of pill-popping, it's cold and weight training. And then, from a supplementation standpoint, I got my hands on some metformin and I compared it to some of these blood glucose disposal agents. And actually, I see a really, really good response to two compounds that I've experimented. One which I compared against metformin, and one that I didn't have a chance to compare against metformin because I got it after I'd already used my metformin. This was a relatively recent one. But the most recent one was dihydroberberine, kind of a more biologically available derivative of berberine that seems to inhibit the mitochondrial respiratory complex and have a really profound impact on blood glucose. And they're looking into it now as like a novel therapy for the treatment of type 2 diabetes.

You can actually get it now in supplemental form like on Amazon, for example, but it's a far more bioavailable form of berberine, which I think we're going to see probably popping up in the diabetic and blood glucose management literature a lot more. So, that one, I've seen good responses to. And then, full disclosure, this sounds like the fox guarding the henhouse, but I developed this after a bunch of kind of internal testing. And that's the formula I developed at Kion, my supplements company, which is basically a blend of a concentrated extract of bitter melon with panax ginseng and astragalus, kind of a compound called InnoSlim. So, it's wild bitter melon blended with InnoSlim. And that one, two capsules before carbohydrate-rich meal, I compared that to metformin and saw an equivalent response in blood glucose management.

So, that's one that I know based on testing actually works. And we did a bunch of testing and developing that one. Those are a couple, dihydroberberine, and then the wild bitter melon combined with the InnoSlim that is in the Kion Lean that I've found to–it's still not going to touch like cold thermogenesis or weight training or a lot of these lifestyle practices. I don't want to make people think they can pop a pill and go eat a pizza and get away with it, but those are a couple I found to work.

Josh:  Now, I definitely have to try those two you just mentioned because I do not yet have experience with them, but I'm always fascinated by these mechanisms that are not quite a pharmaceutical grade.

Ben:  Yeah, yeah. And arguably, more affordable. So, the other thing I actually wanted to ask you about was just from usability standpoint, is there a way to scan? I haven't figured this out. Maybe I'm just [01:09:29] _____. Is there a way to scan straight from the Levels App, or do I still need to open the Libre link, scan with the Libre link, and then the Levels App imports that?

Josh:  The short answer is you can't yet scan straight from the Levels App. The longer answer is this is something we desperately are working towards and it's essentially a regulatory situation where the–right now, the Libre link software and the hardware itself are combined considered a medical device. And so, we're a third party to that. And if we interface directly with the hardware, we need an approval for that. And it's something we can get, something that we're working towards, but it's just a matter of making sure we dot our i's, cross our t's before we roll that functionality out.

Ben:  Okay. Got it. I also wanted to ask you, being a rocket scientist homeschooler with an insider working knowledge of blood glucose management, what your own, besides some of the things you've already highlighted, like CrossFit or walking after a meal, what your own personal practices are that you specifically do yourself based on your previous history with crashes and spikes, and your obvious interest in this, what some of your insider hacks are or any best practices that you haven't had a chance to share yet.

Josh:  Yeah. I mean, I've completely remodeled my nutrition and removed a ton of the old staple. So, I mean, I was basically having rice or brown rice or sweet potatoes with every meal. I used to be this–like I picked up all of the traditional sports science talk, where it's like you got to replenish glycogen after every workout, you got to be carb loading in order to hit the gym and perform at your peak. And in reality, once I had glucose information, I'm having these smoothies that are bran flakes, there's a banana in there, there's like protein with sugar in it. I'm drinking this thing. My blood sugar is going through the roof and then crashing back down. I'm having a reactive hypoglycemic event right as I step into the gym to do the first rep. And it suddenly became clear why I'm yawning at the beginning of workouts, and I'm supposed to be hyped up and hitting this. So, I've completely removed these glucose spiking food ingredients. I eat a low glycemic diet. I prioritize protein for sure. I moderate fat. I'm not ketogenic, but my goal is to maintain consistency, and I get my energy through that consistency.

So, I'm not having these crazy fluctuations. I'm not looking to lift cars and flip those overall day. I don't need a ton of circulating glucose. And all the side effects of that certainly cause enough to manage them. So, I'm pushing more towards nuts and seeds. I swapped out like oatmeal, for example, for chia pudding. Absolutely, chia seeds are like my secret weapon now. I have chia pudding with almond butter. I'll typically go with collagen protein these days, but I'll add some protein in there, mix that up, and it's just a delicious morning breakfast for me.

And that collagen example, instead of whey protein, I've been biasing more towards the collagen because I tend to get a reaction to the way, and it's pretty insulinogenic. And so, I'm also trying to obviously manage insulin. So, collagen tends not to have that effect for me. And then, some other stuff, you're just biasing towards fat mobilization. I was always in the CrossFit space working out in the glycolytic regime really hard, anaerobic workouts. And I've lately been doing more endurance training, trying to train fat adaptation and metabolic flexibility, which I really don't do well. I have a long way to go to get to the point where I'm able to really consistently maintain I think that fat mobilization that I would want to be able to perform in an endurance environment and–But I'm making moves. I practice intermittent fasting pretty consistently. And over time, there's just been this tremendous sort of food freedom where I now eat for function as opposed to out of requirement. I no longer have that like crazy cycle of hunger and irritability driving my food decisions, and I'm much more consistent.

And then, the other big thing is just stress. I mean, obviously, starting a company, super stressful, as you know, and maintaining sleep management and just stress management, like taking time out to breathe and chill out. It's really crucial, and not only for CGM management, but–or sorry, not only for the stress management side of it, but also for glucose management. I see that effect in real-time when I'm letting my heart rate climb, and blood pressure climb, and my cortisol levels are going through the roof and blood sugar's following it. It's pretty amazing to see and it really drives home that all of these four things are connected. I've got to maintain mindfulness and high-quality sleep or my metabolic fitness is gone.

Ben:  Yeah, yeah. I mentioned that briefly in the introduction when I was talking about toxic relationships and how I've found even something as simple as an argument with a loved one will spike the blood glucose, which is just super interesting, especially when you look at a lot of the data on things like bitterness and anger in traditional Chinese medicine, and the correlation between toxic relationships, and emotions, and chronic disease. And I would not be surprised if elevated blood glucose report insulin sensitivity was playing some kind of role in that as well. And the other thing that I'd be remiss not to mention is the–I went to India a few months ago and there is a pretty significant rise in diabetes there without a concomitant increase in carbohydrate consumption. And you actually see this even in U.S. epidemiological data.

A lot of times, sugar thrown under the bus, and carbohydrates thrown under the bus, when in fact, there's more of a correlation between the rise of vegetable oil consumption, and linoleic acid, and canola oil, and a lot of these processed seed and nut-based oils with poor blood glucose management and diabetes. Then there is little sugar and carbohydrates because of the impact on the cell membranes and a lot of the insulin sensitivity issues that occur along with the resistance of fat cell to lysis and the inflammation that's produced via fat cell hyperplasia, or hypertrophy, like an increase in the size of the fat cells in response to high vegetable oil consumption.

And so, that's another thing that I just want to remark upon. And there's some interesting studies, and I'll link to them in shownotes if you go to BenGreenfieldFitness.com/levels. That's where I'm keeping track of everything that Josh and I talk about. And there'd been studies in which they have fed mice, for example, oils such as coconut oil and palm oil, and found that there really wasn't much of an effect on plasma lipids or on the blood sugar increase. But then, you see everything from rodent studies all the way up to human studies a vast increase in insulin resistance and in poor blood glucose management in response to high linoleic acid vegetable oils.

And there's even one study I'll link to in the shownotes, a human study in which they found that reduction of animal fats and replacement of animal fats with vegetable oils, which a lot of people think is a healthy thing to do, that actually resulted in increased cardiovascular disease and all-cause mortality, including an increase in blood glucose and a drop in insulin sensitivity because of something as simple as like stopping marvelly red meat and consuming canola oil instead. And so, I think that the vegetable oil consideration here is something important as well. It'd actually be interesting to add that in as a challenge for you guys, and the challenge part of your app is like, I cooked my eggs in coconut oil versus like spray-on pam or something like that. And I'll bet you'd see some differences there as well.

Josh:  Yes. It's pretty fascinating. I mean, ultimately, I think it comes down to energy toxicity when you overfeed with poor quality ingredients, whether that's vegetable oils or carbohydrates. I think you can ultimately reach a state of energy toxicity where things start to go haywire and being able to–ultimately, we want to be able to incorporate additional analytes. We know just the glucose breakdown byproduct of carbohydrate consumption is not the panacea. It's a really interesting and important indicator of metabolic function, but we want to get to the point where we can get a little bit deeper and add additional analytes that give insight into some of these more fatty acid-related concerns. And it's a tricky one to solve because the massive rise in consumption of all of these hyper-processed, and ultimately, I'll call them synthetic ingredients that did not exist in nature until humans came along. It's going to take some time and we need to course-correct across all of the nutrition spectrum.

Ben:  Yeah, yeah. Well, you guys are doing some cool stuff at Levels regarding this. I think that we have like a special code, because you guys have like a waitlist going, and I believe the way that you're running things is that if people hear this show and they want to get shoved to the front of the waitlist, so to speak, we have a special link. And what I'll do is I'll put that in the shownotes at BenGreenfieldFitness.com/levels. And then, you click on that and that'll get you access to go to the landing page. We'd get access to the app.

Josh:  Yeah. The link should be levels.link/ben.

Ben:  I think you're right. Yeah, levels.link/ben. Yeah. And I'll put that in the shownotes, too.

Josh:  Awesome. Yeah. And we're in this development mode still. We're doing early access. We have, as you mentioned, a very long waitlist. And definitely, looking to get great feedback on the product and continually developing. So, even if you don't want to jump in on early access, definitely check out our website, levelshealth.com.

Ben:  Yeah, yeah. Well, Josh, this has been a fascinating discussion, and it's always fun talking to a fellow homeschooled geek who also happens to be interested in health and fitness.

Josh:  Absolutely.

Ben:  It's a rare unicorn who's as weird as us, but hopefully, people got some good information out of this. And I would encourage everyone, if you haven't tried a continuous glucose monitoring system at least once in your life to get a real understanding of everything that's going on, you really should because it's so biochemically individualized and you get such a massive amount of actionable data. I put it right up there with like sleep tracking, or activity tracking, or HRV tracking, or any of these other metrics. So, Josh, thanks so much for coming on the show and sharing all this stuff with us.

Josh:  Ben, thanks so much for having me. Thanks for being a support of Levels and I'm stoked to do more of these.

Ben:  Awesome, awesome. Alright, folks. Well, I'm Ben Greenfield along with Josh Clemente signing out from BenGreenfieldFitness.com/levels. Have an amazing week.

Well, thanks for listening to today's show. You can grab all the shownotes, the resources, pretty much everything that I mentioned over at BenGreenfieldFitness.com, along with plenty of other goodies from me, including the highly helpful “Ben Recommends” page, which is a list of pretty much everything that I've ever recommended for hormone, sleep, digestion, fat loss, performance, and plenty more. Please, also, know that all the links, all the promo codes, that I mentioned during this and every episode, helped to make this podcast happen and to generate income that enables me to keep bringing you this content every single week. When you listen in, be sure to use the links in the shownotes, use the promo codes that I generate, because that helps to float this thing and keep it coming to you each and every week.

 

As I've mentioned many times before on podcasts, I've been using something called a “continuous glucose monitor” (CGM) at various intervals throughout my life for about 4 years or so.

Considering that, as I write about here, I regard glycemic variability (which is exactly what these CGMs track) and inflammation (which is a bit more difficult to measure as it typically requires a visit to a lab) to be my top two key biomarkers for health and longevity, my use of a CGM has given me some very valuable data on how my body responds to certain foods, supplements, exercises, lifestyle practices, and even emotions.

But how does a CGM work, exactly? 

What does the really tiny “filamentous” needle actually measure?

How do you get yours to “stick” for long periods of time, or in water? 

How does the phone gather data from the sensor, and is EMF a concern?

Does the sensor have to be calibrated to a blood glucose reading due to the fact it is recording interstitial fluid vs. blood? 

Is this type of thing, from an insurance standpoint, that is only available to diabetics? 

What do you do about activities that cause high glucose excursions, such as exercise/sauna/coffee, etc., which wind up decreasing the metabolic score when, long-term, those are all glucose stabilizing/insulin-sensitizing activities?

Are there certain supplements or herbs that do the best job controlling blood glucose?

I explore these questions and many others in this podcast with Josh Clemente. Josh is a rocket scientist who worked at SpaceX for 6 years, managing the team that designed the life support systems in their space shuttles. Over time, he started to notice extreme levels of fatigue and experienced volatile spikes and crashes of energy throughout his day. For someone who worked out consistently and followed the guidelines for what he believed to be healthy practices, it didn’t seem to add up.

After experimenting with glucose monitoring, he realized that he was pre-diabetic (borderline full-blown diabetic) and that the foods he was eating were having a significant impact on his performance. It was this discovery and struggle to derive actionable insights from his glucose monitoring that led him to start Levels.

Today, at Levels Health, Josh and his team are revolutionizing the way people think about their metabolic health. And why is metabolic health so important? Before Levels, an average person had no way of understanding how efficiently or inefficiently their body was producing energy. Levels enables you, using a new CGM system, to access and understand this information in real-time—so you can start making better diet and lifestyle choices to avoid those energy peaks and valleys.

During this discussion, you'll discover:

-How Josh became a rocket scientist…8:50

• Josh was homeschooled and experimented a lot with engines as a child
• Studied mechanical engineering in school
• Became enamored with Tesla's electric cars
• This led to a career with SpaceX

-How Josh became interested in blood glucose management…32:05

• CrossFit was his way of remaining fit when his career began
• Hit a wall multiple times per day: irritable, tired, felt like a terminal illness
• BGF podcasts with Dominic D'Agostino
  • Which Ketone Supplement Works Best: Ketone Salts vs. Ketone Esters.
  • A Deep Dive Into Ketosis: How Navy Seals, Extreme Athletes & Busy Executives Can Enhance Physical and Mental Performance With The Secret Weapon of Ketone Fuel.
• The Ketogenic Diet and Hyperbaric Oxygen Therapy Prolong Survival in Mice with Systemic Metastatic Cancer– paper by Dominic D'Agostino
  • Mice could survive 5x longer in the same environment while in a ketogenic state
• Beyond Trainingby Ben Greenfield
• Wired to Eatby Rob Wolf
• Doc would not allow him access to a blood glucose monitor
• Saw need for a device that measures blood glucose levels in real-time

-How a CGM works, what it measures, and how it compares to a blood glucose stick…19:33

• CGM measures glucose molecules via a patch attached to the skin
• Filament in the skin interacts with sugar molecules in interstitial fluid
• Interstitial fluid reading in a CGM may vary slightly from a blood glucose monitor reading
• Calibration estimates where the blood levels are compared to the interstitial fluid
• Important for people with diabetes who need to monitor blood glucose quickly
• Interstitial fluid monitoring is preferable from a general wellness point of view

-How the Levels app calibrates with the CGMs on the market…24:00

• Freestyle Libre(no Bluetooth at all)
• Dexcom G6(trace amounts of Bluetooth used)
• The Shocking Truth About You Getting “EMF*D”: 5G, Wi-Fi & Cell Phones – Hidden Harms & How To Protect Yourself with Joe Mercola.
• Both devices are factory-calibrated to a known level of glucose concentration

-Gold standard location for placement of the GCM on the body…30:45

• Librewas tested in the upper arm
• G6tested in the ab location
• Upper arm is the more comfortable location

-How to keep the CGM on your body for long periods of time…31:00

• Adhesive is sensitive to oil and skin flaking
• Shower and scrub application area before applying
• CGM adhesion tape
• Skintac Adhesive Barrier

-How to obtain a CGM without faking you have diabetes…37:50

• All devices currently available are prescription only
• Levelsplatform includes physician consult and prescription
• Insurance doesn't recognize a CGM as a legit use without diabetes
• Approximate out of pocket cost – $399 first month, $199 thereafter

-Whether it's necessary to wear a CGM in perpetuity…39:15

• It's up to the individual and their own goals or need for accountability
• “What gets measured gets managed”
• Feedback on one's lifestyle greatly influences our decisions
• WHOOP
• Oura Ring

-What a “metabolic score” is…45:15

• Number of metrics compounded to give a “grade” on your performance for a day
• Fire & Ice: Tips, Tricks & Biohacks To Maximize The Benefits Of Sauna, Hyperthermia, Cryotherapy & Cold Thermogenesis.
• Certain lifestyle practices may distort the metabolic score (exercise, caffeine, etc.)
• Levels rolled out “strenuous exercise detection” to account into the metabolic score
• Cyrex food allergy test

-What an “activity response” is…56:15

• All activities have metabolic implications
• Assumptions made on whether a meal is good or bad for you
• A meal with or without a post-prandial walk affects the activity response
• “Compromise” when variables such as sleep are lacking

-How to keep blood glucose stable throughout the day and beyond…1:01:00

• Cold thermogenesis(3-5 minutes daily)
• Morozko Forge
• Levelsapp contains “challenges” to maintain stability, ID individual sensitivities
• Weizmann Institute 2015 trial Josh mentions
• Equal and opposite hormonal response, insulin releases

-Glucose disposal agents that may be outside the norm…1:06:45

• Berberine and its more biologically available derivative, dihydroberberine, inhibit mitochondrial respiratory complex I: a mechanism for the action of berberine to activate AMP-activated protein kinase and improve insulin action
• Dihydroberberinesupplement
• Kion Lean
• Consistent exercise and sleep are the biggest factors in managing glucose levels

-Josh's personal practices to stabilize his glucose levels…1:11:45

• Removed glucose-spiking food ingredients (rice, sweet potatoes, etc.)
• Consistency is the most important factor
• Chiapudding with almond butter
• Collagen protein
• More endurance training for fat mobilization
• Intermittent fastingconsistently
• Eat for function vs. for requirement
• Stress management
• Sleep management
• Maintain healthy relationships; avoid toxic relationships
• Medicines and Vegetable Oils as Hidden Causes of Cardiovascular Disease and Diabetes

-And much more!

Resources from this episode:

– Josh Clemente:

• Levels Health

– Podcasts and articles:

• Which Ketone Supplement Works Best: Ketone Salts vs. Ketone Esters With Dr. Dominic D’Agostino.
• A Deep Dive Into Ketosis: How Navy Seals, Extreme Athletes & Busy Executives Can Enhance Physical and Mental Performance With The Secret Weapon of Ketone Fuel With Dr. Dom D'Agostino.
• The Shocking Truth About You Getting “EMF*D”: 5G, Wi-Fi & Cell Phones – Hidden Harms & How To Protect Yourself with Joe Mercola.
• Fire & Ice: Tips, Tricks & Biohacks To Maximize The Benefits Of Sauna, Hyperthermia, Cryotherapy & Cold Thermogenesis.
• The Complete Guide to Fasting: How To Heal Your Body Through Intermittent, Alternate-Day, and Extended Fasting with Dr. Jason Fung
• 5 Simple Steps You Can Take To Live Longer, Banish Blood Sugar Swings & Massively Enhance Energy Levels.

– Books:

• Beyond Trainingby Ben Greenfield
• Wired to Eatby Rob Wolf

– Gear and supplements:

• Freestyle Libre
• Dexcom G6
• CGM Adhesion Tape
• Skin Tac Adhesive Barrier
• WHOOP
• Oura Ring
• Morozko Forge(use code BENFORGE to save $150 on any Forge)
• Dihydroberberine
• Kion Lean
• Collagen Protein

– Other resources:

• Cyrex Food Allergy Test
• The Ketogenic Diet and Hyperbaric Oxygen Therapy Prolong Survival in Mice with Systemic Metastatic Cancer
• Berberine and its more biologically available derivative, dihydroberberine, inhibit mitochondrial respiratory complex I: a mechanism for the action of berberine to activate AMP-activated protein kinase and improve insulin action
• Medicines and Vegetable Oils as Hidden Causes of Cardiovascular Disease and Diabetes
• Personalized Nutrition by Prediction of Glycemic Responses

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