WHY THE U.S. MEDICAL SYSTEM IS BROKEN
By: DR. CASEY MEANS & MIGHTY PURSUIT
Dr. Casey Means is one of the world's foremost experts in the area of metabolic health and the New York Times bestselling author of Good Energy. In this episode of the Mighty Pursuit Podcast, we get an inside look into the corruption of the U.S. medical system and why it's failed in protecting people against chronic disease. Mighty Pursuit: All right, Casey, thank you so much for being here. Dr. Casey Means:Thank you for having me. Mighty Pursuit: I wanted to begin by adding some important context for our listeners. Over the last couple of years, we've talked a lot about the corruption in the food industry, and the role that the US government plays in that process. And so we did an entire episode on the subject with Dr. Marion Nestle, who's probably the leading expert on this, and she's literally 87-years-old and has been doing this for 50 years. And then we talked to Dr. Robert Lustig about how the food industry makes products that unleash a wave of chronic disease on our bodies -- cancer, Alzheimer's, all this stuff. But what I didn't fully realize until reading your book was the role that Big Pharma plays in all of this and also just how doctors are kind of really stuck in this corrupt system as well. And this idea that Big Food makes us sick with the products that they're making. But then the medical system and Big Pharma are keeping us sick, which is just wild to me. And so what I appreciated about your book is you aren't speaking from an outsider's point of view, but you were literally inside that system. And there are so many shocking revelations that I had when I was reading your book. And it's just kind of like this vicious, tragic cycle between Big Food and Big Pharma and the medical system, insurance companies. And you called it, "a devil's bargain". And so I think it's without a doubt one of the biggest justice issues of our generation. And I think if anything, the last few years have proven to us that our generation is passionate about justice. And so I'm excited to talk about this. I think a good starting place would be like this quote from your book as it sums up the problem from a 30,000 foot view. You wrote, "every institution that impacts your health makes more money when you're sick and less when you're healthy. From hospitals to pharma to medical schools and even insurance companies." And so, you hear something like this, and people might be thinking, "oh, you're spreading a conspiracy theory" or something like that, which you've talked about. But it's true. It's factual. So tell me how this could be possible when it's supposed to be "healthcare"? Dr. Casey Means: Well, it really just gets down to the fact that health care is a business. And it's not just a business. It's the largest and the fastest growing industry in the United States, which is unbelievable. You think about things like AI or energy or tech. "Oh, these must be the biggest industries." They're not. It's healthcare. Largest and fastest growing. And being an entrepreneur, I co-founded Levels. We think a lot about this idea of LTV, a lifetime value of a customer. And if you think about a business, you want a very high LTV customer. And so when you think about healthcare, what would create high lifetime value in a customer? It would be having a person getting sick young, to be honest. So like in childhood and then going to doctors, many doctors, many times over the course of their lifetime, getting pills, getting surgeries, having interventions done, for decades. That's what's profitable in our system. And the quote that you mentioned, the stark, unemotional economic reality of the business of our healthcare system in America, is that the system makes more money when we're sick and it makes less money when we're healthy. That's the reality. So I don't think there's any nefarious actors in this situation. It's just simply an incentives problem that touches every single aspect of our society. If we can get people to, unfortunately, rack up chronic illnesses and then continue managing them for many, many decades, that's highly profitable. And I think what is insidious is that because of that economic reality, it's an invisible hand that shapes a lot of things about how we as doctors and people fundamentally think about the body. We think of diseases as inevitable. We think of being on medication as a rite of passage as an American. And it's just part of what we do. We think of racking up these diagnoses as just part of the world. But we have to remember that this is all actually very new, all these chronic diseases that you mentioned in the introduction like cancer and Alzheimer's, dementia and astronomical rates of heart disease, fatty liver disease, the fact that kids now have just rampant mental health issues -- autism, ADHD, food allergies, depression, all of it. It's all going up all at once. And again, there's no person, I think, pulling the puppet strings in some industry. It's actually just there's a big incentive problem that gets us to ignore that all of these conditions are connected. They're all quite solvable with simple changes to our food and our lifestyle and reforming our toxic food system. But right now, there's really little education to doctors about those root causes, and we don't really have any financial incentive to approach it from a connected place. So now we are in a total disaster with health. And you'll look at the headlines and they'll literally say, all these conditions are going up and no one knows why. But that's not accurate. The science is very clear on why these conditions are going up. It's because we are eating toxic food. Our lifestyle has changed radically over the past 50 years as we've moved indoors. We're sitting all the time, we're very stressed and it's crushing our biology. And so that's really the message of the book and what I'm really trying to get across to everyone from individuals to investors to doctors to government officials is that this is not complicated. And we could restore American health rapidly, but we have to focus on those root causes that unfortunately the incentives have institutionally gotten us to ignore. Mighty Pursuit: When I think about incentives, we talked about this with Marion Nestle, about the food industry. Do you not think it's an ethical dilemma? I mean, it's one thing, you were talking about businesses. We're not selling the movie or a video game or a piece of clothing, right? And so it makes sense [there] to think about a profit based mindset. But when you have we're talking about our literal health, then why would you operate it like a business and try to maximize profits at somebody's expense? Dr. Casey Means: It's a great question because fundamentally what you would think is that our system would be motivated to have good outcomes. But that's actually unfortunately, just because of the way the business was set up for healthcare, we are not paid for outcomes. We're paid for volume. Isn't that amazing that the actual thing that we get money for as a doctor is seeing more patients quickly, filling up your schedule as much as possible, billing for all of those patients and billing for what you do to them. Okay, so that is how you get paid. And because that's so fundamental to the business, like I said earlier, I think the word that always comes to mind is it insidiously influences everything around it. Like for instance, even how research is done, we start to approach research questions as if it's just inevitable that people are going to get sick. So we have to research these treatments or these drugs, rather than spending research on proactive, root cause based research that would actually help us lead to good outcomes. And to me, good outcomes means a patient that gets healthier. And our system has corrupted what we haven't even thought of as doctors as good outcomes, because we basically learned in medical school, I was at Stanford Medical School. I am telling you, I did not know that heart disease was reversible. I did not know that type two diabetes was reversible. I didn't know that depression was reversible. I literally did not learn that. I learned how to diagnose them and how to medicate them. And the assumption is, well, you'll have these diseases for life. And best case scenario, you will be very well managed on medication. It was only after medical school and after residency in my own digging, that I learned that these conditions are totally reversible, that you can actually reverse heart plaques. This is possible. It has been shown in evidence based research. So even the research that gets surfaced to trainees and doctors and people and headlines, even that is very skewed towards a reactionary based philosophy of medicine, a siloed view of medicine, because it's so rotten from the core, because of the incentives. So what I would love to see is that doctors actually work for outcomes, not for volume. And there has been an effort for that to happen. There was a movement around the Affordable Care Act to move towards value based care, which sounds incredible because the value equation is high value [equals] good outcomes over low cost. And doctors were going to get paid more for high value care. They had to show and provide better outcomes over lower cost. And the way that the government was going to standardize and institutionalize this was to have doctors report on quality metrics. Unfortunately, the quality metrics they chose that doctors needed to report on weren't things like, did you have a patient with asthma who reversed their asthma? The good outcome was, do you have a patient who is on long term asthma medication? So even the good outcomes got co-opted to be medication adherence, not restoration of health. So you take something that sounds great, like value based care --we're going to shift the incentives -- and it still went straight to how many patients can we medicate, which is devastating because I do think if doctors were actually paid for how many patients diseases they can reverse, we would have to move towards healthier food and lifestyle, because that's truly, those are the levers that can change our cellular physiology to reverse disease and restore thriving. Medications can't really do that. Mighty Pursuit: One of the things that, like my mouth dropped is when you talked about RVUs and doctors who work in hospitals. And so this really just drills home this point. So can you explain to me what those are and why it's a problem? Dr. Casey Means: Yeah. So these are essentially units of billing. And when you're trying as a doctor to maximize your RVUs. And so you do this by, let's say you have a chart note for a patient that you saw. You get to add little billing points for how much of the physical exam you did and how much you wrote about their history and how thorough your assessment is, and then all the things you're kind of planning to do to the patient and follow up, you know, come back in six weeks. So basically it's almost like a video game where you're like racking up coins, which are RVUs, which is then you know, how the hospital evaluates how productive you are. So as a doctor playing this RVU game, you are essentially sitting there thinking and not consciously thinking, I want to take advantage of anyone, right? But like the game is I will make more RVUs if I do surgery than if I counsel this patient on nutrition. And that is tied to promotions, that is tied to salary. So it's pretty dark how the system is set up to take these incredible minds, you know, who have spent so much time and energy learning about medicine and so deeply want to get into medicine to help patients, you know, doctors and put them in a system where they're totally pushed towards one outcome and one outcome only. And so even if the intentions are totally pure, you're in a system that benefits off of not truly healing patients because a healed patient is a lost customer. Mighty Pursuit: So how does billing code work? What is a billing code and how does that practically work? Is it a certain procedure? Would that be a billing code? Dr. Casey Means: There's a certain number of RVUs for different procedures that you might do. So if a patient comes into, I was practicing ear, nose and throat and they come in for their post-op sinus surgery exam and you put a camera in their nose, you would put in the note that you did this procedure, and that would then have a number that's associated with it, a billing code, and then you would be appointed some amount of RVUs for that which are standardized. So it's kind of, whatever is going on in that patient room when you're with the patient, you are mentally recording everything you've done during that visit that goes into an electronic health record. And then each of those procedures or whatever was done is assigned a numerical code, and then that particular visit gets some amount of RVUs. Mighty Pursuit: So then who gets billed for that code? The insurance companies? Dr. Casey Means: The insurance companies, yeah. Mighty Pursuit: Obviously medical debt is a huge thing in our country. Is this money stuff that's then coming back then on the consumer or are the insurance companies largely paying the costs of making a hospital profitable? Dr. Casey Means: I mean ultimately the visit will be submitted to insurance and then the insurance company is going to review the notes in detail and make sure that everything's accounted for. And they agree with everything that was billed for. And then the hospital or the doctor's office gets some level of reimbursement. And sometimes there are disputes that happen in that process of something's denied. And then there's an appeal or something like that. But yeah, fundamentally, the money is generally flowing from an insurance company to a doctor or hospital system, and then a patient has some type of copay, or the patient is paying more out of pocket as part of their deductible for their insurance plan. Mighty Pursuit: Yeah, because I think that's what I'm getting is the insurance companies are another part of this equation, because, I mean, even when I think about my own insurance, it's like they're not giving you a good rate for like proactive care, right. And so we'll talk about this later with the whole functional medicine field, it's just disproportionately out of network for insurance companies. And so it's like, okay, you have a disease. Let's do a co-pay now. But it's like, hey, I want to do all these tests or things that are proactive for my health. Oh, okay, you could pay out of pocket for that because we're not going to cover it. And so it's like the insurance companies as well, it's almost like they're wanting to just only step in when you're sick. Dr. Casey Means: Yeah, well, there was an interesting thing that also happened during the development of the Affordable Care Act, which was that there was this idea that, oh, insurance companies are, you know, they're basically making so much money at the expense of not paying out enough reimbursements. So what are we going to do? Well, we have we are going to mandate that 85% of the money they make has to be paid out to basically medical claims, and 15% is what they can keep. And so that sounds good on paper because you're like, oh yeah, we're going to hold those insurance companies accountable and they're going to have to basically not keep as much profit and spend more on patients. But again, it's the devil's in the details. What ended up happening was there was no rule that insurance companies couldn't just raise premiums. So if they're sitting there thinking, we get to keep 15% for ourselves and 85% has to be paid out, well, we will just keep raising premiums so that our 15% gets bigger and bigger and bigger. So patients would think, oh, insurance companies, they're on our side. They don't want us to have to have all these procedures because they have to pay for them. But if they need to create a bigger pie to get a bigger 15%, then what is that incentivizing? More stuff happening to make that 85% bigger and that 15% bigger? Does that make sense? Mighty Pursuit: Yeah, that makes sense. Dr. Casey Means: And that's called the minimum loss ratio. And it's dark because you start to see like some of the things that we pay lip service to, like value based care or holding insurance companies accountable, they're not actually leading to what we think they're going to lead to, which is just wild to me. And one other trend that's interesting is because premiums have gone up so much. So the way that would have worked better is if they'd said, and premiums can't go above this amount, right? Because then it would be like, okay, we do have to actually figure out how to encourage doctors to do less costly interventions because there would be some cap, but there's not. So premiums have gone up hugely outpacing inflation over the past 5-10 years. So what are patients doing? They're like well these monthly payments for my insurance plan are so expensive, I'm going to get a cheaper plan with a high deductible because that's usually how it works. The cheaper the plan, the higher you have to pay out of pocket, which is your deductible, until your insurance kicks in. So when I was practicing functional medicine six years ago, what I found was you'd expect that a lot of people coming to see me would be very wealthy because they were paying out of pocket. But what a lot of people have figured out is that if deductibles are so high that they might have to pay $6,000 before their insurance kicks in, there were many people who would rather see a functional medicine doctor out of pocket, which might be 1000 or $2000, and actually get to the root cause of their issues and maybe save themself a ton of money down the line. So I actually had people from all walks of life coming to see me who had read a Mark Hyman book or a David Perlmutter book, and understood that going to 15 specialists maybe wasn't the answer, you know? And so they were actually putting their money that they would have been spending on co-pays and deductibles and the conventional system towards functional medicine, which was very surprising and interesting to me. People get it. You know, you look at, you're in the podcast world, you look at what the top podcasts in the country are, and most of them like someone like Rogan, you know, or Tucker Carlson or whatnot. They're all talking about functional medicine basically or health, you know, and so I think it's really interesting. You don't see it on mainstream media, but I think there's a huge movement where Americans are really understanding these dynamics and are putting their money towards outside the system because they want to get well, you know. Mighty Pursuit: Yeah, I mean, it's such a systemic thing. I mean, there's a famous saying that goes, "if you know better, do better", right. And so do doctors fully understand the system that they're participating in? That it doesn't work? Dr. Casey Means: I think that doctors feel very trapped in a broken system. You know, it's a massive investment to be a doctor. There are a lot easier ways to make money. People go into it with really good intentions. It's four years of college, four years of medical school, 3 to 9 years of residency, fellowship, board certification, and so many tests. It's incredible how much people invest in this for good intentions. And then I think there's a lot of disillusionment that happens over that period of time where they realize this is not exactly what I signed up for. And I saw so much rampant depression, anxiety. Sadly, there's actually a lot of suicide amongst doctors. There's over 400 doctors who kill themselves every single year. I mean and that's wild to think about. That's a public health crisis. Like that's four medical school classes every single year, just dying. At their own hand and I think you have to think about, what does that mean? These are people who went into medicine to help people, and they have the resources to theoretically understand mental health. And I think it comes down to there being such a spiritual crisis in medicine where you went into it with the best of intentions, and you are then trapped hundreds of thousands of dollars in debt in a system that is undeniably not promoting good public health. Our country is getting sicker every single year. Our country is spending more money every year and getting sicker every year. So that's the definition of a broken system. And as a doctor, you're in that. And it's very hard to pivot or see another way out after those decades of investment. So I think doctors on some level, like on some spiritual level, get it. But I think there's also a dynamic that happens where patients in America are very sick, like 50% of American adults have diabetes or prediabetes. Cancer rates. This is the first year in American history we're going to have over 2 million new cases of cancer. So people are super sick. So doctors, there's this plausible deniability because all those people do need help. They do need doctors. They want to see doctors. So you can feel very good about your work because you are taking care of a massive need. But what I would offer is that if you step back for just a minute and look at everything that's exploding all at once the cancer, the heart disease, the stroke, the dementia, the fatty liver disease, even the fact that Americans did so much worse in the face of Covid 19 because metabolic disease was a fundamental root cause of why people got very sick. If you look at all these things and then look at the science through a different lens, you realize they're all connected by the same physiology -- metabolic dysfunction, our toxic food system, our toxic environment, our sedentary lifestyle, our chronic stress. There's very basic things that are leading to all these diseases. So if you know that, which at this point, I think you can honestly not know that, the fact that our toxic environment and food system is devastating human health, if you're not stopping and actually addressing part of that issue, sure keep doing your surgical practice. Keep seeing patients. But like every doctor should be focusing some energy on this more root cause perspective. So that's where I think there's actually a bit of a crisis of courage, where people are afraid to step out of their trajectory, their path that they're on. Their path that's got a great paycheck and that is super respected by society. But, any doctor who has a sense of what's going on, who's not spending some time focusing on really fixing this problem from the inside, you know, I think for better or worse, they're profiting off the problem. But I do think there are some doctors who don't know. But I think every doctor understands that our system is fundamentally in some way broken. Mighty Pursuit: I mean, you quit in September 2018 and walked away from a mid six figure salary when you realized the way that the system was set up and wanted to learn more about the root causes behind all of these things, which is very admirable. I mean, at some level, wouldn't doctors know what they're doing and continue to participate anyway? I mean, I'm not sure if you saw the show like Dopesick on -- Dr. Casey Means: I haven't seen it. Mighty Pursuit: On Hulu. But that was about the opioid crisis and so on some, some level, Purdue Pharma and pharmaceutical industry obviously knew what they were doing and that stuff was addictive. And so do you think some doctors obviously know and continue to participate? And then I mean, you said the spiritual crisis thing, so do you think that's more of a moral issue to continue to participate in something that doesn't work? Dr. Casey Means: Well having been inside the system, I can really see how it kind of, you get so busy and you're so heads down in your specialty that it's hard to kind of look at the big picture because everything about our health care system has entrenched this idea that the body is all these separate parts, even the way med school is structured, it's like you have your liver month and then your heart month, and then your brain month, and then your GI month. And it's like from day one, it's like the body is all these separate parts, and you're going to choose one of those parts to devote your life to. And then that's what you're going to focus on. And if there's a problem with another part, you're going to send them to that amazing doctor who focuses on that part. What's crazy is that -- and you were mentioning that you've engaged with functional medicine and you've interviewed these amazing doctors -- but it's like, that's not the way the body works. The body is not separated into all these different parts. So even from the core of the education, it's not biologically accurate. But what happened in the hospital is you spent the four years of college, four years of medical school, five years of residency, two years of fellowship focusing on smaller and smaller and smaller and smaller parts of the body. And then you're working 80 to 100 hours a week and you have hundreds of patients you're seeing every week, all of whom want help. So I have so much compassion for doctors because I can tell you firsthand it's kind of a shit show in the hospital, right? Like so many people, so much need, everyone's suffering. And you are an expert, a world expert on a three square inch part of the body. So what do you and you've got this, let's say, I'll just paint the picture. Let's say you're having a surgery day as an ear, nose and throat surgeon. You might do 6 to 8 sinus surgeries that day, maybe a tonsillectomy, a sinus surgery, an ear tube, something like that. These patients are in pain after surgery and they want pain medication. And part of your reimbursement is actually tied to patient satisfaction to how well their pain is managed. So you have 18 minutes in between each surgery, maybe, you are writing the post-op orders. You're writing the prescription. You need to keep things moving. The O.R. is depending on you, the operating room, to keep things moving. So you give that opioid prescription and you think you're being responsible. You only give them ten, or you only give them 15 pills. But if you think about the day to day life of a doctor, like that could just continue for 30 years, right? Just this constant treadmill of people in, people out and giving them a prescription, which is what we were trained to do. The patient had surgery, [so] give them opioid medication. I'll give them a small amount so they don't, you know, get addicted. But unfortunately, if you stepped back from all of that for a second, there's so many things I would highlight to that doctor. One, how many of those surgeries are preventable? Literally like how many? What if you looked at the research, went back, did your own research and realized maybe a lot of the sinusitis is preventable? Maybe a lot of the large tonsils is preventable. Maybe a lot of this ear pus is preventable that you're putting tubes in ear for. Because fundamentally they're all inflammatory issues, right? It's all about inflammation. And I'm just speaking about my specialty -- ear nose and throat. And so what if they stepped out of that matrix for six months and researched, what are all the ways we could reduce inflammation in the body? Maybe half those patients wouldn't even need surgery. I don't know, but I mean, my hypothesis is that if you get to the root of the inflammation, a lot would go away. The second piece I would think about is what are the other modalities we could use to manage pain? Mind body therapies, acupuncture, massage. There are so many other ways to manage pain that we never learned about in medical school. We don't have any education in it. So we stay on this treadmill just for years and years and years and can feel very good about our work because we're taking care of patients. But what I think doctors need that that wake up call is to really look at like, what am I doing that is actually preventable? Like, what could I be doing to actually keep patients out of the operating room? And then for really high risk things that I'm doing, like prescribing opioids, is there anything else I could be doing to support that patient with that need? But they just don't have time or energy or education to kind of do that process. That's why it takes some sort of real reckoning or boldness, I think, to get doctors kind of unplugged from the cord. And usually it's a personal experience. I found most of the functional medicine doctors, the thought leaders, have seen someone in their family or themselves get really let down by the medical system, and it kind of forces them to go in a different direction than what they've been trained.
BIG PHARMA & THE MEDICAL SYSTEM
Mighty Pursuit:Yeah, so I mean, you mentioned learning and medical school. So what are doctors taught in medical school? And as we'll learn later, free interventions like nutrition and exercise are some of the greatest needle movers for our health. And so what are doctors learning about those things if they're just huge things for our health? Dr. Casey Means: Well, 80% of medical schools do not require a single course in nutrition, which is unbelievable because almost every chronic disease taking the lives of Americans early, like heart disease and dementia and type two diabetes are driven by food, and we do not learn about food. I remember attending Stanford Medical School for four years and I was very interested in nutrition. I did nutritional mix in college, and the only thing I recall learning about nutrition was a professor who had done research on the impact of aged garlic on cardiovascular disease, and he gave one lecture about basically how aged garlic, the study showed it did not actually have an impact on heart disease. I'm telling you, that was the extent of my nutrition education at Stanford and almost every disease torturing our lives is tied to food. So what's that about? You know, so I think number one is we're not learning about nutrition and we're not meaningfully learning about exercise, sleep, about stress management, even though we know, without a shadow of a doubt from peer reviewed scientific literature, that those are key drivers of our our health issues, and then not to mention things like circadian biology, like our relationship with light, as well as the toxins in our environment, the 80,000 synthetic toxins that are littering our food, water, air, homes, cars, they're everywhere. That's not even a minute, not even a minute on it in medical school. So doctors do not have the language to deeply and fundamentally address the modifiable lifestyle factors. Of course, we learn that exercise and a healthy diet is important for preventing heart disease. Sure. Yeah, we learn the broad brush strokes, right? It's not like someone saying exercise doesn't matter, but we're not learning how to use it as a meaningful tool versus things like pharmacology. I had hundreds of pages of Excel spreadsheets that I typed up with the size eight font of every single drug. I mean, you learn 20,000. Like truly. You're learning tens of thousands of pharmaceuticals. Their name, their trade name, the mechanism of action, the side effects, the half life, about thousands of drugs. And you're tested on them, to the minutia. But not that way about anything related to food, exercise, circadian biology, stress management, toxins. So it's very intervention focused I would say. So basically medical school is set up as understanding human physiology as it pertains to each organ system. Understanding pathophysiology which is the disease that can help that can happen to each organ system. And then understanding the diagnosis. So how do you actually diagnose the patient, what tests you need to do and what are the signs and symptoms of each disease. And then how to treat it. And that is drugs and surgery. So that's basically the medical school curriculum which sounds reasonable on paper right. It's like, oh yeah, that's how you become a good doctor. But when we know what's causing diseases in this country is not a medication deficiency, it doesn't make a lot of sense to so disproportionately just teach about the medications. Mighty Pursuit: Yeah I mean it sounds reasonable, but I mean, when you look underneath the hood and it's quite dark in the sense of, I mean, how much of an influence do you think Big Pharma has on the medical system? Dr. Casey Means: It's monumental. I mean, of course it's not just the medical system. It's also just the media. You know, 60 to 75% of all mainstream media advertising comes from pharma. So they're controlling our news outlets, how we get literally basic information. And then in terms of medical schools, there's not like hard numbers on exactly how much of the medical school budget comes from pharma. But when I was at Stanford Medical School back in 2011, the school took a $3 million grant from Pfizer, who's one of the leading opioid manufacturers. And our dean was a pain specialist. And so there's sort of this interesting thing that's happening where we've got the largest maker of opioids funding, and the grant was an educational grant for curriculum development. And of course it said there's no strings attached. You know, this is totally without any bias. But like money talks. Right? And so of course we're not going to be only learning about non-pharmacological interventions for pain if the $3 million budget for our curriculum is coming from a pharmaceutical company, so a lot of money is funneling from pharma to the FDA to medical schools, NIH. There are no rules around, no strong rules around NIH researchers taking money, consulting money from pharma. You would think that the people doing the taxpayer funded research to keep Americans healthy would be totally isolated from industry influence, because it really should purely be for American health and the best solutions to understanding why we're sick. But the conflicts of interest are rampant in the NIH. And around 60 to 70% of the FDA's budget, the Food and Drug Administration, is coming from industry, and they're the ones who decide whether drugs are safe and whether to approve them. So something that my brother and I in our book and in our work just suggests such basic things, what if we just got the money out of the FDA and the NIH and our medical school budget? So if you're taking money, federally funded money from taxpayers for these institutions, they should be pure from industry influence. But that is just so far from the case. But that would be a simple thing that could clean up some of these outside forces that are actually influencing the information that we get as people. The news, the research, the curriculum, the foundation of what we learn. So yeah. Mighty Pursuit: It's just wild to me. I mean, really, it's just, you know, Big Food and Big Pharma, like, together. It's like the fact that they're funneling money to these organizations. And so then you have the ultra processed food stuff going on, which covers 73% of the grocery store shelves. And so that's making us sick. And so then it's working to convince the public that that is not making you sick. And so that's the interest. And then it's just like, okay, now you're sick. Oh, Big Pharma has the answer now with all these pills and drugs, and then they're funneling money to the government. It's just kind of crazy. I mean, Dr. Lustig wrote in his book Metabolical that Big Pharma actually underwrites a lot of the budget for medical schools. I mean, can you confirm that, that was just crazy to me that they're underwriting a budget for, like, a medical school? Dr. Casey Means: Yeah. I mean, it's the Pfizer grant I was just mentioning. I mean, that's part of what's going towards how the school operates. Mighty Pursuit: That's insane. Dr. Casey Means: I don't think there's any hard numbers on exactly how much of a percentage it is, but it's not negligible. Mighty Pursuit: And so obviously your brother, who co-wrote the book with you, at one point in his life, used to lobby for big pharma. So can you tell me, if people are not familiar with that, how that actually works? Dr. Casey Means: Lobbying? So the food industry and the pharmaceutical industry are the biggest lobbyists on Capitol Hill. So I think if you ask the average person on the street, they would think it was like oil and gas or something like that. Or building contractors or things like that, it is food and it is pharma. So they are spending far more than any other industry on lobbying on Capitol Hill. And if you look at all the states in the United States, 78% of senators represent a state in which the largest industry is food and health care. So there is a huge incentive for our politicians to protect the businesses that give their constituents jobs. So that creates another, unfortunately devil's bargain where at the governmental level, there is just a strict incentive to keep those industries thriving. And how do you keep the food and the health care industries thriving? The food industry -- and this is just a statement of economic reality -- the food industry makes more money if you have people addicted to the cheapest possible foods, the foods that are cheapest to produce. So if you can get people addicted to cheap food, highly profitable. That's the ultra processed food industry. That's their playbook. If you think about the health care industry, you have more patients over a long period of time in the system having more things done to them. That's the two ways that those businesses make the most money. So of course, at the governmental level, anything that supports those existing incentive systems is going to help create job growth in their states. Huge problem. Right. So it's just, it's wild that you've got these industries putting an all out assault on Capitol Hill, trying to convince congresspeople that it is absolutely in the best interest of their states and their constituencies to keep these current incentive structures strong. Mighty Pursuit: I mean, you mentioned that word spiritual crisis multiple times in your book. A lot of this picture that we're painting kind of sounds like an age old story about greed in some way, especially Big Food and Big Pharma. So do you think that following the money is just kind of a bigger picture of losing our way? Dr. Casey Means: I think it all comes back to money. Absolutely. Like our value system in the United States is money. That's what it is. If you think about it, what do we pride ourselves on in America? It's like our GDP. It's not our total health score. It's not our total happiness or contentment score in the US, it's our GDP. It's like, how much is the economy worth at all costs? I mean, even life expectancy isn't a metric that we track or report on. When we think about the success of the United States, it's literally the gross domestic product. But when you step back and think about it, what's the purpose of a country? What's the purpose of a government? Like it should be to have a thriving, healthy, productive population that's competitive and safe and pursuing health and happiness. And that's not what's happening right now. Like, healthy food is more expensive than unhealthy food because of our farm bill subsidies. We have virtually unregulated toxins going into our food, water and air. We have our main institutions -- USDA, FDA, NIH -- that control food and health are deeply interlinked with industry that doesn't have, that doesn't have individual interests in mind. So we're far off. And I think when I say, spiritual crisis, I think it comes back to a belief that I have, which is that part of why we're going down this track and it feels like a train that's kind of just a runaway train, it's like if we stepped back and got in touch with our spiritual nature and simply, it doesn't matter if you believe in spirituality or God or not, like even if you're the most agnostic atheist person in the world, it's pretty insane that we're here as humans having a human experience in a big universe, right? Like we're here for a short period of time in an infinite universe, and we have this incredible consciousness and we're having this incredible experience. Why wouldn't you want to protect that? Why wouldn't you want to take steps to honor and respect the sheer statistical near impossibility that we're alive for one time. We get to be here and depending on your spiritual beliefs, you have different thoughts about whether we're going to come back and reincarnation. But we know we're here now for a short period of time, and we have incredible powers and capabilities of consciousness and ability to live, and we are choosing to totally be distracted from that fact. No matter where you fall on the religious spectrum, that's a fact. It's wild that we're here, and we are destroying that opportunity by poisoning the body and poisoning the earth that sustains our body. And to me, that just feels so dark. It's almost like with tech and with urbanization and with the rapid pace of change and with just the way that we are so alleged to money, we have forgotten what actually matters, which is that we have to protect this incredible temple of the body while we're here on this planet. Like, what is the real purpose of being here? It's not, we're all going to die, right? Why are we voraciously just accumulating wealth and greed when this is all going to be over in a few decades? It's just, as I've gotten so deep into the science, I'm like, I think this is so much bigger than this because it's not going to be a passion, I think, for just healthy food that's going to turn the direction of our species around. I think it's going to have to be something deeper than that about a recommitment to or about the preciousness of this experience to be alive that we have somehow. And you can see it in so many ways how we are disrespecting that opportunity, one of which is allowing ourselves to become addicted to tech. Right? Like the fact that the average child in America is on a screen over seven hours a day and is outdoors less time than a prisoner like we're choosing that. Families are choosing that. This is a choice. And if we were tapped into our miraculous nature and especially the miraculous nature of our children, where do they come from? Right? It's just, it's a miracle. It's. And instead we are committed to other priorities right now. And we need to wake up from that slumber that we're in. Mighty Pursuit: Yeah. I mean, that's so powerful, I think. It's just absolutely mind blowing to me. I mean, we're in an election year, right? And so it seems to me that I just don't feel like it's talked about. Right. And so there's just so much going back and forth on X and Instagram and all these different things with campaigns and whatever. And it's just like the small fraction of attention that is being paid to this. You know, when arguably I'm like, this should rank what top three -- Dr. Casey Means: At least. Mighty Pursuit: Top one. I'm like, what we're talking about is like the given that the entire population is struggling with chronic disease and stuff. And so, do you think on that level like election year, do you think politicians, is it because of the incentives and the Big Food and the being embedded with Big Food and Big Pharma? Or is it that they know that, like, we're not going to create change or they don't want to attempt to create change because there's – we're going to close this later – but like, literally the president could write executive orders right now. And like literally create change overnight with just some executive orders you know. Dr. Casey Means: Well I think what's really hopeful is you look at what someone like RFK is talking about. And like, this is what he's running on. He is talking about health. Like no one has talked about it in my lifetime, talking about the pesticides and the toxins and the food system and all the corporate problems. And he has said, "I'm going to take this on head on." And even though he certainly, of course, he's running as an independent, he's not in the running for, you know, he's not even close to the polling numbers of the other candidates. In some polls he's getting 20% and that says something. It's like that an independent talking about health issues is getting that much of the poll. I think that's hopeful. And then you do hear, for better or worse, like Trump has talked about the chronic disease epidemic in this campaign, which is not something I've heard about from prior candidates. You know, he's saying, "Why? Why are Americans getting sicker?" And I think it more broadly speaks to sort of this rise and this populism sentiment that's happening where this sense of Americans are fed up by this sort of relationship between industry and the population and the population basically feeling like it's almost like the matrix battery for just these industries that are really running. the government. They seem to be running the course of our lives. And so I think that's why you're seeing some of that political trend of like politicians who are speaking to, and I think this is what kind of Trump plays on a lot is like, I'm going to take him on. I'm going to take these people on for the population. So it's so interesting how these trends are emerging and who knows how all the chips are going to fall, but something is resonating with, like we are going to take on the corporate interests that are keeping Americans down, it definitely seems to be a message that is very alive in this election. And I think that it just speaks to Americans who know what's going on. I think I mean, I get, as I'm sure you do, with a lot of your podcast, just hundreds of thousands of messages from people sharing their stories about how this has basically played out in their own lives. And so I'm very hopeful. I think there's a lot of light, but it's not going to be an incremental fix. Right. My brother jokes that the health care policy changes we need are not like changing a few words on page 200 of the Medicare Part D bill. It needs to be much deeper than that and much more systemic for us to really shift the direction. This is not about changing the prescription drug prices by this much, which is what a lot of politicians have played on to get the older vote in America, like we're going to fight the company. But that's not – we can't get distracted. That's important. But what's more important is just eliminating the toxic stew of our environment that's destroying American capital.
THE MEDICAL SYSTEM IS GOOD FOR...
Mighty Pursuit: No, it's really good. I don't want people to lose the through line, obviously. Here. Oh, RFK or you're here named Trump or Kamala. And it's like, come the 10,000 associations with like a political thing. And it's just like keeping your eye on the ball in the sense of like, what we're really talking about here is like, it doesn't matter who it is. It's just like talking about this in general and like, and then pushing for that I think is extremely important no matter what your political persuasion is. And I also don't want people to come away with an all or nothing mentality in the sense that, like, everything is bad, nothing in the medical system is beneficial. And so you've talked about this in the book, but what is the modern medical system effective in treating? Dr. Casey Means: Yeah, I mean it is so important to draw this distinction. And Calley and I talk about it very specifically in the book that like there's acute issues and there's chronic issues. And where the American healthcare system shines is acute issues. And this is things that are immediately life threatening where you need a swift and dramatic intervention or else you may die. So this is like things like a car accident or a big trauma or an overwhelming infection. Even something like if you're having a heart attack, like getting heart surgery can save your life. And that's amazing. Complicated childbirth. You know, the fact that we can do C-sections now, like, these things are incredible. And I would want to be in America if something like that was happening. But what is ailing the vast majority of Americans today -- because we've gotten the acute issues that used to kill a lot of people, like infectious disease under control -- is chronic issues. So these are the issues that are rooted in the intersection between diet, lifestyle and genetics that simmer and brew over months and years and decades and the most effective intervention for them is modifiable lifestyle factors. It's not medication. This is now 85-90% of our health care costs are chronic issues. And nine of the ten leading causes of disease in the United States other than accidents are chronic issues. So it's not the acute stuff that's really killing us in mass anymore. It's chronic issues. But what has happened is the health care system has essentially taken the trust that was built from how well we've done with acute issues like antibiotics, you know, and then ask people to essentially apply that lens, that intervention lens to all these chronic issues that have cropped up. But it doesn't work, because the more that we are intervening and medicating and doing surgery on these chronic conditions, which doesn't actually affect the root cause, the sicker we're getting. So and this is all happening so quickly, this is now this is like, what, 75 years that this has been an issue like really since kind of World War Two. Things really started picking up. You know, you look at the charts like obesity, diabetes, it all started going up 30, 40, 50 years ago. So this is like brand new issues. And so that's very hopeful to me because we kind of got ourselves into this mess with the wrong paradigm of intervention in the same way we intervene on acute issues to chronic issues. We're kind of seeing that it doesn't really work. We have to get to the core of the root issue. But now we have to shift gears because it's been like 50 years of getting into a huge mess. We're really obviously seeing the approach we're taking isn't working. Let's shift gears. And that's really what the message that I'm trying to share, and that the book is trying to share is that we can. It's straightforward. There are easy ways to do it. This is not that complicated, actually. And we could reclaim our health as a country in just a couple years if we could clean up some of these modifiable factors. Mighty Pursuit: Before we get into chronic disease and metabolic health, I explained to you the value of our company is just being nuanced, but a couple of rapid fire things So what would you say like Big Pharma is good for? And so, for example, one of the guests we've had on this podcast, she's kind of a famous stroke survivor. She had an AVM, a brain stroke, which was genetic. She had a genetic thing going on in her brain. And so she just, like, lost all functionality and stuff like that, and so, obviously might require some medications. And so when it comes to the role of Big Pharma in general, are there certain things where you're like, probably gonna need a medication for that and it's not necessarily something we should push back on versus other things like, I don't know, we're talking about statins later, probably, or just other things that they just like give you that you don't necessarily need. Dr. Casey Means: Yeah, I think there's many, many things. So I would say one category would be infectious disease. But that is very nuanced as well because obviously, you don't want to be giving antibiotics for a viral infection because that doesn't work. You can't treat a virus with an antibiotic that affects bacteria. And we're doing that a lot in this country. But if you are appropriately treating a severe infection with the appropriate antibiotic, that's a great use of pharmaceutical intervention. Again, like the vast majority of deaths prior to this past two centuries have been dying from infection. And so that's amazing. I think a lot about childhood congenital issues as well, where a child was born with a heart defect or some problem neurologically, or just there's so many things that can happen, you know, and that that they're just born unfortunately, with that unlucky situation and that's where I think pediatric surgeons and the people working with children on these more genetic or childhood developmental issues are so valuable. But one other thing we need to think about that again with the nuance is like, are there aspects of our environment that are leading to higher rates of childhood issues -- Mighty Pursuit: Like autism? Dr. Casey Means: Well, yeah for sure. But even something like, heart malformations in children like you would think these must all just be genetic. But there's been data that's shown if you're drinking alcohol, man or woman, in the year before getting pregnant, not while pregnant, but before getting pregnant, it's associated with higher rates of heart issues in children. No one knows that. I didn't know that until I started doing this research in preparation to get pregnant. But like everyone thinks about fetal alcohol syndrome as a mother drinking during pregnancy. But of course, if you think about it, okay, alcohol is a toxin. If it's being bathed on the sperm and bathed on the eggs prior to conception, it also has an impact. So that's just one example of like, I've never, ever once seen a public health announcement of like, we should probably stop drinking alcohol. Definitely three months, probably a year before trying to conceive. So that's just one example. But you also think about the pesticides and the endocrine disrupting chemicals in our society, in our world. Like how are these leading to some of the issues? And of course some of it's going to be purely genetic, no control over it. But that's an example where I think the health care system and farmers are going to mention can be super valuable. I think about childbirth. There are some, you know, births in which historically, like the mother's life would be at risk and the babies. And now we're able to do things like C-sections and, you know, that's powerful. Here's the nuance, though. Why are some hospitals in America 70% of the birth, C-sections? Right. We should really be scratching our heads about that. The rate of C-section amongst hospitals in America ranges from 7 to 70%, and a C-section is like a highly profitable procedure in which gets the women in and out of the hospital in -- you know, but not out of the hospital quicker -- but it's an it's easier from a logistics perspective for the hospital. Right. And so we should be thinking about why, maybe there's some percentage of very truly complicated pregnancies that we need a C-section for, but why is it in some hospitals upwards of 60-70%? So there are situations in which our modern medical interventions are super powerful. Also, my fiance's father is like a pediatric pulmonologist, and he focused mostly on cystic fibrosis (CF), which is a genetic condition in kids. And medications for CF have allowed life expectancy to skyrocket for that condition, which there's truly nothing you can do about drawing that unlucky card. So many examples. I could go on and on and on about where there's a huge benefit of having intervention. With that said, again 80-90% of health care costs in the United States are going towards chronic lifestyle based conditions where medication is more of a bandaid for an issue that we could have avoided, or which we can turn the ship around with simple lifestyle habits. And that's where, again, we've taken the trust engendered by how these medications work for these isolated examples and said, we should use this for everything every time someone gets sick. And from a marketing standpoint, a super smart approach like, oh, of course it works for this, it should work for this. When in fact, doing a keto diet and walking 10,000 steps a day might actually fully reverse the condition than a medication never will. So we have to be thinking that way, like what is my condition? What is the true physiology of it? How is it related to other symptoms and diseases that I have? And then what are the evidence based dietary and lifestyle strategies to reverse? And that's basically what functional medicine does.
UNDERLYING CAUSES OF CHRONIC DISEASE
Mighty Pursuit: So when it comes to chronic diseases like cancer, I mean, craziest thing to me, reading your book. I don't know if you want to call it the cure, but it's in a sense we understand the biological mechanism behind all chronic diseases or the link between all those different chronic diseases. And so knowing that we can reduce our chances of getting those diseases. So obviously, I mean, I do believe that the way we explain things, however, kind of makes or breaks how well someone will digest that or understand it. So can you explain this to me like I'm five years old? Metabolic health, the link between all these chronic diseases. What's happening? Dr. Casey Means: Yes, yes. So. When I talk about how like, we now understand the connection between most chronic diseases that we're facing today in the country, the connecting point that shows up so clearly in the literature is metabolic dysfunction. So metabolic health. Let's start with, what is metabolism? Because before we talk about it's dysfunction, like what is it? Metabolism is the most foundational process that happens in the body. It's the process of making energy to power our cells. So we take in food every meal that we eat, something like 40 to 70 metric tons of food in our lifetime. And we have to convert that food, which is potential energy, into an energy form that our cells can use to power everything that they do. And if you think about it, what is the body? The body is, simply put, the bubbling up of chemical reactions. We have 40 trillion cells, each of those trillions of cells are doing trillions of chemical reactions per second. And our lives is simply the bubbling up of all those chemical reactions. It's pretty crazy. Most of those reactions require, like payment. You need to pay for that chemical reaction. And the way you do that is by making energy, by converting food to cellular energy through metabolism. So we can start to get lost in some of the higher level details of health. Like, how are my hormones and how is my microbiome function, how is my neurologic function, and getting into these specifics. But below all of that, the foundational base layer of all of that is does my body have power? Does it have power? Like you can have a Ferrari, [but] if it has no gas, it doesn't work. It doesn't matter how nice the car is. So gas power metabolism, it has to be going well for any of the other specialized stuff in the body to work. Right now in our modern world, we have a metabolic dysfunction issue in 93% of Americans, and I say 93% of Americans, because there's been a couple big studies in the past couple years showing that in 2018, there was a UNC study that showed that 88% of American adults have at least one biomarker of having a metabolic problem. This power issue is broken. The American College of Cardiology, just two years ago, showed that that number had gone from 88 to 93% basically during Covid. So the numbers are increasing. So that means that among American adults, 93% have a problem with the core foundational process of powering their cells. So what is that? Why would that be a root cause of so many health issues? Well, we have dozens of organ systems in our body, and we actually have over 200 types of cells in our body. So, you know, you've got retinal cells and you've got skin cells and you've got the cells lining your blood vessels, and you've got liver cells and kidney cells and ovarian cells and sperm cells. You have all these different types of cells. They all need energy to do their work. And if the cell can do its work properly, it turns into health. Like if we're well powered and all our cells are doing their jobs properly, we have health. But if this under-powering issue -- metabolic dysfunction -- is happening in the body, it can show up in different cell types with different symptoms. So under powering an ovary cell is going to look different than under powering a brain cell. And that's going to look different than under powering in a blood vessel lining cell, which will look different than low power in a liver cell. So when you look at things like fatty liver disease, Alzheimer's, dementia, depression, migraine, fibromyalgia, polycystic ovarian syndrome, erectile dysfunction, stroke, heart disease all over the body. And you look at the research on what is the cellular process that is disturbed in this condition. You find that it all leads back to metabolic dysfunction. And where we get lost in our system because we're so specialized, like we talked about earlier, is that that brain doctor sees the symptoms of Alzheimer's or depression. And they think, well, those look totally different than polycystic ovarian syndrome. These symptoms and the labs, it's totally different than fatty liver disease. We've got to separate all these patients into different doctor's offices because they're looking at the symptoms, which of course look different. Depression looks different than arthritis, which looks different than heart disease or hypertension. But that's because we were never trained to really think about the core intracellular physiology. We're trained on the symptoms of that core problem in different parts of the body. And how that ties into our earlier conversation about incentives is that by being in this slightly different perspective, by ignoring that sort of core, core root cause, you end up getting one patient with eight symptoms in eight different doctor's offices on eight different medications, maybe getting eight different surgeries, seeing these eight different doctors for maybe 20, 30, 40 years, that is hundreds of thousands of dollars, probably millions of dollars over the course of that patient's lifetime versus if all those patients if all those doctors got together and sort of traced this question of what's the core connecting physiology, understood metabolic dysfunction, understood the lifestyle factors in our environment that are leading to metabolic dysfunction in mass right now, which are the environmental issues, toxic food system. We could potentially help that patient rectify that issue, and a lot of their issues in different parts of their bodies would melt away. And that's what often happens when someone cleans up their diet and lifestyle, gets their blood sugar and metabolic health in order if they find that a lot of their symptoms go away. And I'm not trying to say that this is like the only aspect of health that matters. But if we want to be optimally healthy, if we want to have optimum longevity, we must have good metabolic health because it is the foundation of our core cellular biology. Mighty Pursuit: So what diseases does this influence? Dr. Casey Means: Everyone possible one, I mean, you could name a disease and in some way it is going to be related to metabolic dysfunction. And I say that because, and I'm not saying metabolic dysfunction is the one cause of every single disease, but if you have underpowered cells it can look like almost anything. So some of the ones that like have a direct link would be Alzheimer's, dementia, type two diabetes, obesity, cancer, heart disease, stroke, depression, anxiety, ADHD, autism, eczema, acne, premature wrinkles, erectile dysfunction, male and female infertility, gout, fatty liver disease, chronic kidney disease, increased rates of infection and death from influenza. Covid 19, any bacterial infection, immune suppression like cancer. So really, each of those has a direct, strong link between the physiology of metabolic dysfunction, which I talk about in the book. So metabolic dysfunction is a term for poor energy production in the cells. There's actually a deeper layer to it, which is what I call the trifecta of bad energy in the cells, which is three interlinked physiologic processes: chronic inflammation, mitochondrial dysfunction and oxidative stress, which is basically swirling in our bodies in this modern world that leads to metabolic dysfunction, that leads to these problems in cells. But what I say to specialists like an orthopedic surgeon or an endocrinologist, I'm like, take whatever condition you're focused on and go into PubMed. You know, where all the research papers are, and just search that condition and put the words mitochondrial dysfunction or oxidative stress or chronic inflammation after it. You are going to find dozens, if not thousands of papers that talk about that physiologic process. But again, that's not where our training focus. The training focused on diagnosing, you know, understanding how the organ dysfunction works on that organ level, not the cellular level, the organ level. And then how do you diagnose it? How do you treat it? How do you manage it? Mighty Pursuit: That's really good. Yeah, yeah. In our episodes with Dr. Lustig and Marion Nestle, we talked about why this is happening. I mean, in the sense that our modern world looks nothing like a hundred years ago. And so you have this massive increase in chronic disease and all the things you just mentioned, like the incidence rates of those things 75 years ago were much lower. And so you have, processed food system, the fact that, you know, we're sedentary all the time. You know, these things with Big Pharma that we were just talking about, there's all these things that have changed about the modern world, and now I've appreciated Dan Buettner's work with that Blue Zones and stuff. It's amazing because, I mean, you're having evidence of these people that are living in these zones of the world that are largely minimally effective or unaffected by all the things that we're talking about. They're not dealing with the same issues that we're dealing with. Dr. Casey Means: And they're not spending any money on health care, really. They're just living close to nature.
TAKING CONTROL OF YOUR HEALTH
Mighty Pursuit: And so just to get practical and discuss protocols, we need to have in place to, quote unquote, be healthier, metabolically healthy. I'd imagine the first step is just kind of getting a lay of the land and getting a full picture on what's going on inside your body. Is that correct? Dr. Casey Means: I think that's a great place to start. I mean, fundamentally, I think you actually could start by just doing some of the basics, like clean up the food, you know, stop eating ultra processed food, get more steps. But I do believe that it's very motivating and helpful to have a baseline assessment of the health, like the state of the union of your health. And the way that you can do that is through simple lab tests that you could actually get from your standard, conventional doctor. You don't need a functional medicine doctor for all of these tests. But like, understand your basic metabolic lab work. So this is going to be things like fasting glucose, triglyceride levels, HDL cholesterol, hemoglobin A1c which is an average blood sugar marker. Blood pressure. Take a waist circumference. If you can get a Apob, which is a marker of essentially cholesterol in the body, like LDL that can cause heart disease. Just those tests right there, like get a tape measure, ask your doctor to order these 6 or 7 tests, you can know from those tests whether you are in that 93% of people who have metabolic dysfunction, or the 6.8% of people who are considered to be more optimally metabolically healthy just from those tests, which even if you paid out of pocket, would probably be like 50 bucks. So that's one. I mean, after that, I'm a big proponent of lab testing because I think it gives us the power to understand, if you understand your own health and if you understand the trajectory that you're on and whether you're improving with the choices that you're making or not, you have all the power, right? You can go into your doctor's office as an educated CEO of your own health and be confident whether your strategies are working. So the doctor might say, well, I really think you need this. And if you're saying, well, this is what I'm doing and all my labs are improving, that gives you some confidence and power. So there's now ways to get more extensive lab testing inexpensively through direct to consumer testing. So I love Function Health. My company Levels does labs. But these are things like more high level metabolic testing, like fasting insulin levels, CRP levels, which is an inflammatory marker. Things like, vitamin D levels, which is super important for metabolic health. Uric acid. There's more tests that can give you a richer picture of where you stand. So the nice thing about Function Health is that you pay -- it is out of pocket -- but it's like $499 and you get 110 biomarkers and then a follow up like 50 or 60 biomarkers six months later. So for me, that's just part of my budget each year. $499. And I know I'm going to get at least two huge swaths of information about my health. And I make changes about my diet each time I get the lab results back, because maybe I'll be like, oh, I've been eating way more dairy, and my ApoB went up a little bit. Or like, oh, I had book deadlines, so I wasn't walking as much and my hemoglobin A1c, which is a blood sugar marker, went up, you know, a little bit or my fasting glucose went up. Okay, I guess I need to get back on my walking treadmill desk or like, oh, maybe I need to peel back on the dairy a little bit, so even after all these years, I'm constantly iterating every time. So I just recommend to everyone those first few tests I mentioned. Ask your doctor for them today. We can link to articles about what the optimal ranges are, because you should just sit down with the optimal ranges and your tests and find out, am I metabolically healthy or am I not? Because if you're dealing with any health issue and I mean literally any health issue, if you're not optimally metabolically healthy, that's an area that you can focus on that will make you start to feel a little bit better, because if we're powering our bodies better, then triggering healing in the body is also going to be easier. Mighty Pursuit: Yeah, I want to take a step back, because I think the idea of health and how we perceive health can be a very confusing process. So let me just give you three examples. And just break down each one of those and then we can get deeper into what you're saying. So the first one is like people might think that they're healthy when they're not actually healthy. And so an example of this, and we posted about this on Instagram about a month ago and just kind of blew up. So this is, 38 year old marathon runner in, I think Australia. He's like a TikTok executive. He came down with stage four cancer. I think it was non-Hodgkin's lymphoma. And so you see his case, and you're like, how is that possible? This guy has a rigorous workout routine. He's doing marathons. I can't speak to his eating habits. I can't speak to a lot of the other things that we're talking about. But I think people are just concerned about the rise in incidents with people who are like 30 something years old, and then if you're told like oh, sedentary lifestyle is an issue. And then you see, like a 38 year old marathon runner get's stage 4 non-Hodgkin's so something like that. Is there anything you would kind of add about something like that? Dr. Casey Means: Yeah. I mean, so the interesting thing about. Chronic disease and metabolic dysfunction is that there's so many aspects of our environment that are hurting our mitochondria, hurting these energy producing factories of our cells, that are hurting our cellular biology. And there's eight that I focus on. I can mention those, but the idea is that what one person's issues are that are leading to dysfunctional cellular biology or metabolic dysfunction could be different than another person's. You and I, just because we live different lives in different cities, different exposures might have different vectors that are hurting our cellular health. So what we have to do is know what the main vectors are, those pillars of potentially health or damage in the modern world. Take stock of how it's affecting us. So for this guy, it probably wasn't sedentary behavior, but maybe it was environmental toxins. Maybe it was food. So for me, the ones that I talk about in detail in the book and it's really we're thinking about food. We're thinking about movement, sleep patterns, emotional health and stress, our relationship with light, our relationship with temperature, our exposure, environmental toxins and what medications we're on. So those are the ones that we need that are modifiable. And so when we're talking about food, we're looking at like is it ultra processed or is it unprocessed food? Is it organic or is it covered in pesticides? And unfortunately. We use 6 billion pounds of pesticides worldwide. 99% of the food in the United States is not organic. And one of the pesticides, glyphosate, which is the most commonly used pesticide in the United States has a direct relationship with non-Hodgkin's lymphoma. So you look at someone who might be eating healthy, but you have to go deeper. Like, is it clean? Is there invisible poison on my food, which is what pesticides are? Then you look at the food even deeper. And it's like, okay, well, I need all these micronutrients in my food to let my mitochondria work properly to make cellular energy. Where is my food coming from? So if your food is processed, it's going to be nutrient depleted. But even if you're eating whole food, then you kind of have to go a layer deeper and say, what was the soil like that my food was grown in, and how far did it have to travel to get to me? Because both of those things will impact how many nutrients are in your food. Food that travels long distances, and the average piece of food in the United States travels 1500 miles to our plate. It loses its key nutrients, and when food is grown in damaged soil due to American industrial agriculture, it has less nutrients. So even talking about nuance here, it's like people might say, I eat fine, I eat healthy, but there's like eight layers to think about. And that's not to make people feel scared or like it's impossible, but the more you know -- Mighty Pursuit: It's actually very practical. Like the more you know. Dr. Casey Means: Because these nutrients in the food are medicine, the nutrients in the food are anti-cancer compounds. You know, the nutrients in the food are antioxidants or change gene expression that upregulate our DNA repair enzymes. This is just a statement of fact that the chemicals, I mean the good chemicals that the nutrients in the food change our propensity for health or disease. So we want to look at every layer of food to understand what's really going on in our body. And I look at food as medicine, of course. And so because I look at food as medicine and it's an investment in my health, I'm looking for the highest quality, freshest, cleanest food from the best soil, which means I buy it from the farmer's market and I know the farmers I buy it from, and I know that they care for their soil. That's the best I can do. Maybe in Europe it would still be better, but that's the best I can do in America. And there's 9000 farmer's markets in the US now, so this is possible for a lot of people. I know it's not possible for everyone, but I would say that's high leverage. So that's just food. But we could have an hour long conversation about each of those pillars. But all that is to say that our journey to health is about understanding those, which I talk about deeply in my book, taking stock of where we're crushing it on those in our own lives and where there is room for improvement, and then making steps towards improving them, and then checking our biomarkers every 4 to 6 months to make sure that the strategies we're choosing to employ are having a meaningful impact on our health. Mighty Pursuit: That's good. So the next example, obviously, the crux of your book, which I just thought was absolutely incredible, was talking about your mother's journey and how she died of pancreatic cancer. So this related to a second thing for me, which was like people who seemingly do all the right things but end up with negative results. And so you wrote, "my mom tried so hard to get her health back on track. She stopped smoking. She had a trainer. She joined the gym. She wrote every book on nutrition that you get her hands on and participated in several programs. She tried a whole foods plant based diet." And so I'd imagine a lot of people could feel discouraged in some sense reading that, because it seems like she did go above and beyond in some ways, but still died of pancreatic cancer. And so with her, her case, like, what are your thoughts about that? And yeah, what could have been different or changed? Dr. Casey Means: I love this question because of course I've ruminated on this question like every day since she died three and a half years ago. And the key thing here is that right now, because we don't have a centralizing framework for what's happening to our bodies, people are working very hard on their health, but it's kind of scattershot. It's not pointing the arrow all at where the problem is, which is metabolic health. So my mom, even though she was trying so hard and trying all these different things, none of it was pointed straight at the mitochondria. And so what I would do differently with my mom is I'd take each of these categories of things she was doing: food, exercise, books she was reading and focus it on what we know actually really is the crux of the issue, which is metabolic dysfunction. So let me give you a very specific example. One of the food programs that she went on was called, it was like one of these things in the early 2000s, like Nutrisystem, which was basically a low calorie food. They shipped you everything, packaged food, and it was about low calories. So my mom was basically starving because she wasn't getting enough food, but she was so committed to doing this because she thought it was an investment and losing weight and her health. But then I look at it, it's like if we were really focusing on healing the mitochondria, which is what she actually needed, we would have never done a system like that ultra processed, filled with basically seed oils and ultra processed grains and even added sugars, probably very nutrient depleted because it was sitting in a package. Unrefrigerated, you know, it was just like packaged meals. All it had going for it was low calorie, which is not how you heal the mitochondria. What I would have done for her is nutrient testing. What nutrients is she actually low in, you know, which mitochondrial cofactor is. Mighty Pursuit: I just did that, the nutrient testing. Dr. Casey Means:It's really cool. And this is then I could say great. Your magnesium is low. That's a mitochondrial cofactor. We're going to give you pumpkin seeds, like oh okay, your selenium is low. Let's do more Brazil nuts and really shape a whole foods organic diet that was actually targeted at healing her metabolic processes even when she went plant based. And then she went keto, she wasn't fully holistically thinking about all the elements we need to create a cell that's metabolically healthy, which is antioxidants, micronutrients. In the book, there's five main components of food that help build a metabolically resilient cell, which is fiber, omega threes, a probiotic source, healthy protein, and then micronutrients and antioxidants. And so even if she'd been doing plant based or keto, I would have made sure that she had each of those components in every single meal to build cells that were metabolically healthy. So that's what really breaks my heart about the American patient, is that because there hasn't been this centralizing framework for why we're sick, we are actually working, people spend so much money on food and gyms, and 50% of Americans go on a diet each year. But we're getting sicker every year because we're not focusing on the right thing. It would have been a similar thing with exercise. You know, she was working with a trainer and that's great. I'm glad she was moving. But if I really knew what I knew now when she was getting sick, I would have thought, it's simple, mom, we need you to build more mitochondria to make more cellular energy. We need each mitochondria to be way more active, and we need to get each of your mitochondria making as much energy as possible. So I would have put her on an evidence based strategy to do each of those things. I would have had her do resistance training with heavy weights 2 to 3 times a week, not just like little weights, because it was the early 2000s and women thought that using heavy weights would get you butt bulked. No, I would have put her on heavy weights with a trainer who knew how to do that to build more mitochondria, I would have had her do a little bit of sprint training and zone two training to recycle old mitochondria and create healthy mitochondria, and then I would have had her walking 10 to 15,000 steps a day to basically churn through more energy. And get each of those mitochondria working, but there was no framework. So it's like, oh, I work with a trainer and I'll do Nutrisystem and didn't even know about organic at that time. We didn't even know about the toxins. We would, of course, had her have filtered water and cleaned out the personal care products. But this is for a patient like that, which I think is so many American patients. It would just be like, stop. I mean, I don't want to just say stop and read my book, but it's like truly stopping and understanding where the arrow needs to go and then shape your choices efficiently towards that problem, and then track your labs and make sure they're working. Mighty Pursuit: So how do you define healthy? I mean, you wrote, “you can and fit and should feel incredible mentally and physically most of the time.” Like is that over promising or even realistic for most people? Dr. Casey Means: I think it's definitely realistic. I think we've normalized what Mark Hyman calls "FLC syndrome", which is “feel like crap syndrome.” And I felt like crap for a lot of my life. You know, I was very sick when I was a surgical resident. I had my own slew of chronic issues, and I grew up not being a very healthy child. I was super overweight. So I know what it feels like to just feel like not feeling great is normal. And then you feel you start to feel great and you're like, wow, this is a whole different level. But I think fundamentally it's like, I think it's our birthright to wake up feeling joyful, optimistic, happy, grounded, to feel sharp and to have an absence of any chronic symptoms to really like, I mean, sure, of course we're going to get, like, stub our toe or sprained ankle or maybe have a headache if we're dehydrated here or there, but we should not have chronic symptoms that are lingering over long periods of time. Yeah. And also just feel a deep sense of like purpose and awe for this incredible life. And so I think that's absolutely within the possibility for the vast majority of people. And I only say that because we could get there in a few months if we focus on the right things, you know, which is hard. It's simple, but not easy, as we all know. Mighty Pursuit: No, I know, it's really good. I think it's helped contextualize a lot of things for me. I mean, even in my personal case, like probably about two, two and a half years, I mean, I've been eating organic food for, I don't know, eight years. Yeah. And generally getting movement, although periods of time not. But I was diagnosed with SIBO and then like it's been this chronic kind of belching and getting irritated by FODMAP foods and it doesn't quite go away. But then there's a lot of other factors in your book that I started thinking like, okay, sleep and, chronic stress levels and like other things that like to just isolate on the nutrition and be like, that's the only thing that's like influencing that, like you have that marker down, but like it could be like these other things that might be playing a role in that holistic picture, which I thought was really good. Dr. Casey Means: That's amazing. SIBO is a tough one. That's what gets people usually into functional medicine because conventional medicine doesn't have a lot of good approaches for it. Mighty Pursuit: So I mean, obviously to get these tests and protocols that you're talking about that you just mentioned earlier. I mean, you have to work with a doctor for them to be ordered, is that right? Dr. Casey Means: Yes. Although with the direct to consumer lab testing companies like Function or Levels, they are working with physician networks to help facilitate these orders. So you're not having to go into a doctor's office to order them. You're purchasing it. And then usually filling out an online health questionnaire that is reviewed by a doctor, which is pretty amazing that now with telemedicine laws like that's legal and allowed to be done. And so there is a very easy way to get these tests without actually having to go into the doctor's office. Mighty Pursuit: And then obviously we've mentioned functional medicine multiple times. And so functional medicine kind of looks holistically at the whole body, which is very different from traditional medicine that we're just talking about and the importance of that. And so are there any, obviously you can look for a functional medicine doctor in your own city, but are there any networks or things that you would recommend with that are that are doing this or like you can feel confidence in like going to this -- Dr. Casey Means: Yeah, yeah, there's some really neat companies cropping up, so I mean one place you can look is ifm.org, which is the InstituteforFunctionalMedicine.org. And they have a practitioner directory that has practitioners in every state doing functional medicine, many of which take insurance, which is really cool. Digital functional medicine. Parsley Health is a great resource, which is basically both in person but also digital clinics to be able to see a functional medicine doctor. And they'll order labs that you can get done in your own town and then review them with you remotely. Next Health is an amazing organization that's expanding rapidly, but you can do virtual care and they have functional medicine doctors on staff who will order labs for you and then review them with you. The Whole Foods CEO actually recently started a company called Love Life, which is going to be based in LA. I think they're also doing virtual care, but these are starting to emerge -- Mighty Pursuit: Didn't Mark Hyman start something? Dr. Casey Means: That's Function Health. Mighty Pursuit: Okay Function. Dr. Casey Means: Which is not a clinic in the sense that you're not going to be working with a doctor. But when they order those 109 biomarkers, you are given a functional medicine interpretation of your labs, but you're not actually talking to a doctor. And then with Levels similar, you get labs and there's an interpretation but not actually working one on one with a doctor. Mighty Pursuit: But you could bring those to a doctor. Dr. Casey Means: You absolutely could bring them to a doctor, which is great. So many different groups coming up like that, but certainly Parsley, NextHealth, if you're really looking to talk with the clinician, those are great options. Mighty Pursuit: Really good. All right. So we'll link some of those getting practical in terms of, you know, as you're working through this entire process, you know, symptoms, I think two things that are confusing for people is when doctors themselves might tell you that you're healthy, right? And so you've talked about this in your book about how they'll be like, oh, your blood levels are this, oh, that's normal. Okay. But it's not actually at the range that it should be. So is there anything you would say on that subject? Dr. Casey Means: Well, I would just note that if you're not feeling well. A lot of what doctors are going to look at is your labs and your physical exam. And if your physical exam, there's nothing super off in your labs or pretty much normal. That's sort of the end of what they're looking at. But if you don't feel well, like you should be able to feel well. So you need to find a doctor who takes your symptoms seriously and helps you work on them, no matter whether the labs, quote unquote, look normal. The other thing to realize is that how we're trained in Western medicine is to take all these labs and essentially just look at them very algorithmic and robotically. So like, oh, if LDL is high, then, stop eating saturated fat and go on a statin. If glucose is high, stop eating sugar and here's metformin. And there's two problems with that. One is that the normal ranges that were given on the lab slip, often they are not optimal. So they're basically just showing like across a population of Americans, what is like two standard deviations away from the mean. But the mean is not good. So we don't want to be normal in our labs, we want to be in the optimal range, which is often very far off from the normal range. And so you can imagine a patient out there and I've seen a lot of these where all their labs are like on the very upper end of quote unquote normal. And maybe 1 or 2 is out of range. The doctor looks at that and like it's mostly normal, but if you stepped back and thought about optimal ranges, you'd realize this person is very far on the spectrum towards disease. You do not want to be on the upper end of normal for like all your labs, that means that something's wrong. You want to be in the optimal range, and maybe there's 1 or 2 that is creeping up towards the high end of normal, you know? And here's an example of that. In our modern medical system, prediabetes non-diabetic is less than 100mg per deciliter in fasting glucose. So you get your blood taken after not eating for eight hours. And if it's under 100, you're non-diabetic. If it's been 101 and 125, you're pre-diabetic. And if it's above 125, you're diagnosed with type two diabetes. But you take that normal range which is less than 100. And if you actually look across the spectrum of normal, which would be between 65 and 100, you don't want to have no glucose in your bloodstream. But like let's say the slew that the people in that normal range are between about 65 to 100 mg facilitator as we go from a fasting glucose of 70 up to 85, up to 100, our risk of developing disease skyrockets within the normal range. So I don't want to be told that my fasting glucose is 99, that I'm normal. I want to be told by the doctor, you're fasting glucose is 99, which is technically based on standard criteria non-diabetic. However, this likely represents that you actually are moving down the spectrum of metabolic dysfunction and blood sugar disorders, and you want to get that down as close to 70 to 85 as possible, which you can do rapidly with these dietary and lifestyle interventions. But that is not being told to the average patient that doctors are seeing the 99, it has a green checkmark next to it, and they're moving on. And if the patient keeps doing what they're doing, it's very likely that they'll come back and it'll be 102 and then 105 and then 107, because that's how biology works. So that's why it's so important. And that's why every single company I just mentioned that's doing these labs or functional medicine, they are going to give you both a normal range and an optimal range. Mighty Pursuit: That's good, yeah. And so then in terms of symptoms right. So as I mentioned we've kind of talked about traditional medicine, but it's like you have your 15 minute doctor's visit. Oh okay. You have these symptoms. Let's just treat the symptoms as like the disease itself. Here's some pills. Let's make the pain go away. So, with this approach, it's almost as if it's saying if you're not symptomatic in any way or that if you suppress symptoms, that means that you're not healthy. And so what would you say just about symptoms in general? Dr. Casey Means: Yeah, I like to think of symptoms really as a gift. Symptoms are the way that our body is telling us that something is not working properly and that the body's needs are not getting met. And this shouldn't sound mind blowing, but to me it was when I kind of put this together, which is that if everything's working properly in our body, we're not going to have symptoms. So if we have a symptom, really any symptom, mood, physical symptom. It is telling us that something is not quite right inside the body. So then our job is not to numb that signal. That is, thank God, the body is finding a way to tell us that something's not right. Our initial response in our conventional health care system is that symptoms are intolerable, squash it. But that symptom is basically the body coming to us using the language that it knows to ask us for help. And in squashing it with a symptom based treatment, you know, like an Advil or a Nexium for our heartburn. We lose the insight into that feedback mechanism. So what I would say is that what we should do is when we have a symptom, we should always be asking our body with compassion and curiosity, what are you trying to tell me? What is this symptom saying? And I mean, for a headache, it could be, did you drink last night? Are you dehydrated? Where are you in your menstrual cycle? Like there's just so many things, like chronic stress. There's so many things. Or maybe there was an environmental trigger, you know that's triggering the migraine. So go through the checklist and really try to ameliorate those factors before taking the hammer to the symptom. And so I think once I've started doing that, it's kept me from having to reach for the over-the-counter medications all the time, because I can usually just run through a quick checklist and realize like, oh yeah, of course, of course I have a headache right now. Like, I haven't had a sip of water and it's 2 p.m.. Like, I should probably do that and usually things go away. And I think about even more chronic syndromes like arthritis. You know, my fiance has had tons of knee surgeries because he was a professional athlete, and he had pretty bad arthritis in his knees. And, you know, when we started living together and it was more understanding that symptom more kind of approached it that way. Like, well, what do you think that this is sort of saying like and it's like obviously it's saying that you've had you were rough on your knees in professional sports. But like inflammation is fundamentally a biologic, arthritis and inflammation and inflammation is a biologic process. So what are the things that could be impacting that biologic process of arthritis? It's not just a structural issue because there are people with no knee cartilage and they don't have pain. So there are people with bulged discs in their back who don't have pain. So we know it's the biology, the disease. Well, what impacts inflammation? Nutrition, stress, how we're using the joint. You know, the supplements we're taking. So we went through all those things and really unpacked it. And, you know, three months later, he had no knee pain. He was on track to maybe have another knee surgery. And it's like we just kind of fix the biology of what inflammation is trying to tell me. And we got him on high dose turmeric. And so I just even for long term nagging symptoms like back pain and knee pain and migraines, this exercise. You may still need to take medication, but it's worth it no matter what to have that conversation with your body. Just out of respect for the body and gratitude for it trying to get your attention. Mighty Pursuit: Yeah, it's really good. So, you know, we kind of closed section about laying of the land, blood tests. You know, we're going link to the book. Obviously, there's tons of stuff in there. Biomarkers, measuring weight, circumference, sleep data, movement data, a lot of this stuff. One last thing I wanted to address here before we talk about things that we could do to actually optimize our health. I heard that Andrew Huberman recently did a full body MRI. Like, what are your thoughts on doing things like that or like ultrasounds or Cat scans and like these kind of imaging tests that show what's happening your body on like a one time basis or something like that. Dr. Casey Means: Yeah. Well, I don't have a statement across the board because each one's a little bit different. I think that when it comes to this emergence of this direct to consumer MRI's like Penumbra and Ezra, I think it's astounding what their data is showing about how many actual findings. I believe that for Prenuvo, which does a full body MRI, 1 in 20 people have a fairly serious finding. And in a world in which young adult cancers are skyrocketing, they're up 79%, there's a case to be made that, given the threats we're up against and that these diseases that are cropping up in young people, catching them early might be better. On the flip side, there are incidental findings that are going to pop up on scan. If you do thousands of scans, there's going to be little cysts and things that show up that may have absolutely no biological significance that are going to lead to interventions like biopsies or anxiety. That can be problematic too. So to be totally honest, I have had the opportunity to do those scans and I haven't done them yet because I feel great and I know my personality. And I think that if something benign but present showed up, I think there's a chance that it would cause me a lot of stress. And I think at this moment in my life, I'm not going to pursue that. Maybe in five years I will. But, you know, it's nuanced. And so they're showing a lot of utility for catching early things. But I think you really need to be the right patient and understand how you're going to react to the information before you do it. So talking to someone about what that information is going to, how you're going to act on it, if you find something. When it comes to CT scans, that's something we have to be very judicious about because CT scans have radiation and they expose us to a lot of radiation. So we want to use them very thoughtfully. But I think one place where they can be used very thoughtfully is in understanding our coronary arteries. So things like a coronary artery calcium scan or even better, a Cleerly scan which uses an algorithm to understand not just calcified plaques in the heart vessels, but also soft plaques. The reason that one is, I think, very promising is that heart disease is the number one killer in the U.S., and it's almost entirely preventable. So close to a million deaths per year, preventable from heart blockages. And we have a test that can show us. So even if you're looking at your Apob and your triglycerides and your CRP and all these tests that give us a picture of our cardiovascular health. At the end of the day, what really matters is whether there is a blockage in your heart or not. And that's where these scans. So I know for me and my partner, getting scans like this are a really helpful layer on top of the labs because they tell us the end state of what's happening with all these labs now, because, you know, 50% of people who have a heart attack have normal LDL cholesterol. So even if no matter, labs are helpful, but seeing whether there's really a problem, there can be, so I actually am in favor of very thoughtfully chosen coronary artery scans and an ultrasound of the neck, which looks at the thickness of the carotid artery, wall, which can also be a sign of how much sort of vessel damage we have that can lead to strokes. So carotid ultrasound, heart scans, I think, have a lot of utility. And then, other things like ultrasound to assess fatty liver disease. That one I feel like can have a lot of utility because almost I think 40% of adults now have fatty liver disease, which is fundamentally a metabolic problem and most don't know it. And that can go on to lead to liver dysfunction, later stage liver issues. So I would say, all in -- Mighty Pursuit: Colonoscopies, pap smears? Dr. Casey Means: Well, that gets into more like cancer screening, which I think that ultimately, like I think what I'm better to speak to is sort of more of these consumerised tests that are more about understanding risk of metabolic disease. But I would probably defer to someone who's really focused on cancer to think about things like pap smears and colonoscopies.
THE PILLARS OF HEALTH
Mighty Pursuit: So yeah, as we're getting a lay of the land, there were many areas you recommended that we focus on to optimize our health. So in the interest of time, I'm going to focus on some of the big ones. And so, you know, we talked about nutrition. And so obviously in its natural state, all food is inherently good and it provides nutrients to our bodies and health benefits, all of that stuff. And then, you know, we've discussed the problem of our food supply being heavily modified and all the things that we need to kind of be aware of. And so where do you think nutrition ranks on the importance of kind of optimizing our metabolic health? Dr. Casey Means: To me, nutrition is number one. And I mean, we could all debate on which pillar is most important. But the reason I am partial to food is because I think about the structure of the body. And the vast majority of the atoms in our bodies are made of the atoms that came from food. So food is both the building block of the body. It always kind of makes my head explode. But like a baby is essentially 3D printed in a woman from food. Like the ink is the food and the baby is 3D. It's crazy. So we got to get it right. I mean, it's our structure, but it's not only the bricks that make up our body, it's also the instructions that tell our genes how to use the food. So food is both a genetic regulator, a cell signaling regulator, and the building blocks the body. And on top of all of that, it's not a one time thing. Our bodies are changing every single day. Cells are dying. Cells are being reborn, constantly, as you know. I'm sure you know, like our skin cells turn over fully every few weeks. Our gut lining turns over fully every few weeks. So we are re-3D printing our body out of food every single day. Which is why consistency matters, right? Because it's not like this is happening once a year. Every day we pay the bills with what goes into our body with these atoms from our food. And I could actually make this passionate argument about sleep and stress management and toxins. All of it. They're all important. But if you don't get food right, it's going to be very hard for anything else to work properly. So for me, the number one thing about food is we got to get rid of the ultra processed food. Ultra processed food is a modern industrial invention that is an experiment that has failed. These foods arose out of industrial interests after World War Two, and they are destroying our health. We've got to get rid of ultra processed food. And basically, like you said, all food is inherently good. I agree with that. I think unprocessed, organic, real food from the best possible soil we can find that was ideally grown close to us, because I used to think local food was kind of frivolous, like a nice to have. But now I realize because, yeah, I was like, oh my God, this is getting ridiculous. But now I realize it's because it loses nutrients over time. So local food from good soil means more medicine in our body every single day, constantly telling our genes what to do and how to keep us healthy. And that's the best investment we could make. If you think about it like health care costs are the number one cause of bankruptcy in the United States. So we're going to pay now or we're going to pay later. So we should do everything we can to pay now upfront for the food because we will end up paying for health care costs if we don't get the food right now. Mighty Pursuit: And then you'll have all the symptoms and the diseases -- Dr. Casey Means: And it's so expensive. It's so expensive. And I mean, it's a strong statement, but I'm like, if you have enough money to have an iPhone or a computer or something like this. Like we should be thinking deeply about whether we have enough time, money, and if we are spending two hours a day on social media, we should be thinking about whether we really don't have enough time and money to spend money on organic food and go to a farmer's market. And the reality is, the majority of people have a smartphone and the majority of people are spending two hours a day scrolling. So we need to find the time because it's so high leverage. Eating real, unprocessed food is life changing. So that's to me -- Mighty Pursuit: So when it comes to ultra processed food, what do you think of the phrase everything in moderation? Dr. Casey Means: I am very, very disturbed by the phrase "all good things in moderation", because that's been sort of an American staple phrase for decades. We love saying that whenever we eat something, a treat, you know, all good things in moderation. And now we are so, so, so sick. And so when we think about all the things we're choosing to experience in moderation in our world, it's, you know, a little bit of water from a plastic bottle and it's a little bit of Oreos, and it's a little bit of that lotion that has a bunch of artificial fragrances in it, and a little bit of that deodorant that has aluminum in it, and a little bit of this Advil that I take 2 to 3 times a month, and a little bit of that anti reflux medication, and I'm going to have a little bit of watching Netflix. It's too much. We're applying this principle of moderation. But then we're inundating ourselves with so many inputs that are ultimately toxic. So I think we need to realize that moderation of a lot of toxic things is leading to bad outcomes. And it gets back to what we're talking about in the beginning of the episode. We need to respect our bodies, we respect our lives. And when we truly, fundamentally sit with the miracle of life that we are and go down that more spiritual journey. You don't want to have a moderate amount of toxins in your body. Like, to me, it's just such a priority for me because I'm on that kind of wavelength where my priorities are set to better set my body so I can really, you know, hopefully reach my highest purpose. And so I don't want Oreos like I used to, I was addicted to food for 20 years of my life. But like, I think we got to get back to the basics so that we don't see a moderate amount of poison as an okay thing. Mighty Pursuit: That's really good. I think, you know, so we talked about shopping local, shopping organic, you know, we've talked a lot about what's been done to your food. Pesticides, you know, food additives, chemicals. We talked about this with Dr. Lessig, but I think one thing where people get hung up, even me, is kind of like the debate about specific diets. And so what I mean by that is like, let's just say you have really healthy eating habits. You're buying local, you're buying organic food. Some people swear that being a carnivore healed them and then like, I literally have a friend or it's like, [the carnivore diet] that seemed to heal them. And then there's other people who are like, vice versa with, like, being a vegan or something like that. And so is there anything you would add? Like what is happening there? How could someone not eat meat at all or not eat vegetables at all? And can their health be optimized in some way? Dr. Casey Means: Yeah. Well, I think, you know, I've known people like you from a lot of different dietary camps. I know people who are incredible elite athletes who are carnivores, and I know people who are incredible elite athletes and doctors who are vegan. They're both doing fine, genuinely. And both of them can hold up thousands of research papers showing why their belief system is right, which gets at the bigger problem, which is that nutrition and nutrition research has become intentionally confusing and complicated because similar to the health care systems, it gets us all siloed into different camps, which is ultimately profitable and marketable. And it creates business. And what we need to just step back from and realize is that food is nutrients, and you can get the nutrients the body needs from a lot of different dietary philosophies. We need to focus on what's actually going into the body and isn't meeting the needs of the body. And I like to say, first of all, we need to educate ourselves on what the body actually needs to function. And some of the components I mentioned earlier, like the omega 3s and antioxidants and things like that. Fiber. But then we focus on getting the highest quality real food of whatever category, you know, we fall into, whether it's meat or plant based and eat that consistently. And then we look at two things. One, how do we feel? If we feel incredible and joyful and optimistic and energetic and have no chronic symptoms, then there's a good chance that diet is probably working quite well for us. And then you couple that with the data. How are my biomarkers? Are they getting better? Are my triglycerides going down? Is my fasting glucose going down? Is my CRP going down? Is my HDL going up? Is my Apob looking good? You look at the labs and if you're feeling incredible and all your biomarkers are moving in an optimal range, then we can safely say, this diet is meeting the needs of my body and I'm doing well. And I genuinely think there are very insulin sensitive people who are carnivores and vegan. And I think the commonalities in some ways are just as big as the differences. The people doing well on those diets are eating unprocessed, clean, real food and being thoughtful about what they're putting in their mouths. And the body's also incredible because it actually has a lot of redundant biologic pathways where you can get to the same outcome with very different inputs, which makes sense, because how do the Inuits in Alaska and people who live on the Serengeti in Africa, totally different environments with different food sources, how do they both end up doing well? The body has an incredible capability of using different inputs and creating what it actually needs. So an example of this is like we need omega3 fats in our cell membranes. All of our cells are covered by a layer of fatty acids. And we need an appropriate amount of specific types of fats like omega3 fats like EPA and DHA. But some people eat a diet that has almost no EPA and DHA, these omega three fats, because they're not eating any animal products that have those things. What they might have is higher level omega3, like upstream omega 3s, like Alpha Lipoic Acid, which comes from plant foods. And the body has the capability of converting Alpha Lipoic Acid to EPA and DHA. So even if you're not eating any of that food, like the fish, the fatty fish and game meats that have EPA and DHA. You could be eating a lot of chia seeds and flax seeds and walnuts and hemp seeds and convert it. So it could be two populations, two different people getting to the same outcome that the body needs, which is EPA and DHA. But what's interesting to remember and why people slam the vegan diet is that it can be inefficient to convert ALA to EPA and DHA. So they think, why don't you just eat fish? Why try to convert all of this? Well, look at biochemistry. It takes several enzymes to convert plant based omega3s to EPA and DHA. And those enzymes, they're called desaturate enzymes. They require a ton of micronutrients to do the process of converting ALA to EPA and DHA. They require things like vitamin C and zinc and magnesium as cofactors. So all that is to say, if we're thoughtful and we're eating a nutrient rich diet that supports these cellular processes, we could very well get to the exact same outcome as an animal based eater and a plant based eater. But we do have to be thoughtful about it. We can't just be eating trash, ultra processed vegan food and expect to have the same outcome. Mighty Pursuit: It's interesting. I mean, one thing I've been thinking about meditating recently is like, you know, there's this debate in the modern world, but if you go back 10,000 years ago, it's like what food was available to the hunter gatherer populations. And so they might not have had all these diversity of plants available to them. So maybe as part of an area where there's a lot of meat, you know, hunting, maybe in another area of the world, there were more crops and more things that were available to them. And so, I don't know, it's an interesting conversation, but something that's adjacent to nutrition, fasting. And so are you familiar with Valter Longo's work? Dr. Casey Means: Yeah, yeah, fast mimicking diet. Mighty Pursuit: Yeah. And so I have been wanting to ask about this, because he's coming out with a book next year about fasting and the role that that plays in helping with cancer treatment, which is just crazy to me. I mean, do you have any thoughts there in terms of like, fasting and why it particularly might help with cancer and anything like that? Dr. Casey Means: I'm certainly not an expert on this topic, but I've been following his work and from my removed sort of understanding of what he's doing, like, there's some evidence, I think, that people who do some fasting even before they do chemotherapy can actually have a have a positive impact. And in addition, there are people who are doing long water fasts to basically reduce the burden of their disease, especially for non solid tumors and kind of setting themselves up to do better with treatment. So it's so exciting that this stuff is happening. This work is being done because cancer is obviously a devastating illness. And when you think about fasting you know, calorie restriction and giving the cells a break initiates a lot of biologic pathways that we're not going to be able to activate if we're constantly feeding the body. Or even just like eating healthy food all the time. When we remove an energetic potential energy from the body, the body has to activate all sorts of cellular energetic pathways to utilize the energy that it has on hand that's stored in the body, in our sort of like bank accounts of fat and glycogen to to create energy in a different way. And I think that the core thought is that activating some of those pathways can be very healing for the body in a number of ways. One, it can help actually improve metabolic health because you are kind of clearing out a lot of these toxic fats that have built up inside our cells, like, and just kind of clearing, just clean up basically, because you're you're literally having to use your own energetic resources because you're not getting it from food. And then there's another thought that some of the byproducts of burning fat, like ketones, actually have sort of a healing capability for the body. And, you know, we're not going to be making ketones if we're eating the standard American diet, by and large, because we're constantly eating calories around the clock, many carbohydrates. So we'll just never really give our body the opportunity to tap into fat burning. So it's all about how you use different signals, like calorie restriction to change what is activated in the body and essentially trigger dormant pathways that may have an impact on but again, on healing. Again, not my area of expertise, but I think it's what it speaks to is using these different levers of like food and absence of food and different types of exercise. Honestly, thinking of them as a language in which you talk to the cells in a way they can hear to do the work that they need to do to keep you healthy. So just a different way of thinking about our choices. Mighty Pursuit: That's good. Yeah. And as we kind of get to the finish line, the last kind of three that I want to talk about were, biological clock and sleep, exercise and movement. And then you talked about emotional stress, and the mind. And so you wrote that even if you had a great diet and, but you have poor sleep patterns that might undo everything. So why is that? Dr. Casey Means: Well, think about it. We spend about a third of our life asleep. So it's a very important component of our life. And a lot of really important biologic activity happens while we're sleeping. Like activation of the lymphatic system, which clears out the metabolic waste products from our brain while we're sleeping. And also, the timing of our bedtime and wake time impacts the circadian biology of our body. And so helps set up the body to know when it's supposed to be doing during it's doing different activities, essentially put it on a schedule to make sure that the right metabolic pathways are happening during the day and the right metabolic pathways are happening during the night. And if we're kind of erratic with our sleep or going to bed at all sorts of different times, we just throw the body into kind of mass confusion. Then a third piece is that a lot of hormones that are involved in metabolic health, like growth hormone and insulin like growth factor and cortisol are secreted or modulated at night time. And so if we're skimping on sleep or we're erratic on sleep, we're actually changing hormone expression that has a key impact on our metabolism. So sleep is critical. And what I didn't understand until I really went down the rabbit hole of metabolic health, that it's not just quantity of sleep that matters for our overall health, especially our metabolic health. It's actually quantity of sleep, it's quality of sleep, and it's also consistency of sleep. So consistency of sleep is like how regular are our bedtimes and wake times are. And if any one of those pieces is not optimal, it's going to take a hit on our metabolic health independently. So for quantity, the research suggests that 7 to 8 hours of quality sleep seems to be the sweet spot for metabolic health, where less than that, our risk goes up and actually more than about nine hours, our risk of metabolic issues goes up. So too little or too much is problematic. When it comes to quality, this is about making sure it's uninterrupted. We're not being awoken by light in the room or noises or other things like that. So really trying to make sure we're getting deep sleep and REM sleep and adequate architecture of our sleep. And part of that gets to getting a really dialed in sleep environment where it's truly dark, truly quiet, cool. Good temperature. We're not going to be disturbed. We feel safe and going to bed early at night because that's going to bed, you know, soon after dark. So more like 8, 9, 10. We're going to actually likely get more deep sleep earlier in the night. So we actually can maximize what happens during our sleep if we move it up. And then as for consistency, this is about bedtimes and wake times. And there's a fascinating concept called social jetlag, which is basically. It's a marker of how erratic your bedtime awake times are. So it looks during workdays or like school days. Non leisure days of the week when you're going to bed and waking up compared to weekends or leisure days and you look at the midpoint of the sleep. So if I went to bed at 12 a.m. and got up at eight, the midpoint is four, and if I slept from 10 to 6, the midpoint would be 2 a.m.. And if there's more than two hours in the middle, that difference in the midpoint of sleep between our workdays and our leisure days, it significantly increases our risk of obesity, diabetes, metabolic syndrome. So that just goes to show how the consistency of our pattern really matters. The data is astonishing. If you just take healthy non-diabetic young men and in an experimental setting, subject them to short sleep for a week. So four hours of sleep a night, you turn healthy people into people with pre-diabetes, just by shortening sleep. So that kind of goes to show how, how much of an impact it has. Mighty Pursuit: Now, what would you say about, you know, exercise, sedentary lifestyle. Dr. Casey Means: Wow. I mean, I think at the highest level we are not moving remotely enough in our modern society. The average American gets 3500 to 4000 steps per day, which is like two miles of walking. You look at some hunter gatherer populations that are still living today, and they're getting over 20,000 steps a day. And it's not the steps that matter, but it's it's a proxy metric for how much we're moving these incredible bodies that are meant to move and movement and muscle contraction is a signal to ourselves to be metabolically healthy. It activates pathways that churn through glucose and help us recycle mitochondria. And we need to be moving. Like a body sitting has totally different biology than a body that's moving. And somehow we've bought into this idea that if we just sit all day, but then exercise, that's good enough. Even if we get our 10,000 steps in like a short hour window. But we actually need to really reframe that because we need the body to be moving a little bit throughout the entire day to get our optimal biology. So what I really recommend to people is really the first principles about exercise and movement. We need to, like I talked about with my mom, we need to be making more mitochondria, making each mitochondria we have as healthy as possible, recycling old mitochondria and new mitochondria, and then having each mitochondria process as much energy as possible. And with movement and exercise, we can do all three of those things. And it probably will include some combination of resistance training to print more mitochondria, interval training like sprinting, high intensity training, and a little bit of like low grade endurance activity, like swimming or biking or hiking uphill to really recycle those mitochondria and have that mitochondrial biogenesis and autophagy and then walking a little bit all throughout the day. So just getting up and moving around every half hour to move through the glucose and keep the glucose channels at the membrane. So that type of package, of course, if we're doing all those things, we're going to feel amazing. And the reason gets down to biology, it means that we're truly optimizing that core metabolic biology. Mighty Pursuit: And then the last one, emotional health, mind body connection. I think some people might be confused why emotional health or distress or whatever could influence metabolic dysfunction and even chronic disease. And so is there anything I can say about that? Dr. Casey Means: Yeah, I think when we think about the level of the cell. I'm always thinking about the level of the cell. And If the cell is living in a body that's having stressful thoughts or doesn't feel safe, that cell is living in a body that has biology like hormones and neurotransmitters being released that are saying there's essentially lack of safety in that body. And if that's the case over long periods of time, then that cell is getting inundated with chemical biological signals that there's a threat, that something's wrong and that is going to change the activity of that cell, no matter where it is in the body. Because what the cell is going to do is respond to that sense of stress and fear and alarm and activate pathways of defense and alarm and promote chronic inflammation. And actually the mitochondria, which makes our energy, is exquisitely sensitive to fear and stress and loneliness and these psychological factors because the mitochondria not only makes energy in the body, but it also directs energy in the cells. So if it thinks there's a problem, it will be directing energy towards defense rather than thriving and healing. So part of I think what a key point of what we have to do as humans in our quest for optimal health is to create a sense of safety in the body through our thoughts and through different mind body tactics that can meaningfully change the hormonal and biochemical milieu in our body to one of threat fear, alarm, to want of safety and peace and calm. When we do that, we allow ourselves to put resources towards the things we care about, which is feeling good, thriving and repairing. And that gets so overlooked in our Western system because we don't like talking about feelings or mental health or any of that stuff, and we're sort of isolated from the tribe. We live in isolation now, and we live in a world where a lot of industries have actually figured out that they can get us hooked if we're fearful. So we're going to watch the news and watch Twitter voraciously if we feel the world is dangerous because we're primarily wired to pay attention to threats. So I think this really gets into understanding our relationship with tech and with the industries that profit off of our fear, and of course, also our illness, setting appropriate boundaries with those things and most fundamentally, just getting outdoors more, being outside, away from our devices. Because I think when we spend time in nature, it's one of the best things we can do to actually create a sense of calm in our body, because when we're outside and we're away from the digital world, and we're seeing how beautiful and miraculous our planet is, and we realize that like, oh, there's birds and trees and flowers and clouds and everything is so much bigger than my little life of stress. It really short circuits those patterns that a lot of us are on. So that would be my biggest recommendation. Recommendation to anyone is just to like, find ways to process the deeper seeded fears that control many of us, the childhood wounds. Go to therapy, really, really try and unpack those deep grips on our psyche, and then on a more day to day basis, create really good boundaries with the things in our life that are driving our fear, like technology and the media that we're consuming. And really get your toolbox of mind body practices, very strong meditation, breathwork, walking, whatever it is that works for you writing, journaling, spending time with close friends and loved ones because it has a deeply meaningful impact on our risk for chronic disease as well of course, how we feel during this precious time that we're on this planet. Mighty Pursuit: So good. Yeah. So those four things in your book, you talked about some other ones - getting sunlight early and limiting light exposure late at night, when we eat and feeding windows and then protecting against exposure to environmental toxins. So we'll link that below in the book. But, yeah, this is just incredible. I mean, I feel like we covered so much ground. And yeah, I think honestly, when you reflect back on all of these things, a lot of them don't make Big Pharma or Big Food any money in the sense of, which is, kind of why a lot of them don't get attention, but, you know, they're all natural. They've been going on for centuries, they're ancient practices that I think you talk about in your book that our modern life has kind of taken away from. And so I think you're just, like, making this very practical. And I think it's just going to be so powerful and the work that you're doing. The last thought, I just wanted to ask you, just tying this all together as you close is in terms of building habits around these things, right, so we've covered so much information. Is there anything you would say about like, okay, there's all these different areas. And so the process of tackling those things so people don't feel overwhelmed. Dr. Casey Means: Oh, it's a great question. I mean, the way I approach it in Good Energy is actually just asking people to start with a few habits that they feel inspired and excited to. So I just ask people to choose three of 25 potential metabolic habits and two, what are you feeling most called to change in your life that you feel like you can and that you're going to be consistent with, because I definitely believe that small wins beget more wins. And I also highly recommend an Accountability Partner. So someone who's like a buddy with you in this, whether that's just a friend who you talk to once a week and make sure that you're staying on track because doing things alone is harder. Some people can grit through it and do it. But like, I like to have accountability personally. And so having a check in with someone, doing it with someone can be really, really helpful. And that gets to a broader point about community. I think one of the easiest ways we can get healthier quickly is to surround ourselves with healthy people who have good habits, because when you're choosing to spend time with friends or communities that are doing healthy things, it becomes the default. And it's fun and it's the socially acceptable thing to do. I would say over the course of my life, my community has very much moved towards people who are prioritizing this, and that means that some of your friends might change, you know, and I think that ultimately it just makes it so much easier if every event that you do with people and dinner that you have and meeting is surrounding around health, then it becomes actually harder to not be healthy. So I would say start with things that feel inspiring to you. Small wins beget more wins. Have accountability and really seek out people who are healthier than you and surround yourself with them and learn and stay motivated. Mighty Pursuit: Yeah, well, thank you so much. That was amazing. I think the work you're doing is incredible. And yeah, just so appreciate the time. Dr. Casey Means: Thank you so much.
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