#225: Casey Means, MD -Improve Your Metabolic Health with a "Food as Medicine" Prescription
Follow Dr. Casey Means on Instagram
We hear the phrase, “metabolic health” a lot, but do we really know what that means? And, more importantly, how much do we understand the massive impact that metabolic health has on literally every system of our body?
Today, we explore that line of thinking with Dr. Casey Means.
Casey was trained as an ear, nose, and throat surgeon, but in recent years, she has become a self-proclaimed “Food as Medicine” evangelist.
Why would she make such a drastic change in a successful budding career? Well, as you’ll hear today, Dr. Means (like most doctors) pursued medicine in order to help people, but started realizing that most illnesses - even those she was treating as an ENT surgeon– came back to a person’s level of inflammation and poor metabolic health. So, as a surgeon, she was playing the proverbial “whack-a-mole” with the problems but never identifying the root causation.
Now, she’s on a mission to create a healthier world through her company, LEVELS Health - a continuous glucose monitor company - along with her upcoming book, Good Energy. Dr. Means also emphasizes the need for a metabolic framework in our healthcare system and the importance of nutrition education for doctors.
Today, we focus our conversation on exactly what metabolic health really means, as well as the Nine Elements of Metabolic Health. Casey also discusses the importance of metabolic health as it relates to exercise and even sexual health.
Those Nine Elements Include:
Micronutrients
Fiber
Antioxidants
Omega 3 Fats
Fermented Foods
Minimize Sugar
Food Timing
Eat Organic
Combine Food Optimally
Episode Highlights
0:10:36 The Connection Between Food and Metabolic Health
0:14:01 Metabolic dysfunction in a leading cause of death in the US
0:18:00 Awareness of personal agency in metabolic health is lacking
0:21:05 Physician attrition and burnout linked to lack of progress in patients
0:21:49 Pills and Procedures vs. Lifestyle Medicine
0:25:41 Importance of Micronutrients for Metabolic Health
0:31:41 Micronutrients: The Power of Eating for Cellular Health
0:36:18 Challenging the Medical System's Bias Towards Interventions
0:44:33 Easy Ways to Increase Fiber Intake
0:56:04 The Benefits of Fermented Foods
1:00:04 The Variety of Fermented Foods Available
1:03:12 The Impact of High Fructose Corn Syrup on Health
1:06:28 The Importance of Self-Regulation and Eating Real Food
1:12:44 Fitness Spending vs. Obesity: A Surprising Connection
1:15:42 The Connection Between Sexual Health and Metabolic Health
1:19:52 Erectile Dysfunction and Metabolic Dysfunction
1:22:08 Impact of Diet on Sexual Health in Men and Women
1:26:00 Sexual Dysfunction in Women and Its Relation to Metabolic Dysfunction
1:35:10 Part 2: Exploring Insulin, Glucose, and Continuous Glucose Monitors
Dr. Casey Means, co-founder of Levels Health and “Food as Medicine” Evangelist
About Casey Means, MD
Casey Means, MD is a Stanford-trained physician and Chief Medical Officer and Co-founder of metabolic health company Levels. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tech-enabled tools that can inform smart, personalized, and sustainable dietary and lifestyle choices. Dr. Means’s perspective has been recently featured in the Wall Street Journal, New York Times, The New Yorker, Men's Health, Women's Health, and more.
Episode Resources
Dr. Casey Means Instagram
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Full Transcription via AI Transcription
[0:01] I'm Rip Esselstyn and welcome to the PLANTSTRONG Podcast.
The mission at PLANTSTRONG is to further the advancement of all things within the plant-based movement.
We advocate for the scientifically proven benefits of plant-based living and, envision a world that universally understands, promotes, and prescribes plants as a solution to empowering your health, enhancing your performance, restoring the environment, and becoming better guardians to the animals we share this planet with.
We welcome you wherever you are on your PLANTSTRONG journey, and I hope that you enjoy the show.
[0:41] Hey everyone, welcome to the PLANTSTRONG podcast. I hope that you all had a fantastic, Thanksgiving with family and friends, and that you're getting back into the swing of things as we move through our week.
I want you to know how much I appreciate all of you, how grateful I am for you taking the time to listen to the podcast and to enhance and hone in on your PLANTSTRONG lifestyle.
Now, we hear the phrase metabolic health get tossed around a bit, but do we really know what that means?
And more importantly, how much do we actually understand regarding the massive impact that metabolic health has on literally every system of our bodies?
Today, I want to explore that line of thinking what Dr. Casey means.
She was trained as an ear, nose, throat surgeon, but in recent years, she has become a self-proclaimed food as medicine evangelist.
Why would she make such a drastic change in a successful budding career?
Well, as you're going to hear today, Casey, like most doctors, pursued medicine in order to help people, but started realizing that most illnesses.
[2:09] Even those that she was treating as an ear, nose, throat surgeon, and came back to a person's levels of inflammation and poor metabolic health.
Now she's on a mission to create a healthier world through her work and her company Levels Health, a continuous glucose monitor company.
Today, we're gonna focus our conversation on exactly what metabolic health really means, as well as the nine elements of metabolic health.
Casey also discusses the importance of metabolic health as it relates to exercise and even sexual health.
I was super impressed by her wealth of knowledge, and I think that you will too.
So let's get into it with Dr. Casey Means.
[2:57] Casey, welcome to the show. Thank you so much for having me. My pleasure.
So Casey, how in the world did you get the name Casey as a first name?
I have a really, one of my best friends in the whole wide world has a daughter and her first name is Casey, but you don't hear of a lot of women whose first names are Casey.
I love that question and I am so embarrassed to say that there is like not a great reason for this.
My parents truly just loved the name.
I will say I was originally named Paula Casey Means.
So my first name is actually Paula, which was after St.
Paul, who was a saint that my parents liked quite a bit and his message.
And when I graduated from medical school, I actually legally dropped Paula from my name because that was the time when you're getting licensed and you're getting your white coats embroidered and all this stuff and everything was going to be Paula, which I knew would be confusing for the rest of my life with the first name Paula, but I went by Casey.
So now I have no middle name and I'm just Casey means. Wow. Nice and simple.
Well, good move. It worked for you. Yeah.
[4:15] So tell me You're a doctor and you're working to create a healthier world.
That's like something you're really after.
You're doing some really incredible things. Tell me this, what kind of doctor are you and why did you decide to go into medicine?
Mm. Well, I trained as an ear, nose, and throat surgeon.
So head and neck surgery, ENT, otolaryngology, they are all the same field.
And I was so attracted to that field in medical school because so much of the way we interact with the world is through our head and neck. It's all our senses.
[4:58] And people can really lose faculty of these different senses, smell, taste, voice, hearing.
And I wanted to be a part of helping people, you know, maintain and preserve their senses and really be able to engage with the world as deeply as possible.
And that's just those patient stories in medical school of people who had to have their, you know, their parts of their larynx and their voice box removed or lost their hearing for all sorts of different reasons, or couldn't breathe through their nose.
Like all of these things just really touched me on a deep level.
And I felt really inspired to work on this amazing, complex part of the body.
[5:39] I went into ENT, I trained, I went through four years of surgical residency, and it was very interesting because what I found, and you know, it's funny, as a medical student, you pick a specialty to go into without, you're like 24 years old and you're picking this thing that you're gonna do for the rest of your life.
And it's interesting, this sort of disconnect between what you think you're going into and then what actually really is, is the reality.
And one of the things that was so interesting to me.
When I went into ENT and I'm four years into my surgical training is that I realized that almost every single condition that I was treating as an ear, nose and throat doctor was inflammatory in nature.
You know, like the suffix in medicine for inflammation is itis.
And so what I kind of, I kind of woke up and I was like, everything I'm treating is an itis.
It's sinusitis, laryngitis, tracheitis, thyroiditis, cellulitis, otitis, you know, all these different, um, itis's and, And fundamentally, inflammation, it's the upregulation of the immune system.
It's inflammatory cells in tissues for a long period of time, sort of spewing out all these inflammatory chemicals that creates that swelling and that redness that we associate with inflammation.
And when this is happening in these small areas in the head and neck, like the voice box or the trachea or the ear or the sinuses.
[7:04] It becomes very symptomatic and problematic.
So a lot of what we do as ENT doctors is we either use steroids to decrease that chronic inflammation, or with surgery, we punch holes in things like the eardrum or the sinus wall, or we dilate things that are swollen and closed.
And we basically create more space that the inflammation has essentially impinged on.
So that was really interesting. And I thought, huh, I'm basically an inflammation doctor in many ways as an ear, nose and throat doctor.
[7:36] And it really struck me in this hit like a ton of bricks for me four years into my training that I was not clear what was actually causing that inflammation.
Like it's not, it's not normal for the defense system of the body to be chronically activated.
That's what's leading to these symptoms. And it's like that it's essentially like a war is being fought all the time. But instead of ever asking what's causing the war, we just are constantly going to battle with it with steroids and surgery. And it really struck me.
This is ultimately a cellular physiologic problem that we're basically approaching with this like heavy hammer of drugs or with plumbing with with surgery that doesn't actually do anything to affect what might be causing those cells to be so activated and sort of waging this war inside the body.
So that actually sent me, that was six years ago or so, and that sent me on a totally different trajectory that has led me actually to no longer be a surgeon anymore and to be a company founder and to be really a food is medicine evangelist because what I discovered in that journey of asking why, why all the inflammation, why all this threat signal in the American can body, a lot of it leads directly back to food. And, the really sort of the frankenfood, this non-food sort of like chemical substances.
[9:06] That make up the majority of the American standard American diet today.
You know, almost 70% of the foods in our grocery stores are ultra-processed.
[9:15] Packaged foods that were made in factories so far from the actual soil and the ground that our body's expecting.
And so that was kind of the journey of from an ear, nose and throat doctor to really a Food is Medicine evangelist and really believing that if we can fix our diets, we really reduce that threat signal in the body.
You know, we eat almost 70 metric tons of food in our lifetime.
And you can imagine if 70% of that is sort of these artificial, totally altered substances that our bodies never really evolved to eat, these proteins that are kind of novel and different.
Of course, that's gonna be a huge threat signal for the body.
So how do we get back more towards beautiful, nutrient-rich.
[10:05] Whole foods that our body is expecting, that it wants, that allow it to be in a safer situation and ultimately reduce some of that chronic inflammation that's leading to not only ear, nose and throat issues, but so many of the other chronic diseases that are killing Americans today.
Well, that's fascinating how you went from ear, nose, throat to doing what you're what you are to now and how those kind of those docs kind of connected for you.
And obviously, you are insanely passionate about what you're doing now. It's wonderful.
The Connection Between Food and Metabolic Health
[10:36] I want to go a little deeper. So you mentioned some things you mentioned this, you know, the cells a lot and, and how almost 70% of the foods in the grocery store are coming from a factory and the soil, um, you, you're all about metabolic dysfunction.
Right? And conversely, trying to get people to have metabolic health.
And I think that it was, I think you said that, what, 93% of Americans have metabolic issues?
And you want to expand on that?
Yeah, absolutely. I mean, and it's not coming from me, it's coming from the research literature.
Recent research, as of as recently as last year, looking at large populations of Americans shows that 93% of people in this particular study have.
[11:30] At least one biomarker of metabolic dysfunction. And this was actually a follow-up to a study that was done more like four years ago from UNC that showed that 88% of American adults have at least one biomarker of metabolic dysfunction.
[11:44] So it had, between these two studies over a couple of years and different populations, so hard to exactly know, but looks like it's getting worse essentially every year.
This parallels with other statistics we're seeing, which is that life expectancy is also going down in the US over the past four years, the first sustained drop in life expectancy in well over a century.
And so there's really, I mean, ultra alarming trends happening with essentially our core cellular processes that are just absolutely crippling the American population and our ability to have long, healthy lives and to, you know, reach our highest purpose in this lifetime, because in many ways, ourselves, there is evidence that ourselves are breaking under the stress of the modern industrialized environment that we're living in that essentially ourselves aren't prepared to handle.
And what we see is that Thank you.
The forces that we're living in, we're bodies of 37 plus trillion cells living in an environment, and that environment is really synergistically hurting the parts of our cells that do our metabolic processes, our mitochondria in particular.
[13:02] And this leads to, metabolism is how we make food, how we make cellular energy from food energy.
It's a conversion process of taking all this food energy and converting it into an energy that our cells can use.
And our lives are just simply the bubbling up of all the chemical reactions happening in those 37 plus trillion cells.
And all of those chemical reactions require cellular energy to occur.
So if we have a problem converting food energy energy to cellular energy, we get essentially cells that are malfunctioning little machines.
And then what you end up getting is all sorts of different symptoms and diseases that if you trace it back to the inside of the cell, really fundamentally are about an underpowered cell, a cell that is breaking under the weight of the environment.
Metabolic dysfunction driving leading causes of death in the US
[14:01] And so that term metabolic dysfunction, what it might bring up for people is like, okay, that sounds like I feel like I've heard that in relation to like obesity or type two diabetes, like a lot of people can put those kind of words together.
But what I think what is under recognized in our country and definitely in the medical field is that metabolic dysfunction is actually driving almost every leading cause of death in the United States.
And so many of the other symptoms that we deal with day to day and underpowered cell, a metabolic dysfunctional cell.
In any part of the body can lead to symptoms.
So in the liver, that can look like fatty liver disease. In the brain, that can look like Alzheimer's, dementia, depression, anxiety, fibromyalgia, migraine, all conditions we know are associated with metabolic dysfunction.
In the vascular system, it can look like retinopathy, erectile dysfunction, stroke, heart disease, all these conditions we know associated with the blood vessel lining being problematic.
In the ovary, it can look like polycystic ovarian syndrome, which is the leading cause of infertility in the United States, but it's fundamentally actually a metabolic problem in the ovarian cells.
[15:05] So take any part of the body, and when you zoom in, take any part of the body and look at the symptoms that arise there, and you would probably think, oh, these are all different diseases.
Arthritis is different than Alzheimer's, and it's different than cancer, it's different than heart disease.
And that's the way we thought for many years, because we didn't have the tools to really understand the core physiology. So we were describing these diseases based on their symptoms, which look different.
But if you really zoom in and look at the inside of the cell, a lot of them are rooted in mitochondrial dysfunction, the cells filling with toxic fats and blocking the metabolic processes that let cells run properly.
And that's ultimately metabolic dysfunction. And the way that shows up in our lab work is various biomarkers that we associate with metabolic dysfunction.
This could be like triglyceride levels, fasting glucose levels, HDL cholesterol levels, blood pressure.
[16:02] And those are the biomarkers that get studied in these large studies that we were talking about earlier that suggest that if you look at these metabolic associated biomarkers, waist to hip circumference is another one. Um, we see, I'm sorry, isn't that defined as metabolic syndrome?
Those things you're talking about when you have three or five of them, it's defined as metabolic syndrome.
And so, so these are sort of like these biomarkers that can give us a little clue about what's going on in the cell.
When you take all of them and you study the population, 93% of the population has at least one that is not in the normal range off medication.
So that's pretty alarming.
[16:42] And, um, and my real mission as a doctor on this planet is to help bring a metabolic framework to our healthcare system, because the reality is we're spending $4.1, trillion on healthcare in the United States.
It's over 20% of the largest GDP of any country in the history of the world.
And yet the more we spend, the worse the health outcomes are getting.
It's literally the definition of unsustainability. The more money we throw at the problem, the worse the outcomes are getting.
And I believe that's because we're actually focusing on the wrong problem.
We're focusing on a reactive approach, a symptoms-based, approach to the downstream manifestation of these diseases, rather than a root cause approach that truly addresses the disturbed physiology that's happening and that is fundamentally driven by our diet and lifestyle, which of course, I know you've talked to many guests about this, Cyrus Kambada is not taught in medical school or in our PhD programs.
And it's really a reframe because if you throw money at the wrong problem, of course it's not gonna get better. So we need to be focusing on the right issues. Yeah.
[17:49] Well, I'd love to dive into some of the elements that you say can help with people's metabolic health.
Awareness of personal agency in metabolic health is lacking
[18:00] Before we do, you also say like the elephant in the room in modern America health care right now is that, We have agency over our own fate. And would you say that most people are, for whatever reason, not aware of that?
[18:19] I think that's right. I think they aren't. I think they aren't.
I mean, there are still doctors that I know who are treating chronic illnesses, even treating chronic illnesses related to the GI tract, the part of the body that processes food. Yeah.
And are saying that food has nothing to do with the diseases, or that it's incremental, or that, oh, you know, take this Medicare.
You know, I don't know. Like there's just this complete blind spot in most of health care to basically any of the levers that we can pull that can help us pull ourselves out of our symptoms and diseases. is.
And this is due to so many things, one of the big ones being that physicians are literally not taught nutrition in medical school, even though poor diet is related to nine of the 10 leading causes of death in the United States.
So it's completely like a bizarro world that we're living in.
[19:20] And so there's just, what's interesting is that patients actually in many ways do what doctors say.
When the surgeon general said we need to decrease smoking, smoking went down.
When we said, you know, eat 6 to 11 servings of grains and pastas per day, like those foods went up as a proportion of the American diet.
If every doctor in America was saying.
[19:45] Our chronic disease epidemic is fundamentally rooted in food, and we need to be eating better as a country.
I believe that people would do it.
The problem is that they're not saying that in unison.
There's still so much uncertainty. There's so much nutritional dogma, warring going on, and so people are confused.
So I think a universal message from physicians, researchers, coaches, trainers, just saying like actually we all need to focus on food.
I think people would focus on food, but right now there's just still so much undermining of that message.
And I think it's fundamentally rooted in the fact that we just don't, we're not educated on it.
And every doctor I know who is practicing food as medicine in their practice has had to do it outside of their traditional training. They've had to pursue additional independent training to gain that skill set.
So it ends up being like a labor of love, essentially like pro bono work to become nutritionally literate.
Of course, those are the doctors. I think about like Laurie Marbis, who end up seeing the most profound disease reversal in their patients.
[21:01] And actually physician attrition, physicians basically just quitting medicine
Physician attrition and burnout linked to lack of progress in patients
[21:05] is basically like a public health crisis. So many doctors are retiring early.
And I think a lot of it has to do with the fact that there's a spiritual crisis of medicine where we're working so much, but our patients aren't getting better.
And so one of the things I really think about is that like, if doctors did have more nutritional literacy, it actually could really help them sustain the enjoyment of their practice, because they would see such different profound outcomes in their patients that would be so heartening.
And I think that would really help with the burnout that we're seeing in medicine.
So it's very multidimensional, but.
Yeah, yeah, absolutely. I mean, I would imagine that most physicians go into medicine because they want to help people, right?
Pills and Procedures vs. Lifestyle Medicine
[21:49] And you get caught in this system and before you know it, you're kind of pushing the pills and doing the procedures and you're not getting, as we've been talking about here, to the root causation of the problem.
I saw a cartoon this morning and it was two people behind a desk and one's sign said, you know, pills and procedures.
The other one said, um, lifestyle medicine.
And the one with pills and procedures was literally the line of people was out the door and around the building and lifestyle medicine. There wasn't one person there.
[22:24] I've seen that meme, and I have to tell you, I actually hate that meme.
And let me tell you why. Please.
Because it puts the response, it basically reinforces what I think is such a damaging idea, which is that people are lazy, and people want the easy solution.
And I don't think that's true. I talk to 15 levels members a week, but they're not my patients, but they're people who are striving for better health.
And the dominant message I hear is that they are desperate to do whatever they can do to be healthy, but they are so confused and the system is not helping them.
We have trained patients because of the backwards incentives and education of American doctors.
We have trained patients to believe that that is the answer and therefore they are listening and they are doing it.
But I don't think it's fundamentally an issue with that. People don't want to do the work.
I think that we have literally on every level of society, from advertising on our TV shows to what doctors are telling them in the office, to social media.
It's basically told them that that is the right answer.
But I believe that people, by and large, all walks of life, they're not trying to systemically kill themselves and be lazy.
[23:44] I think the system has been designed to make them think that is the right answer and they're following suit. And that is because of, you know.
Trillions of dollars of interest and incentives across processed food, pharma, health care, industrial agriculture, even the chemical industry, which all want people to believe that the simple solution is the one that's better, even though it's not.
So that's what bothers me about that meme, is that people I do not believe are actually just looking to have the easy way out.
I think we have literally trained them to believe that is what is the better answer.
And we need to empower people to go to the other line. and I think they will.
[24:23] Well, just to get back, and then we'll close this conversation on this.
But if you knew how many times I talk to people that come to our events or our medical immersion programs, and they say that their doctor basically is like, yeah, but you won't stick with it, or you won't do it.
So they're not being empowered by their physicians, or they're saying, yeah, but you know what?
Most people can't do it. so they're not giving their patients the benefit of the doubt, which is infuriating to me.
And then when they do do it, because they've read the books and they believe in themselves and in this lifestyle, and they go back, the physician, instead of saying, tell me everything you did, I want to write it down, and I want to be able to give this to the next person, it's more like, you just keep doing what you're doing, but I don't really need to hear about it.
I mean, doesn't that wow, this is such a shock.
Like I, you know, like this is like really surprised by it.
Whereas like people like, you know, in our community who are practicing this, like, it's not shocking at all.
You know, it's like, of course, this happens, you know, and so it's, I've seen that a lot as well. I agree.
Yeah, it's empowering. Yeah. Okay, let's let's talk. So you have nine elements of metabolic health.
Importance of Micronutrients for Metabolic Health
[25:41] And if you don't mind, I'd love to, I can throw, I'll throw them out to you.
I'll team up to you. And then all right. So the first one that you talk about is micronutrients.
So why are micronutrients important for metabolic health?
Oh my gosh, I love this question.
Um, so micronutrients are essentially like the vitamins, minerals, antioxidants, like the small little molecules that we get from our food that are really important for like several elements of our biology.
Like you have to think of the body, it's basically like a big chemistry set.
And like I said earlier, like we are essentially the product of trillions upon trillions upon trillions of chemical reactions every single second.
And a lot of what is happening in those chemical reactions is transformations that require these micronutrients for those things to work properly.
So these are things like you think about like zinc, magnesium, selenium, B vitamins.
They often act as cofactors for metabolic processes, meaning that like if you're trying to in the body transform.
[26:45] Substance A to substance B. Often that will happen with what's called an enzyme, which is like a protein that converts substance A to substance B in some chemical reaction.
Sometimes that enzyme, which you can think of like a little protein machine, requires a couple little micronutrients to bind to it to act as almost like locks and keys to unlock the ability of that thing to work.
So you essentially want your body to be filled with a lot of these micronutrients in the right levels such that all these chemical reactions can happen properly.
[27:17] And so unfortunately, in our ultra-processed, largely ultra-processed standard American diet, so many of the foods have been so stripped and transformed and ground down from when they came out of the soil to when they actually make it to your food, that so many of these micronutrients are just being lost.
Our food is like devoid of the richness, the chemical richness that was in it when it came out of the soil. And a second problem is that the soil now in the United States has become depleted in many ways of life.
And so the food itself actually isn't being sort of injected with the micronutrients it needs as it's growing because the soil is essentially depleted.
So if the soil is depleted of micronutrients in life, the food is going to be depleted.
And this is largely because of our industrial agriculture culture, where we are spraying our crops with pesticides. We're using really aggressive agriculture techniques like tilling.
We're not using cover crops in between harvests, which basically inject the soil with more nutrition.
[28:27] We've disaggregated growing plants from the pasturing of ruminant animals, which is basically animals walking around on the farms and pooping and peeing and agitating the soil with their hooves, which brings through that the nitrogen in the urine and the bacteria in the feces, actually builds a thriving ecosystem in the soil.
All of this has essentially led to food that is objectively more micronutrient deplete, and that's been studied.
[28:55] And so what happens is then you have this body that's eating all this stuff that looks like food, but the molecular composition of the food is actually sort of less than what it could be if these things were different.
And so we really, a big focus for me in helping people optimize metabolic health is get the most bang for your buck with each bite that you're eating.
And that usually means moving from processed foods to whole foods.
And then secondarily moving from foods that are conventionally grown to more foods that are regeneratively grown or organically grown.
Organic is great because the, you know, the, the food is going to.
[29:37] Have had less of that exposure to the pesticides that can create more lifeless soil.
Regenerative is actually better because that's vegetables that are grown on a farm that has ruminant animals on it generally.
So you're kind of, the soil is gonna be as rich as possible and as filled with life as possible.
So that's kind of the skinny on micronutrients. They're key factors for metabolic processes.
The second thing I would also just mention about micronutrients is that many of the micronutrients, um, these vitamins, minerals, cofactors, many of them are antioxidants or, or polyphenols.
So these, these types of small molecules that actually have a different function in the body, the antioxidants and, and many of these like overlap in categories.
So there are some, like, um, there are some micronutrients that are both cofactors for certain reactions, but they're also an antioxidant and all an antioxidant means is that it has the chemical structure to basically take on an electron from something else in the body or the cell, an unpaired electron that could be damaging if it's not neutralized.
An electron is, you know, negatively charged and it can go, it wants, if it's unpaired, it wants to go around the cell and bind with things.
And if it binds to the wrong thing, it can cause damage to it.
So an antioxidant is floating around to bind that electron and neutralize it so it doesn't cause damage in the cell.
So these micronutrients can act as antioxidants, um, which is important.
Some of them are polyphenols, which are often the plant chemicals that give, that give plants their beautiful color.
[31:05] Um, and polyphenols are fascinating for so many reasons. I think about them as like little molecular medicines.
One of the big purposes of them is they're actually consumed by our microbiome and transformed into healthful postbiotic chemicals, many of which are metabolic regulators.
And so polyphenols are important. So these beautiful small molecules and plants that give them color, And then the last thing I'll mention is that some of these micronutrients, like selenium, for instance, they actually are critical when you're making a protein in the body, when you're expressing the genes and then turning that gene into a protein.
Micronutrients: The Power of Eating for Cellular Health
[31:41] Sometimes you need to like, the cell is essentially as it's making a protein, it's grabbing all these things from the cell to build that protein.
And sometimes it needs to grab certain micronutrients like selenium.
There's a class of proteins in the body called selenoproteins, which need selenium as part of the manufacturing process.
And part of that class of proteins are many of the antioxidants that our bodies make.
So we eat antioxidants and we make antioxidants.
We can do both of those. We wanna do both, but to make key antioxidant proteins like.
[32:15] Glutathione and other things like that, you actually need to be able to pull these micronutrients in the manufacturing of those things.
So several different reasons why we want to basically think of eating as being...
I think of grocery shopping as like a micronutrient and antioxidant hunt, because it's not that we're just buying food, we're buying molecules, and we want to get, maximal positive molecules to the body that we know are going to help our biology.
[32:45] So that's kind of the skinny on micronutrients. I can go quicker for the other eight, but I just could talk about micronutrients all day.
But tell me this, so for somebody that didn't study nutrition in medical school, you obviously have studied it and studied it extensively.
Is that just from diving into books and educating yourself or where'd you get your education?
Great question. So I actually was so lucky when I was an undergraduate at Stanford, It was right during like the Human Genome Project and also during when 23andMe was starting in Silicon Valley.
And so I got very interested in genetics and I got so lucky.
One of the classes I took was about nutrigenomics, which is basically how the food goes into our body and changes our gene expression.
I had gone through high school biology thinking our genes are our destiny.
And what I realized is that it's actually the interaction between food and our genes that leads to the expression of our reality.
[33:46] And, you know, two easy examples of this that I learned about at like age 18, that would then put me on a particular track forever of like really believing in the power of food was curcumin from turmeric and, isothiocyanates from cruciferous vegetables. So with turmeric.
You know, everyone says, Oh, it's so anti inflammatory. And people in India eat all this turmeric.
And until recently, there was very little reported Alzheimer's disease, what's that relationship, you know, and basically, in turmeric, there's a substance called curcumin, which actually, literally interacts inside the cell with this genetic pathway called nf kappa B, which is our master inflammatory genetic pathway in the body, and turns down the expression of the NF-kappa B pathway through, very clear molecular interactions.
So you can eat this thing and change your propensity to have a pro-inflammatory state in the body.
And like we talked about earlier, most diseases affecting Americans today have this sort of inflammatory metabolic underpinning.
[34:52] The second one was isothiocyanates from cruciferous vegetables.
And those are a chemical in cruciferous vegetables. And amazingly, and Michael Greger talks about this a lot in How Not to Die, you chop the cruciferous vegetables and you actually want to let them sit out for like 45.
Yeah, like you need to let them basically activate with air.
You crush the tissue with the knife.
You let them sit out to air and a chemical reaction happens in the plant which activates these chemicals and then, and makes them more heat stable.
And then they go into your body and they change the expression of this pathway called NRF2, which it actually upregulates NRF2, and that's one of the genetic pathways that causes you to make more antioxidants in the body, which then quell those unpaired electrons and keep a more sort of safety environment in the cell.
So I learned these things at a young age, and you can't put that genie back in the bottle.
[35:51] Anyone who says like, oh, people just they're on a track and it's the family history and da, da, da, it's like, wait. But I had learned that there's something else here.
So that was kind of what kicked it off. And then frankly, it was just a series of disappointments in my education after that where it's like, why aren't we talking about this?
I know there's power here. But I go through four years of medical school.
We're not talking about food.
I go through four years of surgical residency. We're not talking about food.
And I'm like, where did this go?
Challenging the Medical System's Bias Towards Interventions
[36:18] What happened? And did you ever ask your professors or chief interns or whatever?
Oh, yeah. Oh, yeah. I got a reputation.
[36:32] And the way that it works, because our healthcare system is so biased towards interventions and we're so incentivized to be more focused on medications and surgery is I got a lot of really patronizing replies like, you know, you didn't become a surgeon to basically be a nutritionist, you know, something like that.
And I'll never forget, I got really, I was reading a lot of Dean Ornish's work when I was in the surgical world.
I was starting to kind of dive in and I remember obviously reading about his incredible heart disease reversal program. And I had never learned in four years of Stanford Medical School that you could reverse heart plaques, right?
We all thought, oh, once they're there, they're there.
And then all you can do is kind of try and make it slow down.
But he showed with his groundbreaking research that you can actually reverse heart plaques.
So I'm looking at this. And I'm, as an intern, a first-year resident, you do a lot of cardiac surgery rotations.
And it's triple bypasses and and these cracking the chest open to kind of like redo the plumbing of the heart vasculature for heart disease, it's stents, it's things like that.
And I'm thinking, here we have nutrition can reverse heart disease.
[37:53] And heart surgery does not reverse heart disease.
It just creates a new pathway for blood to flow.
So why do we think that the nutrition route is literally wimpy and the heart surgeon is a hero and no shade on the heart surgeon, like that's great that we can do that.
But like, why isn't it flip flop that the nutritionist is the hero and we would try and avoid the heart surgeon ever getting that place ever.
And so just that just I was, I was talking about these concepts like, and what happened was when I went into residency as a surgeon, I kind of felt like I wanted to be a hero.
And over time, I started really feeling that sense of weight of like, I don't feel like a hero, I feel like a plumber. And how do I actually reverse the physiology?
And so I would talk about these things, but again, I would get some feedback like that's not evidence-based.
[38:50] This is not in our guidelines, you're not a nutritionist, and you can always pull the evidence-based medicine card, I think, in medicine of like, well, it's not in our guidelines.
But what I've come to realize is that our guidelines can be very biased towards pulling in specific research that promotes our sort of intervention path.
And so, I still, of course, believe in evidence-based medicine, but I think a lot of our research and a lot of our guidelines are compromised because they come through a lens of already not even believing that nutrition should be in it.
So of course, those studies don't get as much funding, they don't get brought into conversation.
95% of the people on the USDA food guidelines, this past food guidelines, had conflicts of interest with food companies, you know?
And a huge percentage of the NIH's budget comes from industry.
[39:44] So it's a big system. And so people will say to you, said to me when I brought this stuff up, but it's not in the guidelines, we're not gonna do that.
You put yourself at risk for practicing differently, focus on what's in the guidelines.
But then you start stepping back and asking, well, what, why did the guidelines become how they are?
And it opens up a real, real can of worms. Yeah.
Teaching the Untaught: Food Design and Technology
[40:05] You were saying, hey man, the, the emperor's not wearing any clothes.
Yeah. Yeah. Yeah. Well, and isn't it funny how.
Yeah, the nutrition is a wimpy because it doesn't, it also doesn't make, you know, the doctor or the hospital really any money, right?
That's right. Exactly. And those procedures.
[40:25] Yeah. Yeah. And so you also, are you still teaching a course at Stanford, food design and technology?
We're not teaching it right now. I was so COVID, one of the silver linings of COVID was that it was all remote. So I was able to teach that course remotely, but now everything's back in person and I live in LA.
So I'm not teaching it right now, but it was really a joy to be able to go back to my old stomping grounds almost 10 years later and teach a course all on the things that I basically wasn't taught in school.
So that was very exciting and full circle. Yeah, yeah, really.
All right, let's keep moving then. So I'm gonna go to number two of your nine elements of metabolic health. and, well, healthy meals.
And so the second thing you talk about is fiber. Of course, I've had Dr.
Will Bolshevitz on the show twice, but what can you add about fiber regarding a metabolic, how it helps to a meta, let me rephrase that, how it helps to eat a meal that has fiber for your metabolic health?
[41:35] Yeah, I mean, you've had the GOAT, the greatest of all time on the podcast talking about this, so there's probably very little that I can add, but I just think it's a public health emergency that we're not eating nearly enough fiber in our diets.
It is so interesting to me. We have maybe 100 trillion bacterial cells in our gut, way more bacterial cells than human cells.
And what I really love to think about is, I'm not eating for me.
I'm eating for my 100 trillion bacteria in my gut, because they are the first pass on the food.
They see it before my gut lining sees it, by and large.
And we know so much now about how if our gut is problematic, if our microbiome is more in a dysbiosis state, like not the right sort of pattern of bacteria, our health will suffer.
Like it is related to cancer. It is related to Alzheimer's. It is related to heart disease. It's related to stroke. It is definitely related to depression and anxiety.
You can literally transfer the bacteria from a mouse that has anxiety, transfer their microbiome to a mouse that doesn't have a microbiome and it will have anxiety like it's it's just so wild.
And so when I'm again with the with the grocery store, I'm thinking micronutrient hunt and how do I get the best meal for my microbiome from this from this grocery store?
[43:04] And you know, the best thing that we can do for them is protect them.
So that it and feed them so that would be fiber.
And so basically, these indigestible carbohydrates and starches that don't necessarily go into our gut lining, but that they transform into healthful postbiotics.
So they make them into postbiotic chemicals by transforming them, and then we absorb the postbiotics.
So we don't absorb the fiber, we absorb the thing that the fiber was transformed into by the microbiome.
And many of those short-chain fatty acids like butyrate, they actually go straight into our cells and have an impact on our mitochondrial function.
And there are- That is crazy. Isn't that so crazy? It's so crazy.
It's so cool. Well, and it almost goes back to what you were saying earlier with the soil, right?
With the ruminants and the urine and the feces and just how it's all this.
You need the diversity of all the different species for optimal health.
Yes, yes. So I'm thinking, you know, I think the USDA has put out that over 90% of Americans do not get enough fiber, which is crazy.
Imagine you are starving the 100,000, bacteria inside your gut that are sitting there just waiting, waiting to produce the stuff you need to be happy, healthy, live a long life, be fertile, all the things.
They just are sitting there like, we want to do this work, just give us the food, you know, and we just starve them of fiber.
And again, that's our ultra processed food that strips off all the fiber.
Easy Ways to Increase Fiber Intake
[44:33] And then the second piece, the second thing that microbiome eat is polyphenols, these plant chemicals that they can convert into healthful chemicals for us.
And so you You just really want to be thinking about with your fiber, with your diet, maximal polyphenols, and in my mind, maximal fiber.
There are indigenous cultures that we've studied in various parts of the world.
There are some that eat low fiber, but there are some that eat over 100 grams of fiber a day.
[45:01] And so I really, you know, the USDA says we need to eat around 30 grams of fiber a day, but I really encourage people to ramp up to 50, 75, which is not that hard.
And the way that I do it is that I just keep fiber sources at the ready so that they can be sprinkled on everything.
So if you, let's say you're pinched for time and you're not, you know, like obviously if you can cook your beans and lentils yourself, that's great.
But I have, always have 15 cans of organic BPA free cans, black beans, pinto beans, navy beans, chickpeas.
So that's a can of, if I, a can of beans has, you know, five servings, nine grams of fiber per serving. So, you know, you're looking at like.
You know, in the 40s of like fiber. So keep those in the pantry.
And I actually, on Monday, I'll take like three or four cans, rinse them, strain them, dry them, put them in Tupperware so that they're easy.
Because then every salad you make, everything you make, you can just dump a half cup of beans on the side.
If you have to, so just make it easy for yourself.
Then on the counter, have chia seeds, basil seeds, flax seeds.
[46:13] Other pumpkin seeds, just have them out and ready.
Cook in the crockpot lentils and put some coconut milk and some tomato paste in there and some curry, just a few easy spices.
Do that on Sunday night. Have it in the fridge. Put it on the side of any meal.
So right there with lentils, beans, nuts, seeds, maybe make some chia pudding for the week.
[46:37] Plus, then you add in whatever other vegetables you're eating just throughout the week, which do have certainly fiber, but not as much of those key fiber foods that I just mentioned.
And it's really actually so easy to get 50 plus grams a day, but you've got to prepare.
You've got to be thinking about what are my key fiber sources and how do I have them literally accessible for all three meals of the day. So I figured out the amount of grams that I got just in my, my breakfast bowl, and it was 41. It's like crazy high.
What about what about, you know, you hear short chain fatty acids a lot with with the microbiome and fiber. Can you talk about that for a sec?
Yeah, so basically, short chain fatty acids are a type of postbiotic meaning so there's prebiotics, probiotics and post postbiotics.
Prebiotics are essentially what the microbiome eats.
Probiotics are like the actual bacteria and post biotics are the things that the bacteria make by by transforming the prebiotics.
So there are metabolites produced by the microbiome in the large intestine through anaerobic fermentation of indigestible polysaccharides, like dietary fiber and resistant starch.
And there are three main forms of short chain fatty acids, which is acetate, propionate, and butyrate.
And this is about 80% of the short-chain fatty acids that.
[48:06] Are produced and uhm– and they are absorbed through the intestinal lining and just have like several different uhm– effects on our mitochondrial function and our– our cellular biology.
So uhm– yeah. So that's kind of the skinny and short-chain fatty acids.
Dr. Justin Marchegiani I wanna get one thing– try– try and get straight with you because I've heard different numbers and uhm– so I– you've said it twice or three times, we've got about 37 trillion cells that comprise us, roughly 37.
But I've also heard that we have 10 times the number of microorganisms in our gut.
But that would be like 370 trillion. And yet I've heard you and other people say about 100 trillion.
So I know it's not a big deal. I'm just wondering if it's 10 times or it's one and a half times, do we know? Yeah.
I think we have no idea. I think of it as like, I mean, I've heard so many different things, like between 37 trillion and 100 trillion human cells.
And then we know we have significantly more microbial cells, also not just on our gut, but of course, all over our skin, vagina, but mouth, all of it eyes.
[49:17] And so it's basically the way I think about it. There's a lot more bacterial than human cells, but it's, and they're both in the many trillions.
So it's a lot. Yeah, it's a lot. Okay. Alright. Let's- let's move on.
Okay. So, number three, I feel like you already addressed. It's antioxidants.
You'd lump that in with the micronutrients, right?
You're- you're- you're number one answer. Absolutely. That's right.
So we're- I think we're good there.
Number four is Omega-3 fats.
Yes. Uh, what exactly are you referring to here? The D- the uh, DHA and EPA or- or what exactly?
Yeah. I mean, there's several different types of Omega-3 fats starting with, alpha-linolenic acid that can get converted to EPA and DHA.
And this is like, of course, one of those really interesting conversations that becomes very controversial in the plant-based and animal-based community because, of course, the omega-3 fats that get.
[50:16] Incorporated into our cell membranes and that have some of that like anti-inflammatory, promoting potential are more the EPA and the DHA.
And people say, oh, this is why you need to eat meat and salmon and eggs and things like that because that's the actual source of those foods.
Algae does have EPA and DHA, so that's a great plant-based source of that.
And then the argument often becomes if you're just eating plant-based sources like from chia and flax and other plant-based sources of upstream.
Inefficient Conversion of Omega-3s to EPA and DHA
[50:55] Omega-3s, it's not an efficient conversion process to the EPA and the DHA.
[51:01] And one of the things I really push back on with that is is that there are ways to make the conversion process more efficient.
So one is that, so it's a multi-series enzymatic conversion from basically plant-based omega-3s to EPA and DHA.
And what's really interesting is that those conversions all require those enzymes to have the proper micronutrient levels that are cofactors for those enzymes.
And there's a really interesting fabulous micronutrient test from this company called Genova that basically looks at your EPA DHA levels ALA levels and all your micronutrient levels for those enzymatic Processes and can tell you like are you low on some of the co-factors that allow that conversion to work?
Properly and some of them are like B vitamins vitamin C I Think it's like I'll have to I'll have to look there's a great image that shows all the co-factors, for the different enzymatic reactions.
I think manganese is one of them. But basically, the bottom line is, if we're eating a sort of thoughtless, low-micronutrient diet, and we're expecting to convert these omega-3s to the EPA and DHA, we might be stunting our ability to do that.
So we have to think holistically about the biochemistry of the body and optimize and support those processes.
The Impact of Plant-Based and Animal-Based Diets
[52:30] And there are people who, you know, I kind of have a foot in both worlds, because I was in the plant-based world.
And I'm also kind of very know like the ketogenic world very well, because I focus on metabolic health.
And there's obviously a huge camp who believes in more of an animal-based diet.
But a lot of people will say like, Oh, I was plant-based. And I just like, felt horrible.
And then I ate more omega threes from animal based sources. And I felt so much better.
But my first question would be like, what was your plant-based diet?
Like, did were you optimizing?
Yeah, these conversion processes to basically make what you you are just like, essentially, the body is like a we are a synthetic machine, we can synthesize things, but we have to be thoughtful about giving the body what it needs to do those synthesis processes.
So, so that's kind of one thought just on like sort of plant-based.
[53:19] And anyways, the key point about the omega threes is that they're critical for structural biology.
As parts of our cell membranes, they're also critical for sort of like the chemical processes in our body.
So our immune cells actually come around and they snip fats off of our cell membranes to basically be used as substrates to make various anti-inflammatory, or pro-inflammatory chemicals in the body.
And so if you have a higher density of omega-3 fats in your cell membrane, just statistically, it's kind of going to be more likely for those immune cells to be snipping off fats that are going to go towards more of the, the resolving of inflammation processes.
So you want to do whatever you can to load the boat in the body with these fats.
So that just sort of statistically, there's more likelihood of kind of moving down the anti-inflammatory pathway.
[54:16] So that I kind of find that I think about that a lot with nutrition is like, all these cells are are essentially blind.
Like they don't, I mean, they all are blind. Our cells don't have eyes.
They don't really have, a lot of it is like, how much are you loading the body with these micronutrients and these omega-3s, so that when a cell is kind of blindly looking to grab things, you have given the body enough of that stuff for it to be able to grab the right thing. And I think about that a lot with omega-3s.
Yeah, and obviously, you know, our audience is primarily whole food plant-based.
What do you recommend as the best whole food plant-based sources for Omega-3s?
Yeah, I mean, three amazing ones are flax seeds.
Well, four, flax seeds, chia seeds, basil seeds, hemp seeds in terms of those.
I love basil seeds, which are a little harder to find. there's a brand called Zen Basil that makes them, but they actually have a much higher omega-3 content than chia seeds.
And you use them identically to chia seeds. So those are a really nice source.
And then I really like different, like algal oil, I'll sometimes take.
[55:37] But those are some... And then hemp seeds I'll use to make like a sort of of muesli type thing or like a no oats oats kind of thing with a bunch of different seeds.
But those are my those are my favorites. And I have them all in jars.
And I just basically sprinkle those things on like, on everything. I mean, there's almost nothing that you can't sprinkle some ground flax or ground chia on. What about green leafies?
The Benefits of Fermented Foods
[56:04] Green, like leafy greens? Yeah. Yeah. I mean, certainly, I think the omega-3, concentration of those are going to be drastically lower than some of the other things I mentioned.
But certainly, like every little bit counts.
Yeah. Okay, Let's move on. So your next on the list is fermented foods.
Yeah. You're a fan of fermented foods. I don't eat enough fermented foods in my life. Okay.
Yeah. I mean, I do the tempeh, but you know, that's about it really.
Interesting. And is that because you don't like the flavor or?
I'm typically not a fan of like sauerkraut and stuff that's fermented.
Kimchi. Yes. But is so surprising. Yeah.
[56:52] So, you know, the fermented foods, it kind of goes similar to the conversation we were having about, about earlier about short chain fatty acids and fiber, like it's all about protecting the microbiome.
[57:11] And fermented foods, they have bacteria in them. Something really interesting that's emerging, though, in the literature is like it's kind of a question of whether it's probably the bacteria in the food that are helpful in part.
But it's also that a lot of these fermented foods, the bacteria in the food has actually already made some of those postbiotic chemicals even in the food.
So when you're drinking a kombucha, you're drinking the bacteria.
But there's also going to be the chemicals. The bacteria in the drink have already done some fermentation of the sugars and the starches in the drink, whether it's yogurt or kefir or kombucha.
So there's going to be post-biotic chemicals that you can just directly absorb in that as well. So it's probably a blend of both the, bacteria in the food and the chemicals they've created in the food that are helpful.
And then you take something like a sauerkraut, which also has fiber, and then you've kind of got a triple whammy.
You've got prebiotics as fiber, you've got probiotics with the actual bacteria, and you've got postbiotics with whatever they've created in that food.
So it's really kind of like a triple hit. But there was a really interesting paper in, I believe it was in Cell, and it was, you know, premier medical journal, and this was published.
[58:27] In 2021, it was called gut microbiota targeted diets modulate human immune status.
And they were basically looking at how fermented foods change the markers of inflammation in the body.
And something that was really pretty crazy about this study is that they actually showed that yes, the consumption of probiotic rich foods has a distinct impact on the inflammatory profile of the body, but it was people who ate around six servings of fermented food per day that had that maximal impact.
That's a lot of fermented food. So a lot of people I think are like, oh, I eat fermented foods.
I put a little bit of sauerkraut on top of my salad, like a little, as a little touch.
And what this paper said to me was, oh God, I think we actually need to be eating like fermented foods, there's two different types in like every meal we eat.
And that can seem really overwhelming. But if you think about it, it's possible.
Like you could have some, like a half a cup of unsweetened non-dairy yogurt for breakfast, and maybe a tiny little side of greens with some sauerkraut on top.
[59:43] For lunch, of course, it could be a soup or a salad or something with a sauerkraut or a kimchi.
Maybe you do cauliflower fried rice with kimchi on it and a kombucha, a low sugar kombucha.
And then for dinner, add two others. But when you think about the options between.
The Variety of Fermented Foods Available
[1:00:04] Natto, miso, kefir, kvass, kombucha, yogurt, sauerkraut, kimchi.
I may have said some of those twice.
The other cool thing is you can ferment basically any vegetable.
You can even ferment fruit. You can ferment asparagus, cabbage, beets, zucchini, onions, really anything.
So I think learning how to actually ferment is really such a powerful thing.
It's a lot cheaper, too. but you can just basically go to the farmer's market, buy whatever looks good, put it in jars, you put salt and water, you let it sit for several days, you have to release the gas.
[1:00:45] But naturally, the bacteria on the food is going to interact with the salt and water and essentially is going to ferment.
And so it's a real shift though, I think, to realize that we should probably be eating a lot more than we think.
So I keep a list handy of all the different fermented food options just to spark my brain. And similar to what I said about the fiber, I load my fridge with it.
I always have five different types of fermented vegetables from the farmer's market or ones that I've made. I always have yogurt.
I always have kvass. I always have miso in the fridge.
That when I'm making a salad dressing, I put three tablespoons of miso in it, you know I've started making my chia pudding with yogurt instead of coconut milk, which is a slightly different flavor But I know I'm getting more bacteria So it's just kind of a reframe but I think we I think it's it's the evidence shows it's really valuable to eat fermented foods.
[1:01:43] And we probably need more than we think I know I need more that's for sure.
Yeah Okay. Well that was that was man nicely done You, you say to minimize sugar.
I think most of us know that, you know, most Americans get, what is it?
I think the average is 30 added teaspoons of sugar a day in some form or another.
And I think most Americans know it's bad, but, you know, dive in the way only you can about why it's bad for metabolic health.
Yeah, I mean, this is, so the molecule of sugar in and of itself is not necessarily a problem for our cellular biology.
It's the quantity of refined ultra processed grains and sugars that we're eating.
Because a refined ultra processed grain basically is sugar.
[1:02:41] And it's essentially a whole food that has been stripped of the fiber and the protein and you're just getting that sort of straight carbohydrate, which is essentially sugar.
And so there's all these different statistics that you will find about how much more sugar we're eating than we were 100, 200 years ago.
But by some accounts, some studies are showing that we eat 152 pounds of sugar per year now.
I mean, that is unbelievable.
The Impact of High Fructose Corn Syrup on Health
[1:03:12] And this is not fruit sugar. This is not whole grains. This is high fructose corn syrup. up.
This is ultra fine white cane sugar.
You know, this is what Americans are eating. It's like fruit is not the problem.
[1:03:26] The the issue is with what it does to our metabolic health is that if you if you task any machine, with all of a sudden having to do 50 100 times more work than it's meant to do, like it's going to have dysfunction, that every single one of those molecules you put in the body is going to have to be processed by the body.
So it's like we're tasking the mitochondria in the cells with just far, far, far too much work.
And every time we do the molecular conversion of these things, it produces metabolic byproducts like reactive oxygen species and other things.
And the body just doesn't know what to do with all of this. So what happens is, if the mitochondria essentially can't...
It's seeing drastically more sugar in the diet, what's it going to do?
Well, it's going to try and convert as much of it as can. It's going to get overwhelmed.
It's going to be producing a lot of this oxidative stress and free radicals.
It's going to start to get damaged. It's going to get overwhelmed.
And it's going to instead of converting that food to ATP to cellular energy, it's going to have to store some of it.
It's going to have to basically shunt it to a different pathway, which is essentially printing fat inside the cells.
And Cyrus talks about this, like the intracellular fat, the diacylglycerides and the ceramides and things like this, it's like.
[1:04:45] When you can't process all of the substrate, you're going to turn into something else. And so we're loading ourselves with basically the conversion of sugar to fat.
We're just just overwhelming the machinery, essentially. And one of the one of the analogies I like to say is that, like, imagine that you had because I get the question a lot.
Well, if we're giving the body more of this food, why aren't we just making more energy?
And it's like, if you had a cheese factory, and let's say that cheese factory is used to making a certain that They get milk, and they make cheese.
And let's say all, and it's working great. And you get an exact right amount of milk for the capacity of the machines, and you make a certain number of cheese, and everything's going great.
All of a sudden, let's say 50 times, 50 more trucks of milk deliver on one morning.
And what would happen? The factory would not make 50 times more cheese.
The factory would go into chaos. There would not be refrigeration space for the milk. The workers would be overwhelmed.
The machines would be overwhelmed. and you would probably end up making less cheese because it's a shit show.
And that's what's happening in the body. And the core message that I think is so important to realize is that part of what's happening is that these ultra-refined forms of food.
[1:06:00] They don't trigger our body's normal satiety mechanisms.
So our body's exquisite at essentially limiting our food intake if it's getting whole foods and it's getting what it needs.
And that's why if you have a Whole Foods plant-based person or a carnivore.
[1:06:19] Both of them are not going to overeat.
And the reason is because our body is exquisite at self-regulation.
The Importance of Self-Regulation and Eating Real Food
[1:06:28] That system breaks down when you ultra-process foods.
And so the issue is with chronic overnutrition and the overwhelming of our cells with these sugars and refined grains is that they're not food that the body knows what to do with.
And so we overeat and we have chronic overnutrition and we totally go up the system.
So I tell people who are just getting started, like do not worry about dietary dogma.
Do not worry about any of the noise out there on social media.
If you can do one thing, it is just eat, start by eating real food, like unprocessed whole food.
And I think what people often find is that And if you can kind of force yourself to do that, you end up learning how to self-regulate.
And that self-regulation translates to our cellular biology because you're not overwhelming the cells with too much substrate, which ultimately kind of breaks them.
[1:07:23] So, this is, I mean, you, wow, do you ever know your stuff?
I, I would, I, I prefer, this is incredible.
I want to move to another topic right now. The, you know, just so people know the remainder of your nine is basically focused on food timing or eat organic, which we've talked about a little bit already.
And then also to combine food optimally, which we can, let's, let's save that for another time.
Um, but I'd like to move on to exercise and what's your one takeaway for, for people regarding exercise?
Ooh, well, I'll give a controversial take because I feel like people, you know, I know you've had a lot of people on talking about exercise, but my biggest take, and I just finished writing my first book and it's coming out next May. Ooh, congrats.
Thank you. So fun. Does it have a title? Does it have a title?
Yeah, it's called Good Energy, and it's all about how we make cellular energy in the body.
And so it's really a metabolic framework for health and disease.
[1:08:32] But obviously read thousands of papers about food and exercise.
The biggest takeaway I have about exercise is that I think the concept of exercise is actually hurting us.
And I know that sounds controversial, but- No, bring it.
The reason is, of course, exercise is good for the body and we want to exercise, but we have very much created this framework where we think that if we exercise, which essentially in the mind is, for a short period of the day, we check this box off and we do this thing, and therefore the box is checked and we're done.
That has created a culture where we think that, okay, the rest of the day doesn't really matter.
And the truth is, is that our bodies are meant to move in sort of lightweight, low-grade ways all throughout the day.
And it's more of that building movement, just movement into the day throughout the entire day that is, I think, most powerful for longevity.
That does not mean we should not, quote unquote, exercise, resistance training, high intensity, any interval training, play sports.
But the idea that doing it for an hour to a day is what the body needs to be optimally healthy is wrong.
We need to be moving throughout the day. And there's been New York Times articles saying like sitting is the new smoking. Like this is not totally new information.
[1:09:58] And that, you know, you can't exercise a sedentary lifestyle and those things are coming to the forefront. But what I really saw was that from a cellular level Why this makes sense is that...
[1:10:13] When we move our muscles, even if it's literally just like standing up every half hour to walk around for one minute, that movement is a stimulus to the cell to do a lot of different things.
It literally, that is energetic information that tells the cell, for instance, to move the GLUT4 channel, which is what brings glucose from the bloodstream into the cell, to move it from the inside of the cell to the cell membrane so that it can actually let glucose come in.
So just moving muscles activates pathways, even if it's literally just walking to the bathroom, of bringing those channels to the membrane.
So you think about a person who's maybe moving, they set an alarm every 30 minutes to get up and do 10 air squats, or to walk around their house once, or to take the stairs in their apartment building down and up, two minutes.
That person, if they're doing it every half hour or hour, their body all day is essentially metabolically activated.
[1:11:12] It's primed, the genetic pathways, the receptors, all these things are like, it's a body in motion.
It's creating that physiology all day because you're hitting it every little bit.
Versus someone who, let's say, has an eight-hour-a-day desk job, maybe they get up twice, once for a snack, once for the bathroom, or three times the whole day. Otherwise, they're sitting.
And then at night, they exercise for 30 minutes. They're not going to have stimulated that biology all day.
It's a very they will be stimulated when they exercise, but like it's a totally different Milieu in the body, so there's this term that's been created called neat which is non exercise activity thermogenesis Which is essentially this like funny acronym for essentially just like moving more throughout the day It's like how do you in non exercise forms move your body like oh you park farther away from the grocery store?
And you walk more, you take the stairs instead of taking the elevator, you fidget your leg while you're at your desk, you use a standing desk, you garden, you're standing in the kitchen.
It's basically like movement thermogenesis in the absence of true exercise.
And the studies basically show that people who do more neat are much healthier.
There's also studies that show that if you're getting above about 8000 steps per day compared to someone who gets less than 4000 steps per day, which is the average American is getting in less than 4,000 steps a day, that you get above 8,000.
[1:12:37] You start slashing your risk for heart disease, stroke, dementia, depression, obesity by like 40% to 60%.
Fitness Spending vs. Obesity: A Surprising Connection
[1:12:44] And it's not the steps. It's a proxy for how much you're just moving throughout the day.
And one really interesting fact that I came to in my book was the US, similar to the health care, the more we spend on fitness memberships and the more gyms per capita in the United States that exist, the fatter we are getting.
Isn't that interesting? The more we're spending on fitness programming...
The more unhealthy that we're getting. So it's similar to like, the more we spend on healthcare.
And I think part of it is a similar message, we're focusing on a little bit of the wrong issue, which is that we actually need to be thinking about how to build low grade movement into our entire days, which is not what gets accomplished through a fitness membership, or a gym or whatever it is, we need to be really thinking creatively as a culture about what it looks like to have a more day-to-day active lifestyle.
[1:13:39] Now, the reality is we're not going back in time to where the majority of the population was working in agriculture and stuff. We're on your feet all day.
A lot of us are knowledge workers. A lot of us are at desk jobs.
That's the reality. We can't go back, or maybe we could, but we're probably not going back to an agrarian society. So then what does it look like now?
Is it treadmill desks in schools?
Is it standing desks as a default for everyone? one?
Is it that we just put parking lots farther away from stores?
Is it that we have more walkable neighborhoods? There's been data showing that if you have sidewalks in your neighborhood, you immediately drop your prediabetes and obesity risk just from the mere presence of them being there.
Is it that we have new building construction standards that there need to be staircases is everywhere, and the elevators are more hidden.
I don't know, but we've got to be thinking a little bit differently, because sitting bodies are the problem.
And we need to be moving more throughout the day. So that's kind of one of the things.
So how that looks in my own life. I mean, I'm sitting right now, unfortunately. But this is a standing desk, and I have a treadmill desk, actually, directly across from me that I use all the time.
[1:14:53] But it's just thinking in all those little ways, how do I, as I'm at the computer, how do I move?
Set my alarm to do 10 air squats, I keep a kettlebell right next to me at my desk.
If I'm catching up with a friend or scheduling a meeting, I always try and do a hiking, metering, or walking meeting, those types of things.
So just thinking creatively about it.
[1:15:14] Terrific. Oh, great stuff. You know, and so much of it is, you know, Dan Buettner and all his work with the Blue Zones, right?
But it's like, yeah, I mean, you just want to make it part of your day and, like they do, ideally.
Let me, let's finish with this, and then I wanna make a proposition to you. So, so.
The Connection Between Sexual Health and Metabolic Health
[1:15:42] We got a lot of men and a lot of women that are listening right now, and I'd love for you to talk about sexual health and how that relates to metabolic health.
All right, go.
I love this topic. Oh my gosh, it's just so fascinating.
[1:16:04] Well, I'd say highest level, metabolic health, our blood sugar levels, our insulin levels, they're basically deterministic of both our state of fertility and our sexual health.
So more like the sexual pleasure arousal side of things, two different things, right?
Both related to kind of our sexual organs, but fertility and then sexual health and sexual pleasure, uh, and arousal both are totally related to our level of metabolism.
And of course, first principles, of course, if our cells in these parts of the body aren't working properly, we're going to have issues, whether it's the blood vessels, the penis, or the ovarian theca cells, or the blood vessels that bring blood flow to the vulva and the clitoris, like all these things are cells that need to function properly.
So let's just briefly touch on, I mean, I think it's interesting to talk about fertility briefly.
So we're in a fertility crisis in the United States. I don't know why it's not front page news every day, but- What does that mean exactly, a fertility crisis?
Well, infertility rates are just going up basically every year.
Rates of miscarriages are going up, rates of inability to conceive, um, placental dysfunction.
Um, all of these things are increasing. Reports suggest that sperm count is down 50% in the average American since 1970.
[1:17:33] And PCOS, polycystic ovarian syndrome, which is the leading cause of infertility in women worldwide, is going up every year.
And it's estimated to be somewhere between 12% and 26% of women in the United States.
So let's just take sperm count for a moment.
So something really interesting about obesity, and especially fat around the midline, which is the visceral fat, which is really the metabolically unhealthy fat.
There's three different kinds of fat in the body. There's subcutaneous fat, which is the one that's like under our skin that we traditionally think of as sort of like fat that we can see.
Then there's visceral fat. And interestingly, subcutaneous fat, that's actually not associated with premature mortality.
Like having a little bit of the fat under the skin is not really dangerous fat.
There's visceral fat, which is the fat around our organs, the fat that like marbles us on the inside.
[1:18:31] That is the very dangerous metabolic fat, and that's the fat that you can't necessarily see, but it often correlates with subcutaneous fat.
And so that's kind of a key, key fat that we need to assess actually through lab testing and through scans like DEXA scans or other scans that look at the fat in our organs.
And then there's intracellular fat, which is fat that's actually inside our cells, which we never ever want.
And that's definitely fat we can't see, but a muscle cell filled with fat, a liver cell filled with fat, very, very bad.
So in men who have more visceral adiposity, which is that metabolically unhealthy fat, that fat actually acts as a hormonally secreting organ that converts testosterone to estrogen.
And so what, and Dr. Ben Bickman from Utah, he talks, he's a metabolic researcher.
He talks a lot about how like fat around a man's middle is basically like a giant ovary.
[1:19:28] So you're basically, it's an estrogen producing machine, and that is gonna affect spermatogenesis.
That's, you know, you need this perfect balance of hormones to create sperm effectively.
And if that's thrown off, there's gonna be an issue with sperm production.
The second way in men that this is related, kind of overlaps with the arousal and sexual health angle, which is erectile dysfunction.
Erectile Dysfunction and Metabolic Dysfunction
[1:19:52] And so an erection is just blood flow to the penis.
It's tumescent tissue. You're filling the penis with blood and that's part of arousal, but also, of course.
[1:20:02] Ejaculation, which is important for fertility. And so what's happening from the metabolic lens is that insulin resistance has a strong impact on our ability to dilate blood vessels because for two for multiple reasons.
One is that insulin resistance in the brain actually perturbs the central the brain part of nitric oxide production.
And then in the actual blood vessel walls that produce nitric oxide, which is the chemical in the blood that that dilates blood vessels, insulin resistance blocks nitric oxide synthase from making this chemical that causes our blood vessels to relax.
And then of course, you take Viagra, which basically brings artificially through drugs, more nitric oxide to the bloodstream and allows you to have an erection.
Well, we could also fix that problem by improving our insulin resistance and freeing up our natural nitric oxide production capabilities.
So from a hormone standpoint and a blood flow standpoint, that metabolic dysfunction is directly impacting male sexual health.
[1:21:09] And then I'll just briefly mention on the female, and it's something wild is that over the age of 45, around half of men are dealing with issues with erectile dysfunction.
And there's many doctors who say, like, erectile dysfunction is metabolic dysfunction until proven otherwise.
If you're having issues or that seems to be changing, you need a full cardiometabolic workup.
And it's essentially one of the earliest signs for men before they drop dead from a heart attack or before they get Alzheimer's dementia that there's something going on with our ability to dilate blood vessels that often goes hand in hand with high blood pressure and needs to be evaluated.
Impact of diet on sexual health in men and women
[1:22:09] I, you know, it was, they talk about this in game changers, very poignantly, you know, you remember there's that fascinating scene where they give the men the three different burritos and like, look at nighttime erections.
And it's like, it's pretty fascinating.
So, um, yeah, so there's that.
And then with women, so polycystic ovarian syndrome is a fascinating condition.
Basically, insulin resistance in female bodies leads to a state, well, in all bodies, where we have a state of hyperinsulinemia, high insulin levels, because of course, if the cells become filled with toxic fats, because of mitochondrial dysfunction, the insulin signal doesn't work properly.
That creates insulin resistance. The body says, oh my God, the cells are insulin resistant, they're insulin resistant, they're not taking up glucose as effectively, we need to produce more insulin to overcome this block that's actually caused by problems inside the cell.
So the body spews out all this excess insulin and trying to drive glucose into these cells that are basically saying, we don't want any more glucose in these cells. We already have too much.
[1:23:17] And the body basically gets filled with insulin. That's hyperinsulinemia.
Well, that insulin also stimulates every other cell in the body.
And in the ovary, it stimulates the theca cells of the ovary to produce more testosterone and more androgens.
And that, of course, in women, because it's a delicate balance in both men and women of what hormones you need at what levels.
And that over androgen synthesis creates menstrual irregularity and many of the symptoms of PCOS, like excess hair growth and acne and hirsutism and things like that.
And so a lot of the interventions in the research literature to basically reverse PCOS naturally have to do with, getting insulin resistance under control through diet. There's a really interesting study a couple years ago, it was a 12 week intervention that was looking at a very plant-forward Mediterranean diet plus a polyphenol supplement.
So it was a low carb, plant-based Mediterranean diet with a polyphenol supplement.
And the average participant in that study lost 22 pounds and reversed a lot of their insulin resistance and their hormones became more regular in a PCOS population.
So food-based interventions can really help with that.
[1:24:33] And they need to be focused on reversing the insulin resistance.
So you take away that insulin signal, the theca cells stop producing so many androgens and you start getting more normal hormones.
So the way I kind of think about it, it's like in men, metabolic dysfunction is causing an imbalance of estrogen.
In women, metabolic dysfunction is creating an imbalance in testosterone, and both are leading us to basically have struggles with fertility.
[1:24:59] And then we talked about erectile dysfunction in men.
Well, it's exactly the same for women, arousal, lubrication, all of these things as a result of blood going to the sexual organs in women.
[1:25:13] It's not as obvious because there's not a penis that's becoming erect, but those tissues are actually becoming erect in a female body as well.
And to mess it filled with blood.
So if there are issues with dilation of small vessels in the female sexual organs, because of insulin resistance, leading to endothelial dysfunction and central nitric oxide, reduced stimulation, you're going to have the exact same issue, which is essentially, you know, less ability to become aroused. And, it is actually devastating the rates of sexual dysfunction in women after the age of menopause close to 85% of women report sexual dysfunction.
[1:25:53] Whether that's lack of sexual pleasure, lack of arousal, lack of lubrication.
That is astonishing.
Sexual dysfunction in women and its relation to metabolic dysfunction
[1:26:00] And I, some of that has to do with the drop in estrogen after menopause for sure.
But I think a lot of it and what's compounding it is that it's coupled with metabolic dysfunction in women, which goes up after menopause, because that student is somewhat protective metabolically, um, that is basically making the issue worse.
So it's, it's, it's bad because it's pretty messy, isn't it? Yeah.
Yeah. And this is a huge part of our life force, right?
You know, our sexual energy and metabolic dysfunction just like really put some water on that flame.
Um, but it's also, I think we really need to think about sexual dysfunction, infertility, erectile dysfunction, all these things as very much some of the earliest red flags to potentially future, more life-threatening, issues and start seeing that link.
Brief personal story, you know, my mom unfortunately passed away two years ago from pancreatic cancer, which is one of the cancers that we know is super driven by poor blood sugar control and metabolic dysfunction.
[1:27:10] And when she was in her late 30s having kids, she had these early signs of metabolic dysfunction and insulin resistance.
Like I was born at 11 pounds, nine ounces, which is almost definitely shows that she had metabolic dysfunction.
And the reason for this is, so above about eight and a half pounds, a baby bigger than that is considered fetal macrosomic, meaning like fetal macrosomia means big, big bodied baby.
Like if you translate that macrosomia, big body and kids who are born that are fetal macrosomic, which I was like squarely in that category at 11 pounds, nine ounces, go on to have higher rates of metabolic disease, obesity, diabetes, et cetera.
It also is a signal that the mom may have had some issues with metabolic issues.
Insulin, is an anabolic hormone. It's a pro-storage hormone. It's a pro-growth hormone.
Impact of Insulin and Glucose on Birth Outcomes
[1:28:10] That's, why it's associated with obesity and it can drive cancer growth. It's anabolic.
Well, it also grows big babies. And so I don't believe that insulin crosses the placenta, but the glucose, high glucose in a mother can cross the placenta and actually lead to insulin resistance in the fetus and drive, so something I think about, I haven't had children yet, but I want to in the next couple of years, but in terms of having an easier potential birth, one of the biggest motivators for me is if I can keep my insulin and glucose very, very low and just healthy, that is not only gonna lead to better birth outcomes regardless, because we know that obesity and diabetes, it is associated with increased rates of things like placental dysfunction and miscarriage and more difficult birth outcomes, But it also like it could impact the size of the baby and I think there there kind of was this funny thing in our Culture where we like sort of celebrated big babies like I was celebrated as a big baby But we actually want to help we want a healthy size baby, which bigger is not necessarily better So anyways with my mom I look back and you know She had this which is a clear sign that there was something going on in her body, Then she of course in her 50s went on to get high blood pressure and then she got the high cholesterol and she got the prediabetes, and then she got the gaining weight around the midline, and then all of a sudden she dropped out of pancreatic cancer.
And everyone's like, all her Stanford doctors were like, this is so unlucky. This is so, oh my gosh.
[1:29:39] Between her diagnosis and her death, it was only 13 days. It was very fast.
And everyone's like, oh, this is just so shocking.
It's so unlucky. And it's like, it's not shocking, and it's not unlucky.
There were signs for 40 years that this physiology was going on, that was going to lead do a huge problem.
And of course, she was shuttled to all the different specialists, she was on all the different medications.
And I think this is happening in so many American families where there's all these different things going on. And we're playing whack a mole in all the different sub specialists office.
And what if we could really, if we did have a more holistic root cause metabolic lens, we could really help people understand how these things like fertility, and then and future disease are related and empower people to get on top of it.
But if the OB-GYN isn't mentioning it and the primary care doctor's not mentioning it and no one's mentioning it, of course.
[1:30:32] People, it's going to be harder to create change. So I just wish if I could go back in time, and we had a different system that her OBGYN could have said to her, this is really not healthy that you had a baby this big, I want to do a bunch of metabolic tests in you, I want to check your fasting insulin, I want to check your triglyceride HL ratio, I really want to figure out what's going on inside your body, Gail, my mom.
And if things come back poorly, we're going to really need to focus like full court press on diet and lifestyle to get your physiology under better control.
How different the next four years could have been.
And so that's really what, one of the things that really motivates me.
Yeah, no, you said it there. We really need, literally and figuratively, we need to get on top of it. Yeah.
Favorite Food: Ella's Flats and Beet Hummus
[1:31:14] As we wrap up the sex chapter here.
Yeah. Let me ask you one more question before we close out.
And that is, do you right now have a favorite food? Oh, my gosh, that is such a great question.
The first thing that came to mind was Ella's Flats, which are a cracker made all of organic nuts and seeds.
They're really high fiber, and they feel like a no compromise way to have a really good cracker that's like low-carb, you know, not has a bunch of refined grains in it, really delicious, you know, lots of great nuts and seeds.
So that's one of my favorite things, Ellis flats, and I dip it and I make a beet hummus.
And so I have my cute little Ellis flats with some beet hummus on top.
And I love it. How about you?
Discovering the Delights of Tropical Fruits in Kauai
[1:32:08] Yeah, it would definitely well right now it's it's the Keefe mango. It's this Keefe.
It's called the Keefe Kong. And it's like the most incredible mango and each one is a pound and a a half or two pounds.
Oh yeah, it's fantastic. Oh, I made it with my hands.
Oh yeah, you got to get in there. I was just in Kauai for two weeks, which was very lucky.
And I have to change my answer because I, there was a passion fruit, lillipoy plant and a star fruit tree in the yard.
And I have not eaten those before. And I was just like, oh my God, blown away.
Flavor is like nothing else. and soursop as well.
So tropical fruit, I feel like, would also be high on my list right now.
There's so much good stuff out there. I've been to Kauai before.
I've hiked the Nepali Trail and eaten the passion fruit along the way.
It is remarkable. It's unreal.
Nice. So here's my proposition for you.
I feel like we've done a pretty good job making a dent into how just insanely knowledgeable you are on all this metabolic health.
And, you know, I love the fact that you have a book coming out in May called Good Energy.
Wow, how that's really catchy, beautiful title for a book. Congrats on that. Thank you.
But I really want to dive more into insulin resistance, insulin sensitivity.
[1:33:38] You know, I know you're a fan of the continuous glucose monitor, you know, you, you're the co-founder of levels and you guys have one, but I just, I don't feel like I know enough.
And so I'd love to bring in, have a three-way conversation between myself, yourself, and somebody like Cyrus Kambada with Mastering Diabetes.
So if you're game, let's schedule that for a part two of this podcast.
And I think it'd be a riveting conversation.
I think everybody would get a lot out of it.
I would love that. I would love that. I love Cyrus Kimbata's work.
I think I have his book right here behind me and he's been a huge influence on me.
So that would be really fun to talk about that. And of course he's super well-versed, and continues to do his monitors, given his work and his type one diabetes.
And so it'd be fascinating to talk about that. Yeah, we'll be happy to.
Yeah. Listen, Casey, I am so glad that we got to spend some time together this morning and appreciate your work, everything that you're doing.
So glad that you got out of the ear, nose, and throat and into metabolic health and what you're doing.
So thank you for making the world a better, healthier place.
And can you give me a little PLANTSTRONG fist bump on the way out? Boom.
[1:34:59] Thank you. Thank you. We'll see it. We'll see us shortly. Okay. Okay.
As you heard there at the end, I'm gonna have Dr.
Exploring Insulin, Glucose, and Continuous Glucose Monitors
[1:35:10] Means back on the podcast so we can dig a little deeper on insulin, glucose, blood sugar, and the rise of continuous glucose monitors.
Until then, as Dr. Means says, eat real whole foods.
And as I like to say, always keep it PLANTSTRONG. We'll see you next week.
Support the PLANTSTRONG Podcast for exciting plant news.
[1:35:37] Thank you for listening to the PLANTSTRONG Podcast. You can support the show by taking a quick minute to follow us wherever you listen to your favorite podcasts.
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Thank you in advance for your support. It means everything. The PLANTSTRONG podcast team includes Carrie Barrett, Laurie Kortowich, Ami Mackey, Patrick Gavin and Wade Clark.
This season is dedicated to all of those courageous truth seekers who weren't afraid to look through the lens with clear vision and hold firm to a higher truth.
Most notably, my parents, Dr. Caldwell B. Esselstyn, Jr.
And Anne Crile Esselstyn. Thanks for listening.
