“The most important things that I do every day are to take walks after my meals and make sure that I sleep a full eight hours. Those two simple things, which require a lot of adjusting for your lifestyle, have an outsized impact over the years and decades as they compound.” – Josh Clemente

In this episode of Outliers, I’m talking with Josh Clemente (@joshuasforrest) about the concept of metabolic health, the importance of feedback loops, and why our daily choices have such a huge impact on our overall health.

Josh Clemente is the Founder and President of Levels, a metabolic fitness company that helps people see how their choices affect their health in real-time. Before founding Levels, Josh was the Lead Life Support Systems Engineer at SpaceX, where he led the development of pressurized life support systems aboard spacecraft. He’s also worked as a Senior Design Engineer at Hyperloop One and is a certified  CrossFit Level 2 Trainer. In 2019, he founded Levels, which is a comprehensive app that uses constant glucose monitoring to provide easy-to-understand feedback on your diet, exercise, and daily activities. 

Chapters in this interview:

• 00:00:29 – How Josh’s engineering background and role at SpaceX led to the creation of Levels
• 00:06:32 – How a ketogenic diet can affect your life expectancy
• 00:07:57 – The basics of ketones and ketosis
• 00:13:34 – How real-time data can help people choose the foods and activities that are healthiest for them
• 00:21:17 – Surprising insights from Levels customer data
• 00:31:01 – How Levels converts raw data into easy-to-understand scores
• 00:39:58 – Levels’ expected launch date
• 00:43:03 – Whether glucose alone is the best indicator of overall health

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Links from the Episode

• Connect with Josh: Twitter | Instagram | LinkedIn | Levels
• This SpaceX alum co-founded Levels, a health startup that measures your metabolism in real time - The Hustle
• Levels Raises $12M for its Biowearable Device that Monitors Glucose in Real Time - AlleyWatch
• SpaceX and the Dragon spacecraft
• CrossFit
• Metabolic fitness
• Glucose monitoring
• Studies of Dominic D'Agostino 
• Ketogenesis
• Ketosis
• Ketones
• Metabolism
• Macronutrients: Carbohydrates, fat, protein
• Blood-brain barrier
• Anabolism
• Hyperinsulinemia
• Insulin resistance
• 2018 University of North Carolina study: 88% of U.S. adults metabolically unhealthy 
• Finger prick devices, which can be found at drugstores
• Wired to Eat: Turn Off Cravings, Rewire Your Appetite for Weight Loss, and Determine the Foods That Work for You by Robb Wolf
• Diabetes
• Cortisol
• Adrenaline
• Fight or flight response
• Glucose levels and diabetes’ 
• Cardiovascular disease
• 2015 Weizmann Institute Trial - “results suggest that personalized diets may successfully modify elevated postprandial blood glucose and its metabolic consequences”
• Twins trial in the U.K. 
• Microbiome
• Body composition
• Resting heart rate
• Dawn phenomenon
• Circadian clock
• Whoop
• Glucose intolerance
• CDC National Diabetes Prevention Program
• PCOS (Polycystic Ovary Syndrome)
• Stroke
• Alzheimer's
• Dementia

Key Takeaways

“The most important thing is that people understand that beneath physical fitness and mental health is metabolic fitness. Our brains and bodies are composed of individual cells, all of which need energy, and they need to be able to access it efficiently. If they can't, things go wrong. You cannot achieve physical fitness or mental fitness without that metabolic function beneath it. And more importantly, this is not something that's out of your control. It's hard to measure for sure, but very simple things can improve it.”

“The most important things that I do every day are to take walks after my meals and make sure that I sleep a full eight hours. Those two simple things, which require a lot of adjusting for your lifestyle, have an outsized impact over the years and decades as they compound.”

Daniel Scrivner (00:00):

Josh, thank you so much for your time. I'm so excited to chat with you today about all things metabolic health and Levels and glucose and chat about it all.

Josh Clemente (00:08):

Daniel, thanks for having me on. I'm thrilled to dig into it.

Daniel Scrivner (00:11):

So it's been so much fun preparing for this interview and doing all my kind of homework and research and listening to some of your previous interviews. And I thought a neat place to start, and I know it's only tangentially related, would just be talking about some of what you did at SpaceX before founding Levels. Can you share a little bit of your background in what you did there?

Josh Clemente (00:29):

So my background is in mechanical engineering, I had a fascination with vehicles of all kinds, anything that goes fast when I was younger. And so that mechanical engineering was my way of working on those things. And ultimately, I ended up at SpaceX after school as my first engineering job, can't really ask for a better kind of initiation into the world of-

Daniel Scrivner (00:47):

Seriously.

Josh Clemente (00:48):

... machines. So I spent about six years there, I did a bunch of different stuff. I started out as a manufacturing engineer, essentially trying to get the Dragon spacecraft from kind of a first article prototype, to multiple sort of production processes so that we could make the spacecraft at rate. And then from there, I moved into more systems, responsible engineering, we called it at SpaceX, which is like, you are kind of a project manager, you own everything from the design through to flight. And so that system and everything it touches has to work and it's your responsibility to make it happen. And then lastly, I maintained that role, but moved into the new life support program that SpaceX was starting. So initially, it was just a launch company, meaning you basically put a satellite on the top of this giant candlestick and put it into orbit, that's your job. And so that's easy enough, if something goes wrong, there's insurance for satellites. But once you start carrying humans, it becomes a whole different beast.

Josh Clemente (01:43):

And you can imagine, think about everything that airlines have to do with the FAA to fly around on planes that can glide to a landing basically, anywhere. Now imagine that it's a giant, explosive, 10 story tall building and those people don't really have many options if things go wrong. So it was kind of a redesign of the whole systems approach we took at SpaceX, I got to be one of the first to work in that program, and eventually led a team, developing breathing apparatus and similar life support projects for astronauts.

Daniel Scrivner (02:10):

Sounds incredible. And if you like to work on fast stuff, it seems like you can't really be working on a rocket, so it's-

Josh Clemente (02:16):

No you can't.

Daniel Scrivner (02:16):

It's a good place to start. So I know part of your story, as I understand it, part of the kind of founding story of Levels is based a little bit in your experience working at SpaceX. I've worked for a couple of startups and obviously, I would probably bet that SpaceX is a little bit more of a challenging environment. But I know the idea of work-life harmony, work-life balance just does not exist. And you're working really long hours and you're just often not taking much care of yourself. So can you talk a little bit about what a day in your life looked like then and how that eventually led to you founding Levels?

Josh Clemente (02:46):

I like starting with the day in the life. So looking back, days bled together, I literally lived work at that time. And SpaceX set up an environment where you really could live at work if you wanted to. It was not so far as Google where you had rooms available, but there was always space under your desk to crash and there was food downstairs. And so many of us who were young and were trying to prove ourselves and honestly had more responsibility than we could ever have imagined, just leaned in. And so I really didn't take a break. I don't think I took a weekend off even for several years continuously and rarely went home for holidays, I would go home for Christmas Eve and Christmas Day, that sort of thing and the rest of it was just immersed in work. And for a long time, that's phenomenal and you love it. And then something changes where I think the toll that it takes that constantly beyond, starts to set in.

Josh Clemente (03:36):

And I kind of assumed the type of person that I am, that would never catch up with me, it was something I enjoyed. And the payoff of having a project you work on going into orbit and seeing that happen was like nothing I'd ever experienced. So I just kind of leaned into those moments and struggled through the rest. But long story short, I got to a point in my life support program, where I now had a team, I'd been there for five years and I was at the point where I needed to perform at my best and that burnout had set in. So mentally and physically, I did not feel like I was performing.

Daniel Scrivner (04:10):

It's like the worst timing.

Josh Clemente (04:12):

Exactly, the worst timing. And it was when it mattered most to me. Delivery was so important not just for myself, but for everyone who is working with me. And I was having these... They were truly episodes. It was like my mood would fall out from underneath me, I would be irritable, dead tired, I'd want to sit down and go to sleep. And that's all I wanted to do. And it was a true struggle to get through a workday and I just had not ever experienced that. And separately, but related, I've always been a physically fit person. I've been active my whole life playing sports. I was a CrossFit trainer at this time, and it was kind of a side thing I did just to stay in shape. And I was physically in shape. My doctor would laugh at me every time I would come in to get blood work done. He'd be like, "If you knew some of the people that came through this door, you wouldn't worry about these things. You're one of the fittest people I see." And that was the philosophy I had, that fitness was health.

Josh Clemente (05:04):

And so when this happened to me this sort of burnout, I became brutally aware of the fact that there's clearly something off here, I should feel healthy and yet I don't. So that started a process of self exploration or experimentation that kind of coincided with my work at SpaceX, but ultimately led to discovering metabolic fitness, glucose monitoring, and now has become Levels.

Daniel Scrivner (05:27):

And I know there was this pivotal research paper and I'm blanking on, I think it's Dominic D'Agostino. But can you talk a little bit about what that felt like to kind of discover that paper and then the path that led you off on?

Josh Clemente (05:38):

I was basically in charge of the development of an oxygen breathing apparatus. So delivering oxygen breathing gas into the Dragon spacecraft, and then also to the spacesuits for the crew members to breathe. And there are certain scenarios that you need to be aware of when you're designing these systems, that would be failure modes. And so one of these situations was like, what happens when, or if there's high pressure oxygen delivered to the spacecraft, what can happen in the situation? So I was researching this. And essentially, there are central nervous system issues where if you're in a high pressure oxygen environment, even though we all breathe oxygen, if it's too high, it's so reactive a molecule that everything becomes fuel. And so your brain can literally become this... They call it central nervous system toxicity. But essentially, you're developing these reactive oxygen species, these byproducts of reactions happening with the oxygen that can really destroy your brain tissue very quickly and you can go into seizure and you can even die.

Josh Clemente (06:32):

So I found this paper from Dominic D'Agostino, who's a ketogenic researcher at the University of South Florida. And it basically showed that in mice or rodents, when they're on a ketogenic diet, or when they're in a ketogenic state, and I can explain what that is in just a moment, but essentially, they're metabolizing these fat molecules instead of sugar, and they can live up to five times longer in the same environment when in this ketogenic state. And to say that that shattered something in my consciousness is to understate it. I had to reread it like five times because to me, a calorie is a calorie. Something that you metabolize is just a calorie, its energy and what you eat does not matter. So that was what I believed, it was what I had kind of been taught my whole life. And to see that there's actually a physiologic change that allows these rodents and I'm extrapolating to humans, but allows this organism to develop essentially superpowers by eating something different, was something I couldn't wrap my head around.

Josh Clemente (07:29):

So that actually is the moment that I started to think, "Wait a minute, what if I'm doing the wrong thing? What if I'm just eating the wrong things? Or rather, if I could have superpowers, because of what I eat, I'd like to make sure I am." So that's where I started to explore human metabolism, explored diet, nutrition, general wellness practice as an avenue to potentially improve my own, as I mentioned, flagging energy levels and overall disposition.

Daniel Scrivner (07:57):

And you touched on it there just whether it's ketogenic or ketosis. And I know there's a lot of terms that people potentially have heard or haven't heard. But can you just set up for people I guess, what is ketosis? What is your body processing? And how is that different and distinct from glucose in your blood?

Josh Clemente (08:13):

Yeah. So actually, I'll rewind even a little bit before that and talk about metabolism. So metabolism, we kind of talk about this all the time in society. But most people in the context of I have a fast or a slow one based on if I gain or lose weight, but the actuality of it is, metabolism is all of the processes our bodies use to turn our food and environment like sunlight into energy. And every cell and every tissue in your body requires energy to function and to survive. So this is happening in orders of magnitude, we can't even comprehend all the time. And the primary fuels that our bodies use for these metabolic processes are glucose, which is sugar and fat. And inside of fat, if you click into that, there are different types. So most fat molecules don't dissolve in water. And so they can't cross this barrier that's around the brain called the blood brain barrier.

Josh Clemente (09:03):

But ketones are a specific type, they're basically a repackaged fat molecule that can cross the blood brain barrier. So it's kind of a specific fat that your body can produce and it can be used by the brain for energy. So it's a very unique molecule. And most people are not producing ketones, unless they're deliberately doing something like either fasting for extended periods, or eating a super high fat diet. So 80% of your calories are coming from fat. And in those circumstances, your body kicks into this mode called ketogenesis, where it's basically breaking down the nutritional fats and the adipose tissue on your body and turning it into ketone molecules.

Daniel Scrivner (09:40):

That's pretty incredible. I guess in terms of how your body processes that, or how that... I'm guessing we'll get to this in a little bit. But is that a gentler fuel source for your body as compared to something like glucose?

Josh Clemente (09:52):

Well, it's a different fuel source. And that's really what all of this research and ultimately what Levels is working on is that we've now got the data we need to recognize that all calories are not the same. So there are these different molecules, I just laid out three of them. The fourth sort of macronutrient is protein. So we're basically consuming fat, sugar and protein every day. And each of those molecules has a completely different implication for our metabolic processes. And those implications are hormones. So when you consume, you just think of the human body as a giant chemistry set, because that's ultimately what we are. And what you eat is just like pouring chemicals into the chemistry set. So when those chemicals arrive in the bloodstream after being digested, other chemicals have to respond to them. These are signaling molecules and these are hormones that are basically marshaling resources. So for example with glucose, the glucose is the primary energy molecule and most modern people. So most of us are well fed all the time, we're sedentary. And so what we eat typically contains carbohydrates, those break down into the bloodstream.

Josh Clemente (10:58):

And the way the body gets those out of the bloodstream is through this hormone called insulin. And insulin's purpose is to store things. The way it works, it's like a key in the lock of every cell. So these cells have receptors, they identify insulin, when insulin attaches to them, they open up these transporters and glucose moves into the cell to be used for energy. Now, insulin, we call it an anabolic hormone, because it is primarily focused on storing things. And when you have high levels of insulin, your body's constantly storing the glucose that's being released into your blood and turning it into body fat. Now, the difference is, for fat there is no insulin response. So fat can be readily stored on the body without hormones, and it can also be readily metabolized as long as there is no insulin in the blood. So imagine a situation where you're constantly eating a high carbohydrate diet that is also high in fat. So insulin is circulating in the blood and it is preventing anything from being burned, it's basically only storing.

Josh Clemente (11:58):

And you're in a situation now that you can store the energy that you're consuming, but you can't access it for energy, because insulin levels are high. This is a situation that can for many people go on, basically daily for decades. And ultimately, when you are in this what's called hyperinsulinemic state where insulin is always high, your cells eventually get to a point where they stop responding. The mechanisms are hard to explain, but just imagine like you walk into a kitchen and there are freshly baked cookies. You smell that, it's like a very strong smell. And then 20 minutes later, you're no longer aware of the smell. So your body has sort of adapted to the environment and is no longer sending that strong aroma, even though it's still there. This is how I would describe the insulin resistance process, where insulin is so high all the time that your cells tend to essentially desensitize to it and the problem is that you're now in what's known as an insulin resistant state, which is where things go haywire. So insulin is constantly elevated, you can't oxidize or use the fat that's on your body for energy.

Josh Clemente (13:04):

And you're basically locked in this energy crisis, where when you need energy, you can't get it because you're blocked and where you can only add energy for brief periods of time as you spike your blood sugar and in the period between that spike and when it's sort of marshaled into fat stores. So anyway, all that to describe the hormonal differences between the macronutrients we're eating. Carbohydrates signal insulin release, fat does not. And so that's a very big deal, especially in modern society where we're experiencing such high rates of metabolic dysfunction.

Daniel Scrivner (13:34):

And I want to come to that in a second. There was a fascinating analogy, I love that cookie smell example. So I want to just stop for a second and I guess transition and talk a little bit about what Levels is and I'll try to tee it up and you can take it from there and help flesh it out a little bit more. But my understanding of it (I've been trying recently) is... it's basically an app that pairs with a sensor, that sensor is, I think a constant glucose monitor that's always in your body. And it allows you to basically have a feedback loop where you're able to see how your choices and your actions influence that glucose level. And what's fascinating about it, which I definitely want to spend some time talking about is there are a lot of inputs into what that level looks like. It's not just what you eat, it's the level of activity when you have that activity, how you manage your stress. Do I have that right and can you flesh that out anymore about what Levels is?

Josh Clemente (14:23):

My summary I like to use is, Levels answers the question, what should I eat and why? If we think about it, if most people sit down and I ask, you're about to eat lunch, what are you going to eat and why? Most people scramble and they start thinking, "Well, I'm going to eat what I ate yesterday, or I'm going to eat this thing that I read on the internet that this person I trust said."

Daniel Scrivner (14:41):

Or what sounds good.

Josh Clemente (14:41):

Or this thing my mom cooked.

Daniel Scrivner (14:42):

Yeah.

Josh Clemente (14:43):

Yeah, it's typically emotion driven or flavor driven. It's never data driven. I have no examples of someone who's using data to drive their choices. And typically, that's okay. But the reality is that in the modern times, where we essentially have an extremely processed food supply, we don't have a feedback loop between the actions we're taking, the foods we're eating and their effects on our health. It's very easy to go way off in the deep end through this sort of compounding and quiet process of developing metabolic dysfunction. And the reason this is so critical is if we look at the state of things today, here in the United States, a study was conducted by the University of North Carolina in 2018, that showed that 88% of US adults are metabolically unhealthy on at least one metric. And 70% of people, 70% are overweight or obese. 90 million Americans are pre diabetic and 84% of them don't know they are pre diabetic.

Josh Clemente (15:36):

That 90 million, so 70% of them are likely to get type two diabetes, it's one of the top causes of morbidity in the United States within five to 10 years if they don't change something. Now, how are you going to change something if you don't know there's a problem? Remember, 84% of that 90 million don't know they have it. So this is a silent epidemic that's building and it's reached literally epidemic rates. And it's slowly moving down our age brackets. It's reaching younger and younger audiences every year.

Daniel Scrivner (16:03):

It's depressing.

Josh Clemente (16:04):

Yeah, it's a sad state of affairs. And I think it all comes back to this problem of there is no feedback loop. We're making choices based on emotion and on flavor. Where potentially, we're adjusting things by trial and error based on, say, how the bathroom scale is changing. "Oh, I gained 15 pounds this year, that's not good, I should probably change something about what I'm eating for lunch." Well, that's a really long feedback loop, a year is too much time to figure out which lunch is causing the problem. So the philosophy that is driving Levels is that we can use real time biometric data, in this case, your actual blood sugar levels, your glucose levels, to close the loop within minutes between an action you take and the reaction your body is experiencing. And there are implications to all those reactions. So for measuring glucose, we can assume the results in terms of insulin. So if you have a large blood sugar elevation, we know physiologically that you need insulin release in order to move that out of the bloodstream. And so there's likely a large insulin response.

Josh Clemente (17:01):

So with these sort of real time predictions based on your biometric analytics, we can help you understand how a specific nutritional decision is affecting you within minutes. And that is a powerful thing for driving behavior change. So the Levels system is, again focused on using these biometric sensors, which I can give some history on, if that's useful, connected with a behavior change platform, which is what we're developing. It's the sort of analytics layer, the detailed data science that is helping to drive decision making through simplified scores. So rather than trying to tell you your glucose variability is X percent, and your postprandial response is moving at X rate per minute, instead, we just say, "That meal was a two out of 10 and here are some recommendations on how you could potentially improve it." Something as simple as taking a walk or a swap on a certain nutritional ingredient. So, that's the direction we're moving in. It is just simplifying and helping to remove the cognitive burden of interpreting complicated glucose information.

Daniel Scrivner (17:58):

And having to become a doctor of some sort to try to figure out how to change your behaviors. So those stats are scary. One of the things that I thought was pretty incredible, again, going back to your story is via using Levels, you actually found out that you were borderline type two, can you talk a little bit about what that was like figuring that out?

Josh Clemente (18:15):

Yeah, we skipped right past that. After that paper that kind of shocked me into a realization that I needed to take the other parts of my lifestyle seriously, I started to prick my finger obsessively to measure blood sugar. And this was basically having an understanding of where our energy is coming from, I knew that glucose was one of the primary molecules. And you can go to CVS and you can buy these finger prick devices where you can basically take a blood drop and get a single measurement. So I started to do that and plot these numbers in Excel, and it was like, kind of a point cloud—it didn't really make any sense to me. It was very unsophisticated, what it should look like anyway. And anyway, I read a book called Wired to Eat by Robb Wolf. And in this book, he talks about this new device called a Continuous Glucose Monitor. And I was like, "Wow, you can just wear this thing continuously, and it'll give you your blood sugar information." So I asked my doctor for one and he said, "That's for people with advanced uncontrolled diabetes. It's not even for people with just diabetes, it's the worst cases."

Daniel Scrivner (19:13):

And it's not experimenting.

Josh Clemente (19:14):

Right. "This this is not for you to play with." And when I came away from that... Well, I can circle back on that. But ultimately, I did get a device. And when I had about two weeks of data, I had enough information to know that my glucose was in the pre diabetic range at least, and it was touching diabetic zones regularly. And the scary thing was that I was doing things at this point that I thought were all healthy. I was working out regularly, I was eating whole foods, I was sticking with brown rice, instead of white rice. I was having sweet potatoes, I was having [crosstalk 00:19:47] goes in every meal. Yeah. And so to see how bad things were, essentially within a month, I had changed everything about my lifestyle. And it has sustained since then. So I mentioned I was a “calorie is a calorie” type person. Once I saw how brown rice affected me, I haven't touched candy, which I used to be addicted to in years.

Josh Clemente (20:06):

In literally three years since putting this device on because the realization that the effects of my daily decisions were compounding together and I was heading in a very bad direction very quickly, was all I needed. I wasn't trying to get unhealthy and I wasn't willing to compromise a short term reward of taste for a snack with the ultimate potential consequences of getting a truly diagnosable disorder. So that experience of understanding or identifying that I had this kind of latent, unknowable borderline or full blown prediabetes and then looking into it and realizing I'm not a needle in the haystack, I'm like, a needle in a haystack of needles, everyone is pre diabetic. And this is a huge problem. And then yeah, the device helping me get out of it.

Daniel Scrivner (20:51):

That story is incredible inn part just because it just goes to the core of I think what's so broken with how we think about health. You alluded to a few times, but just to reiterate it, you look incredibly healthy, and you've always been active and you took all those popular diet to kind of ideas and were implementing those. And so clearly, I think what's powerful about Levels is it tells you your internal health, as opposed to just your external health of, how are you looking? How are you feeling? How much do you weigh? It's just really incredible.

Daniel Scrivner (21:17):

So one of the things that I wanted to talk about a little bit is just surprising discoveries or insights, I'm sure, clearly, you talked about brown rice there and I remember reading something maybe a month ago about just how much sugar in rice, which for me was also like, "Oh, my God, there's sugar and rice!" But I would love it, just to riff on that for a little bit, can you share, I guess some of either what you've learned or what you've observed from, I think at this point, it's potentially 1000s of people that are using Levels, you're collecting data on?

Josh Clemente (21:44):

The interesting thing starts on day one. So for me it was putting this device on, and immediately having a feedback loop. I felt like I was in conversation with my body. So sort of throughout my life, I've either had coaches or doctors telling me to eat healthier and workout more. That's like the continuous refrain. And different ones had different opinions about what healthy meant, which fed confusion, of course, as we all are, if you Google the healthiest diet, you're going to get 10 different conflicting answers. And so being able to just immediately get a feedback loop from my body was like, it was the first magic moment for me. So then there was the process of experimentation. And a couple examples that I really like to highlight are, well, one in particular, is the recognition of stress and the role that it plays in overall health, but specifically metabolic function. So again, we're these giant chemistry sets. And as I mentioned, hormones have massive roles to play in how we function.

Josh Clemente (22:39):

So there is another hormone called cortisol, which we're all pretty familiar with. It's the fight or flight hormone. It's associated with adrenaline as the fight or flight mechanism. And this is the stress response, where essentially when cortisol is flooding the system, your body is in a state of elevated stress, it's in a position where historically, evolutionarily we were probably in danger and we needed to escape. And oftentimes, that meant needing fuel. So to run or climb a tree or whatever it was.

Daniel Scrivner (23:08):

Probably lots of fuel.

Josh Clemente (23:10):

Right. So I'll just give an example. I was a few weeks into using the CGM and I had a really stressful phone call. And it was a meeting essentially, but it was a presentation as well. And I did this call and my heart rate I knew was elevated the entire time. I was just kind of gasping for air throughout. And then I looked at my CGM data afterwards, and my blood sugar had gone to 145 milligrams per deciliter, which, for people who don't know, after a carb heavy meal, your body should stay below 140 milligrams per deciliter.

Daniel Scrivner (23:39):

Wow!

Josh Clemente (23:40):

That's considered the pre diabetic threshold. If you respond beyond that, you want to very quickly get out of that range, because it's not good. So I hadn't eaten a single calorie.

Daniel Scrivner (23:48):

Just to clarify too, what did it start at? What was that climb like in the meeting?

Josh Clemente (23:52):

It started at about 85 or 90 milligrams-

Daniel Scrivner (23:54):

Wow! That's a huge climb.

Josh Clemente (23:56):

Yeah, it was a 50 point change and I hadn't eaten anything. And at first, I thought that was a problem. And then I started to see this happening repeatedly, throughout any stressful moment, I started to see these elevations. And some of them were small, and some of them were huge. I started looking at the mechanism and the mechanism is, when cortisol is released, it signals to your liver you got to escape, we need fuel. And so it essentially stops the action of insulin, you start producing new blood sugar and it just floods your system. Now, the reason that's important is that for the everyday person who's just trying to get through a workday and for many of us who have weight loss as a primary goal, every time we allow stress to build, we're potentially introducing a fat gain moment where during that time period, we're producing blood sugar and then we're storing that as fat immediately thereafter, because we're not using it for exercise. And so that mechanism of stress then extrapolates out from just those acute moments, to the sort of pervasive chronic stress. So this is where sleep comes in.

Josh Clemente (24:55):

So when I started to see the difference in how my body responded both for my baby fasting glucose and to meals specifically, after say four hours a night of sleep or a red eye or something like that, versus eight hours of deep rest, it completely changed my approach to sleep. So for anyone who's used a CGM, well, I'll just give my example. I will get off the plane after red eye, I used to take these all the time, I don't take them anymore, my blood sugar will be 15 points higher than it was yesterday. And then throughout the day, every meal I eat is aggravated. It's an exaggerated blood sugar elevation and I remain higher longer. And so again, this is a phenomenon that's been studied in the research environment. And they've been able to show that just a single short night of sleep can cause essentially an acute 40% increase in insulin in the body.

Josh Clemente (25:44):

So in order to clear the same meal out of your bloodstream, you'll need 40% more insulin. And going back to the conversation about insulin resistance, that's not something you want. So I started to get this appreciation, which I think is counterintuitive or non intuitive that this device that is measuring blood sugar that you think is only associated with food, is actually telling you a huge amount about everything you're doing in the way that your lifestyle is wrapped up into a context. So combine that with... I'll give a few food examples here. One of the earliest ones, I was in New York and I was going to another stressful meeting. And I stopped right outside the office building and there was this organic juice cart. It was a pressed juice cart, and they had a drink on the menu called health drink. And that health drink was carrot juice, celery juice, green apple juice, nothing else. I watched the lady press it right there and I drank this during the meeting.

Josh Clemente (26:34):

And what was funny is everyone in the meeting was commenting on how healthy I was. They're all having Coca Cola, or they're having snacks, and I'm drinking a pressed juice. Well, halfway through the meeting, I checked my blood sugar and I was well over 200 milligrams per deciliter.

Daniel Scrivner (26:47):

Wow!

Josh Clemente (26:48):

So this is well beyond the diabetic threshold, which is 180. You should never exceed that if you don't have diabetes, or at least that's the standard of care as of today. So my blood sugar remained up there for some time, it came crashing back down, I was starving, I was irritable, I was shaky all those sensations really from my SpaceX days. And again, this was something that I had actively chosen as a healthy alternative to a coke, or to-

Daniel Scrivner (27:12):

It's called “health drink.”

Josh Clemente (27:13):

It's called “health drink.” And a lot of people every day are using press juice as a healthy option. And so for many of us, if we are not metabolizing that effectively, that's as bad or worse than that Coca Cola, it really depends on how we're metabolizing. It's super important to have the real time context. Another interesting one I think, for many people is, Google the healthiest breakfast out there, top three guarantee it is going to be oatmeal. Steel-cut or rolled oats, doesn't matter, it'll be on the list. About 60% of the people, 70% of the people. Last time we checked in the data set, have a pre diabetic or diabetic response to oatmeal every morning. And that's just plain oats, no sugar and maple syrup. And you'll note that on oatmeal, there's typically a heart healthy label saying this is good for you. Well, glycemic elevations and variations are both closely connected with risk of cardiovascular disease. So if people are actively trying to pick this oatmeal breakfast to make themselves healthier, or to improve cardiovascular health, it may not be working and it could be working directly against them.

Josh Clemente (28:15):

And so again, I'm not saying that this is the case for everyone. And I can touch on the personalization piece. But it's certainly important that we as individuals are not guiding our choices based on marketing. Because marketing is not always data driven. It's important that we're connecting them with our own bodies and what's really happening.

Daniel Scrivner (28:31):

Yeah, and I'd love to talk about that personalization piece, because to me, that's the power of technology. That's the power of what Levels can deliver is rather than, as you alluded to before, putting people into very simplistic fuzzy buckets of like, this is the diet for you, or what are you after, okay, this is what you should do. It really takes it all the way down to the individual level. And one example I heard you give that I thought was fascinating is giving two people the same thing, whether it's a banana and a cookie and seeing inverse effects there. Can you talk a little bit about that personalization piece?

Josh Clemente (29:00):

One of the fascinating things about the tech that's coming out is that miniaturization, like the microelectronics revolution, is allowing us to make these devices smaller and smaller and more convenient, last longer, more affordable. So the proliferation of what's allowing Levels to exist is also allowing better research. And one of the most interesting trials happened in 2015. It was called the Weizmann Institute Trial in Personalized Nutrition, it was published in the Cell Journal. And basically, they took 800 people without diabetes, put these continuous glucose monitors on them, and had them eat standardized meals for about two weeks. And in this data set, they could show that to people who ate the exact same two foods. In this case, it was a banana and a wheat cookie, had equal and opposite blood sugar responses, so the inverse effect. And this effect has since been restudied or replicated or bolstered in some way by multiple studies since one of which was the Twins Trial in the UK, which showed that the same effect is evident in identical twins who share 100% of their DNA.

Josh Clemente (30:00):

It's not just genetics that dictate it, it's actually more likely the context of our sort of lifestyles. So you can imagine if two people are one of which slept for four hours last night, and one that slept eight hours, and one of which has 25% body fat and the other is primarily lean muscle mass, they have different genetics, their microbiome, all of this stacks up into a context for how their metabolic system is functioning. In that context is what Levels calls metabolic fitness. So this is the degree to which you have developed a context for optimal metabolic function. It's something that is trainable, you can improve everything from body composition, through to muscle mass, through to stress and sleep quality. But what you can't do is change your genetics. So I think the good thing that we learned from that trial is that this is not binary, it's not something that you're stuck with because your parents had it.

Josh Clemente (30:51):

It's something that with focus, effort and repetition, you have control over and you can improve, just like you can work your way towards benching 300 pounds, or you can work your way towards a fast quarter mile, we can do the same with metabolism.

Daniel Scrivner (31:01):

One of the pieces that I wanted to talk about for a little bit is, I don't know to draw a little bit of a parallel between glucose monitoring and heart rate monitoring. And heart rate monitoring, you're looking at multiple different variables, you're looking at everything from heart rate variability, your resting heart rate. I'm guessing that there's probably a lot of signals that you're looking at on the glucose side that then derive some sort of simplistic, easy to understand score. Can you help us understand those, or kind of illustrate some of those?

Josh Clemente (31:26):

We do pull in additional data in addition to glucose, which includes heart rate and sleep. But right now, our core focus is on improving the actionability of real time blood sugar information. If you just buy a CGM, which are prescription only in the United States and put it on, you're going to end up getting this sort of raw data stream, it's going to be like a curve, it doesn't quite look like a heart rate, it doesn't change that quickly. But it's kind of all over the place. And understanding exactly what you're looking at and what's influencing it, can be somewhat tricky. There's a ton of variables, each of which has been studied separately, that all matter. So Levels is focusing on stripping away the complexity and providing you with the minimal amount of clean, easy, use interface that will help you understand the actions you're taking and how they're affecting your body. So the two scores that we've developed primarily are, the first one is called the zone score. So when you're using Levels, you are logging your activities.

Josh Clemente (32:19):

So whether it's a meal you eat, or exercise that we can detect through Apple Health, or your sleep, all these things are stacking up into a context like we just touched on. And so when these zones happen close by, or these activities happen close by, we capture that and call it a zone. So let's say you eat a meal and you go for a walk, we will contextualize both of those and then discover how or track how your body responds over the corresponding say about two hours. Once your blood sugar returns back to normal, we'll give you a score just on a one to 10 scale for how well that meal or that set of activities affected you. And this is a very easy way to again, get rid of the complexity and understand, "Okay, between this meal where I ate it, and I sat on the couch, or I did work all day. And this other meal, which was exactly the same, except I took a walk, the difference was a six out of 10 versus a two out of a 10.

Josh Clemente (33:10):

And the difference was the walk." You start to make these connections using the simple scoring mechanism between the way these activity combinations affect you. And then the second metric that we're developing is the say score. And so we currently call this the metabolic score, but we are developing a third which is going to take that name, we're going to split it into two. But anyway, the day score is giving you just a grade point average or a grade overall out of 100%. So each day, the goal should be to get 100%. And this is the combination of all of your zones, it's the combination of the time in between zones. So how well you sort of adapt and return to a low controlled baseline, the effects of stress would be captured in here, the effects of what's called the dawn effect, which essentially is a stress mechanism. But people who wake up in a stressful environment will have this big blood sugar spike first thing in the morning, that's called the dawn phenomenon.

Josh Clemente (33:59):

It used to be assumed that that was only something that happened in diabetes, but we see it with a huge portion of our non-diabetic users. So this is a natural phenomenon, but we want to control. So all of this stacks up for your day score. And then as you string together streaks of high quality day scores, that ultimately should eventually lead to better metabolic fitness overall, which is what we will track with our third metric.

Daniel Scrivner (34:21):

What was the dawn score? Dawn effect?

Josh Clemente (34:24):

Dawn phenomenon or dawn effect.

Daniel Scrivner (34:25):

Dawn phenomenon. I've never heard of that before. And it sounds fascinating. As soon as you said that, I've got a five week old at home. And so constantly at night, I'm waking up to basically a crying baby. I'm pretty certain that's what's happening with me. But I guess more generally, is that people waking up to alarm clocks? Is that people waking up traveling? What causes that?

Josh Clemente (34:45):

It's a good question. So there's a lot of theories. One of the theories is that this is something that when moderate is good, it's basically your body going from... So while you're sleeping, you have very minimal energy demands. Your brain is running but your muscles aren't and you're at rest. So your body will typically have a blood sugar drop overnight. And that's good. But then, as your circadian clock senses that you're about to wake up, there's a natural flood of cortisol that's released to get you primed. So to essentially get your blood sugar back up, get your heart pumping and get you on your feet. And this seems to be closely timed with the wake up or the patterns that people follow for their sleep. Now, the issue is that for someone who's chronically stressed, or seems to be for some, this may just have gone a little bit errant, where you'll have a huge blood sugar spike and you haven't eaten anything and this is happening every single morning.

Josh Clemente (35:36):

And of course, as we know, that's not something you necessarily want. So the dawn phenomenon seems to be worse for people who get shorter sleep and it seems to be worse for people who ate a very indulgent meal the night before. So it could be like you're releasing more glucose, because you had more the next day, which is-

Daniel Scrivner (35:52):

On that ice cream.

Josh Clemente (35:53):

Exactly. It's very individual, very personal. And the mechanism we know is cortisol, but we don't know specifically why it's worse in some than others.

Daniel Scrivner (36:01):

It's fascinating. So I want to ask one more question and then I would love to just explore a little bit about what things look like behind the scenes at Levels and how you guys are processing this data and some questions around hardware. But one thing I know quite a few people that have been early users and adopters of Levels. And it's been fascinating, because they've all noticed really striking differences. They've all, similarly to you I think, just had a lot of aha moments using it. I know two people… clearly there's 1000s that are using Levels now, what are some of the stories that you're hearing coming out of people that are using it that are remarkable, or I don't know, insightful or just crazy?

Josh Clemente (36:37):

Really remarkable ones are the people who discover something that would have been a problem long term. So they find out that things are really not good and they then very quickly, just make simple micro optimizations. And the way I like to put it is, they're making micro optimizations and Levels gives them the digital receipt.

Daniel Scrivner (36:55):

Interesting.

Josh Clemente (36:55):

So you simply add that walk onto your meal and you see how much better your blood sugar response is to it. And you repeat that over and over again, or sometimes you remove a nutrient and or adjust the portion size or you start to embrace sleep. So we've had a few examples of people that have really transformed their metabolic health in 28 days and many of them have turned into subscribers and continued long term. But we're talking about across multiple biometrics, not just glucose control. So those are my favorites for sure, and there are several. And then specific examples that are really just I enjoy tremendously are just hearing from people who restore their confidence in the foods they're eating. So a lot of people are really anxious and tend to follow very stringent dietary philosophies because either they're fearful of gaining weight again, maybe they've had a weight gain issue in the past, or they're just generally afraid of getting a bad outcome health wise and they have no confidence because they don't have the feedback loop.

Josh Clemente (37:52):

So one person that I know, she was eating a very strict ketogenic diet for years. And she really missed just the better diversity in her diet. And by using CGM and using Levels, she was able to see that she could stay in a ketogenic state, despite eating fruit and having specific vegetables that were more on the starchy side. And all it took was just accurate timing and accurate portion sizing. And so she's dramatically broadened her dietary approach while staying in a ketogenic state, which she wants to do for therapy and weight loss. And it's massively improved her quality of life, which matters just as much as our quantitative risk of illness because, again, stress hurts. So, that's one example. Another one is one gentleman, he was using the product and he wasn't eating oatmeal at all, it was the kind of the opposite of the example I gave. And so growing up, he really loved oatmeal. His wife I think, told him that it was bad for his blood sugar, so he had stopped eating it.

Josh Clemente (38:49):

And ultimately, with Levels, he found out that there was a recipe for oatmeal, that by adding some almond butter and some chia seeds, and so basically a little fat and fiber, he could make a really hearty meal out of it and his blood sugar was super controlled. And specifically, if he worked out just prior. So these are examples where he basically wrote a long note that said, "I stopped eating this out of fear. It was always my comfort food my mom gave me growing up. And this has allowed me to sort of live the lifestyle I had hoped for and do it in a way that is healthier and fits with my goals." And I just love those examples.

Josh Clemente (39:21):

And there are so many of them that people, whether it's just finding out that sourdough bread works better than potato bread or white bread, being able to navigate all of this complexity and have ultimately a lifestyle that is even more enjoyable than you might have assumed you could get that is tailored specifically to you, the individual, is we're getting these anecdotes all the time and it's really fun to see the differences but also to just embrace the positive reinforcement. A lot of people feel that, "This thing is just going to tell me I can't do anything I enjoy anymore." It's really not the case, you can find that there's a lifestyle that works for you that you'll likely enjoy a lot.

Daniel Scrivner (39:58):

Those are great, great examples. And yeah, I think it just again goes to the fact of you're tailoring it for specific individuals, you're giving them confidence and you're allowing them to choose what it is or find out what works for them. And it's incredible. So just to switch and transition and talk and explore Levels a little bit, just to set things up, can you talk about where you're at now? I believe you guys are still in a bigger and bigger beta. And where you're heading in terms of kind of an official launch, you don't have to share a date. But just in the scheme of things.

Josh Clemente (40:27):

We've been in development since we emerged from stealth, and that's been a little over a year now. We're essentially using the feedback from our earliest adopters to rapidly improve the product. We've gone from essentially zero app to where we are today, hand in hand with our earliest members. And so this process is invitation only, we have a limited, essentially resource allocation in order to make sure we're capturing good feedback. And we've been slowly increasing volumes and definitely building our scalability in our systems, but our launch is contingent on a few more product milestones we want to get across. And that will likely happen later this year. But we've had about 6000 people total go through the program thus far.

Daniel Scrivner (41:07):

That's the 28 days?

Josh Clemente (41:08):

Yeah, that's the 28 day program. We also have several 100 subscribers who are long term users. And our primary focus again, as I mentioned, was just customer feedback. So we're really focused on that single one month experience right now. And then for the full launch and for the future, we're going to transition to subscriptions as kind of the primary approach, since we do see so much benefit for the reinforcement and accountability. So when people learn these lessons, when you have that real time data stream and it's always right there, you kind of can continue to reinforce the habits that you've developed. So I think the subscription will be the long term approach.

Daniel Scrivner (41:43):

Do you think you'll have... Because it's been interesting using it and initially, I did think, "Oh, I just will get sensors forever and continue to..." But I think there is something really interesting in that model, as I understand it now is you effectively get two constant glucose monitors, each one of those is good for 14 days, add those together, you get 28 days, and it seems like that maybe can serve as a diagnostic period. Is that kind of how you're thinking about it once you launch, or will it just be people saying yes or no deciding to kind of sign up?

Josh Clemente (42:10):

It's always going to stay the case that we'll meet people where they are. And it's not necessary that you sign up to some commitment, or do this long term. Within 28 days, most people tell us that they learn more about their bodies than any other, whether it's bio nutrition class, or chemistry class, or what have you, they learn more about how their bodies function because it's real and it's a close loop. So it is valuable for people in just a single month. But I think that in the longer term, the lessons keep rolling in. I've been wearing one now continuously for close to three years and it's the most important piece of data I have in my life. It truly teaches me just as much as something like [inaudible 00:42:48] helps people understand sleep, this helps me understand the entire context of sleep integrated with my overall metabolic status. So I'll continue wearing one, I don't really have a plan to not, it's really fascinating for me and I think a lot of people see that, but it's certainly not necessary to wear it continuously.

Daniel Scrivner (43:03):

And I wanted to ask one kind of, maybe a shot in the dark. But in my mind, maybe it's a clarifying question, is typically in life, in business, it's a bad idea to focus on one step to the exclusion of others. And that's just a recognition that everything is a lot more complex and we give credit for and if you're looking at one stat you may be missing some things. And so one thing I was curious about is, initially when I was thinking about it, I was like, "Oh, glucose is just this kind of very simplistic measure of sugar energy that's in your blood. But it seems like maybe it's closer to something like pH where it's describing the environment in your body." Can you talk about why glucose alone gives you so much insight into those different parts of your life and your health?

Josh Clemente (43:42):

That's a really good question. And certainly I want to front run by saying, glucose is not a panacea. It's not the only molecule that matters by any measure. It is however, one of the most important to today's society. And the reason for that is that we have such rampant rates of glucose intolerance specifically. So again, all of the prediabetes and type two diabetes cases are avoidable, chronic lifestyle decisions. And the CDC says and they have a diabetes prevention program, which is oriented around better lifestyle choices. It is these micro optimizations about better exercise, better sleep, better eating. It's just that we don't understand at a societal level, how bad this is and what it means. So it is all glucose intolerance and that tends to lead to insulin resistance. And insulin resistance affects us not just in the diabetes spectrum, but also it is associated with PCOS, which is the number one cause of infertility in the world. It's associated with the stroke and Alzheimer's dementia and...

Josh Clemente (44:40):

Actually Alzheimer's dementia is being called type three diabetes today, because of the way brain insulin resistance develops, that stroke and cardiovascular disease and all of these other conditions that we call by different names, but ultimately have metabolic implications. They have chronic lifestyle implications. And most of them happen due to this glucose insulin feedback loop getting out. And it's really due to the fact that glucose is the primary energy molecule our bodies run on. And because of the situation we're in, where energy resources are very high, we've got a ton of food supply, we're not really in a scarcity mode for most of us and we are increasingly more sedentary as we move to an information age, this is just breaking down. So I would say that understanding your glucose status and projecting your insulin status as a result is the most powerful thing we can do for metabolic health today, but it's really important to Levels that we introduce additional analytes that help paint the broader picture.

Josh Clemente (45:31):

So we are actively working in the background on our research program and then also our innovation program to find the next real time molecule that we can introduce to the platform.

Daniel Scrivner (45:40):

It's exciting. I was going to ask that directional question. So I'm glad you touched on that. I know you're not the CTO, so I don't expect you to answer this maybe as fully as someone on the technical side could. But I'm curious just to talk a little bit about, so you've got a bunch of users that effectively have this constant monitoring with the app, they're constantly sharing this data on the back end, I'm sure you're seeing a lot more data than is being presented in a positive way and are probably doing very interesting things there. Can you talk a little bit about how it works from a technology standpoint, tech stack?

Josh Clemente (46:12):

Right now, the app is the primary input mechanism. We have sort of a prescription process that people have to go through, the devices are prescription only. So we've essentially built a one of a kind one off platform where people can gain access to consultations with physicians who are licensed in their state, prescriptions can be generated, pharmacy fulfill devices into their door. So that whole system was built up internally. And then the app, which we have versions for both Android and iOS, and data system is currently live. And the way that we're analyzing and introducing those sorts of insights we're developing is through what's called the insights framework. So we have some data scientists currently on the team, who are digging deep into both the broader population set and then also specific subsets in order to identify opportunities for very simple insight surfacing. So we're constantly... Our intention is, essentially, we will never sell data for any reason. We will, however, use the data we're developing to improve the product and of course, for research purposes.

Josh Clemente (47:16):

And the research is kind of twofold. It's one, what are our current members using, or seeing? What are they facing? How can we help them connect dots more easily? And this could be as simple as when you eat the same meal twice, reminding them about the effects of something simple that modified that decision. That's kind of the simple-

Daniel Scrivner (47:35):

Make sure to take a walk.

Josh Clemente (47:36):

Exactly. It's kind of a simple thing, but timeliness is key. Again, we have to shorten feedback loops. So, that's what our data science team is looking at, is digging into sleep, what happens during overnight sessions, what happens to people who have severe dawn effect? Who are those people? What are the variables surrounding those episodes? And then this is raising honestly more questions than answers. So we now have the largest data set of its kind in sub diabetic people with lifestyle information attached. And so we're the ones seeing a huge amount of variation and also, again, these sorts of phenomena that aren't discussed in the literature and have not been studied at scale. So we're also developing a research program that will work hand in hand with our tech development to take advantage of this data set. It's really important that we don't just use this ourselves, we want to push the state of metabolic science forward. And so our tech development is also taking that into account.

Josh Clemente (48:30):

And essentially, considering ways that we can build extra analyzable datasets that can be shared with research teams, obviously, with consent from the member whose data it is, but ultimately, with the intention of making this a transformational data set, not just something that we internalize.

Daniel Scrivner (48:47):

That's incredible. Thank you so much for your time, we've talked about a tremendous amount. I would love to talk for 30 more minutes, but I want to be respectful of your time. So I'll ask you one more closing question and then we'll just talk about where people can go to find more. But if someone's listening to this, we've covered a lot of different topics, I guess, what do you hope somebody takes away from this conversation if there's just one insight, one idea?

Josh Clemente (49:07):

The most important thing is that people understand that beneath physical fitness and mental fitness or mental health, is metabolic fitness. Remember, our brains and our bodies are composed of individual cells, all of which need energy and they need to be able to access it efficiently. If they can't, things go wrong. And so you cannot achieve physical fitness or mental fitness without that metabolic function beneath it. And more importantly, this is not something that's out of your control. It's hard to measure for sure, but very simple things can improve it. The most important thing that I implement every day is I take walks after my meals and I make sure that I sleep a full eight hours. Those two things in combination helped me maintain control after a meal and the way my body metabolizes. They fit in some physical movement, because some are significantly better than none.

Josh Clemente (49:54):

And the sleep helps me manage my stress and if I don't sleep well at night means that there's something else that's disrupting it and I can focus on where that's coming from whether that's a personal issue or a professional issue or what have you. So those things, I think, those two simple things, they require a lot of adjusting for your lifestyle, but they will have outsized impact over the years and decades that they compound.

Daniel Scrivner (50:14):

Yeah, those are fantastic. For anyone listening that wants to follow you, learn more about you, where can they go, and where can they go to sign up to be a part of Levels once it's launched?

Josh Clemente (50:24):

Well, I'm on Instagram @Josh.f.clemente, Twitter @Joshuasforrest, Forrest with two Rs. Levels is @Levels on both those platforms. You can also find us on our website at levelshealth.com, and I would highly recommend going to the homepage to sign up for our wait list. As I mentioned, we're in this invitation mode right now, but we do have a large waitlist at about 88,000 people right now and we're eager to get this product launched. So you'll get all the details through our newsletter once you sign up. And finally, check out the blog. So the link is right there on the homepage. This is where we synthesize all the information that is relevant to the individual and how you can better understand what metabolism means for you and what metabolic fitness means for you. So always open to feedback on what we're producing there.

Daniel Scrivner (51:07):

Thank you so much for your time. Thank you so much for coming on the show.

Josh Clemente (51:10):

Thanks a lot, Daniel. This was great.

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On Outliers, Daniel Scrivner explores the tactics, routines, and habits of world-class performers working at the edge—in business, investing, entertainment, and more. In each episode, he decodes what they've mastered and what they've learned along the way. Start learning from the world’s best today. Explore all episodes of Outliers, be the first to hear about new episodes, and subscribe on your favorite podcast platform.

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