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i think the free exchange of information and the individual ownership of it is key to this next wave of bio-wearable technology

hello i'm very excited today to be joined by josh from levels so josh thank you so much for joining me here today i would love to know more about about you i'm really excited about hearing about what levels is up to it sounds fantastic um could you just give me a short introduction as to who you are and how you got to got to be here at levels definitely first of all thanks for having me on scott i'm excited to dig into this conversation my name is josh clemente i'm founder and president at levels and my background is in mechanical engineering systems engineering primarily aerospace systems i started off working at spacex eventually led a team working on life support systems for their astronaut program and then i moved on to hyperloop one which is working on faster than sound transportation at the ground level and since then i've done a few startups and ultimately through my own personal sort of health exploration and experimentation discovered um how much opportunity there is to make a difference in the world of metabolic health which i consider to be the largest health crisis in the world right now and so that's what levels health is focused on right i mean that's it that's very interesting i'd love to touch more on your previous experience in hyperloop and spacex and how you end up being the founder of a a bio wearables company with that wonderful mechanical background but um let's just pick up on that last thing you just you just mentioned there because this point of this series of interviews that i'm doing is really trying to find those founders and leaders of technology companies that are trying to make a big difference this planet i mean what you just said there sounds like a you know a huge task the things that you're trying to try to deal with do you want to explain to me how you um how you found yourself you know so passionate and caring about that that you ended up starting up this company definitely you know it's grounded in a pretty personal experience where um i was working you know a very stressful personal project at spacex actually and uh you know had had a team we were trying to accomplish things quickly and of course with a human safety program or a human life support program it's also quite stressful in and of itself and so um i i hit this point where i felt like i had a terminal illness myself and i had always been someone who cared a lot about physical fitness associated that with with prime overall health and so so it didn't quite make sense to me why i would feel so poor every day i was having these energy crashes and move just my mood had deteriorated over long periods of time to the point where i felt like a different person and just was dragging myself through every day my my doctor and i tried to figure out what was going on just through some regular blood panels and that didn't really lead anywhere and so ultimately i started to just research the human metabolic system on my own and for those that aren't familiar metabolism is the set of processes that your your body uses to generate energy from the food you eat and the environment like sunlight in order to create energy for your tissues so all of the cells in all of your tissues in your body require energy in order to function and that energy comes from these metabolic processes so i just wanted to understand where is my energy coming from why do i not feel uh like why am i so fatigued all the time despite being a fairly fit person and that opened up a big can of worms for me so i started to understand you know the biophysical processes that that have to work in order for me to feel good or to to have the energy i need and i both recognized that i didn't have any data that was telling me whether or not i was making good decisions about where my energy was coming from and secondly the statistics globally on metabolic health and metabolic function which i had never heard before i'd never come across them before were absolutely outrageous i mean i had never realized the degree to which society is heading very quickly in a dangerous direction with overall metabolic health we're we're basically breaking down from the inside in a preventable way and so these two things together encourage me to start experimenting with with data gathering for my own health and wellness you know tracking biometrics essentially so starting with my blood sugar levels by pricking my finger i just wanted to see what was going on and through this process i ultimately accidentally discovered that i was either pre-diabetic or borderline pre-diabetic depending on you know specifically which doctor you ask but um that was the final straw so to speak where i had now come to terms with both the processes at that stake how bad things had gotten globally and the fact that i personally had just by accident discovered that i was affected myself and that led to a realization that this is something that there's huge opportunity with new technology to improve upon but we have to improve accessibility and then we have to enhance the actionability of that technology if that makes sense so make it more insightful easier to grok and get started with no matter who you are or what you know about the human body so that's really interesting i mean i don't know much about those statistics you uh you mentioned just then maybe you can throw a few numbers at us in a minute but i think i was working on some mental health projects uh recently and um i think in terms of mental health mental health is as big if not bigger than the combined diabetes and cancer care in the us alone so from what you're saying though this kind of yes uh is waiting to happen this crisis of metabolic health is waiting to happen and um thinking on to the united nations sdgs number three is all about good health so surely i mean give us some numbers get us help me understand how big this is how big this problem is well um so first off it's it's pretty important to touch on you know that i i like that you brought up mental health because oftentimes in society we get we get caught thinking about improving mental health improving physical health through exercise what we don't consider is how the underlying foundation of both of those is metabolic health if your brain cannot produce the energy it needs or if your muscles cannot access the energy they need you cannot improve physical or mental health so if your metabolic system is going haywire you you can't you just frankly just can't get healthier mentally or physically because you're breaking down hormonal processes in your body which are necessary this is why in type 2 diabetes for example the risk of depression and severe anxiety is more than double this is why specific to brain health alzheimer's which is currently being taught in medical schools as type 3 diabetes is affected by the same insulin resistance process which is it's a it's essentially a metabolic breakdown that affects our bodies when we are diabetic so that's why that that relationship is being sort of uh explored further and it's becoming clear that these these metabolic system breakdowns do affect us in ways that we call mental health deterioration or physical health deterioration but they're all sort of part of the same thing so um some statistics you know here in the united states i'm most familiar with the stats here and they are globally increasing at an increasing rate so i'll i'll give you stats here and then i'll give you the global numbers that i am aware of um the united or the university of north carolina in 2018 published a study that showed that 88 of american adults are metabolically unhealthy and there are 90 million here in the united states who currently have pre-diabetes meaning that they are trending quickly towards type 2 diabetes and 84 of them don't know it meaning they have no idea that they have a metabolic condition underlying so this is through random testing from our center for disease control 10 fully 10 of the population here in the us is type 2 diabetic that number is increasing and it's increasing among younger and younger people so so if you combine the pre-diabetic and the diabetic you have over 30 percent of the population that is currently type 2 diabetic or at risk of it and if they don't do something about it 70 will convert to type 2 diabetes in the next 10 years this is a this is a large-scale global epidemic that you know in financial terms will cost the united states 600 billion dollars by 2030 and that number is again increasing globally there are over half a billion people with type 2 diabetes today and again that number is increasing at a dramatic rate especially in developing nations where you know productivity is moving to more of an information less less manual labor more sedentary lifestyle you know so we're working in an information environment and frankly food processing is closely associated with developing nations so as the food supply becomes more and more processed it becomes more energy dense and at the same time we're doing sort of less active work with our bodies expending less energy and those two things combine to create a perfect for a perfect storm of metabolic dysfunction and so you know those are those are some high level numbers we can jump into some deeper but you know ultimately what we're seeing with covid is that outcomes risk of negative outcomes from covid are closely connected as well with metabolic status so people who have type 2 diabetes are at more than twice the risk of of death or severe complications from covid so you know that is not something to be ignored it demonstrates exactly what the problem is so that we have this underlying epidemic of metabolic dysfunction that we don't talk about and it it is essentially taking away our resilience against other um potential attacks whether viral or uh or autoimmune or what have you and uh so it's important that we recognize that this is the collision of two pandemics and if we can increase increase metabolic health we can uh very likely improve resilience from you know the next viral attack that we may see no that's very very important to understand that those numbers are eye-opening um really i mean when you try put them together there they are mind-blowing so i mean it's for me i i came from a cybernetic background and now end up talking about these kind of things on a daily basis you came from this mechanical engineering background and now it's quite clear you are so well versed in all of the in this market you're in um how how did that i mean you talked about your personal journey there but that change in mindset how did you find finds changing from the kind of mechanical world to the bio world and what did you learn along the way well um you know i was always very interested in chemistry i never really had a fascination with biology i think because when i was studying it it was um you kind of you start off learning about the single-celled organisms and it's very abstract it doesn't really have relevance it feels like so i i was much more focused on machinery and how systems work and i you know that was the thing that got me going is interesting solving interesting problems of of complex machines and um ultimately i didn't really think i had an interest in the biological world for for those reasons but when i got into the whole system's understanding of how the human body functions it was absolutely fascinating to me because there are these mechanisms that are quite well understood but we completely ignore in our in our day-to-day so we have this metabolic dysfunction crisis and what we choose to do is in order to to try to keep tabs on someone's health is we take one measurement per year if we're lucky and we you know that this for people who are you know for metabolic reasons this might be a fasting blood glucose check or a an hb a1c check which is another single screening measure and so if you get a blood panel from your your physician annually they'll typically check this the problem is that um you're taking one point a single data point and you're projecting that out you're extrapolating that to define the entirety of how this person's body is functioning at least when it comes to to blood sugar management and in systems engineering which is you know what i've been doing for for my career you'd be fired for trying to do something like that especially for a system as complex as the human body so the reality is that these things break down in a compounding way very slowly and without serious symptoms so people don't have a sensory feedback mechanism telling them that something's going wrong acutely at least it takes a very long time until you realize huh i don't feel as healthy as i used to or i've gained a lot of weight and i can't explain it uh or my energy levels are gone and so these are they're sort of nebulous breakdown without good you know without without a significant feedback mechanism um so so that i think recognition that using the systems engineering practices that that i come from which are uh you know monitoring what you want to manage and ensuring that you've you've monitored and controlled it controlled for it well before breakdown occurs that's what i want to apply to the way we approach day-to-day living which is that today we're flying blind every day you're making hundreds of decisions which uh you have choice over you know whether whether it's what you're eating for lunch or if you exercise or how you exercise or how much sleep you get all of these compound together and they either compound in a positive direction and you get healthier or in a negative direction but without a feedback loop you don't really know most of us are making these decisions based on emotion you know it's i like the taste of that food or my mother always made it for me when i was growing up or i read about it on the internet well that's not sufficient in today's world where we have such a processed food supply and we have to be conscientious and aware of the the effects especially over time so i want to you know bring closed-loop data streams objective data into our own conversation every day and make sure that people are you know whether or not they have a dietary philosophy they cling to make sure that it's grounded in objective data that's telling them that uh you know they're heading in the right direction and guiding them in the right direction if not that's really interesting he brought up feedback now as a cyberneticist and that's my life feedback and um i was talking a couple weeks ago about um safety in virtual reality and xr environments and one of the topics of that was how we can use xr to future self so to be our coach for what we do today by giving us that view of what will happen if we do this or what we do if we do that so i think to your point sometimes these decisions like you said are emotional they're habitual and we don't see that but actually by doing this today it might feel good it may give us that comfort but actually this is what's going to happen in the future i wonder whether there's a space for the kind of data and insight that you're capturing in that future selfing kind of coaching towards a better self do you see that ever happening i think so yeah you know the the ultimate goal is that um you know we have the ability at the individual level to take control of our daily choices and and and to make them in a way that leads to positive outcomes today i i you know and i touched on some of the stats there are there are many more that are more disturbing um but which relate i think specifically two outcomes you know there are 2.2 million deaths attributable to high blood glucose in 2012. so 2.2 million global deaths most of those happen before age 70. diabetes was the seventh leading cause of death in here in the u.s in 2016 and high blood sugar metabolic dysfunction is associated with with six or seven depending on who you ask again of the top 10 causes of death so you know these are these are not it's not just something that that we're saying well there's this weird marker where the blood sugar is erratic it's this is leading to uh an unhealthy life and ultimately a shorter life globally and at large scale so i don't believe that anyone wants that for themselves i genuinely i'm not one of those people who believes that people just don't care they don't want to be healthier which is why they're not eating healthier and working out more i think it's that people don't know they don't have confidence in the decisions they're making because they don't know what to do there's a lot of contradictory information about what i should do every day what foods i should eat what it means to be more active you know and i i believe that if people had better information they would they would of course implement it in order to live a healthier life to be there for their families to have a you know a more enjoyable health span so uh i i 100 believe that we're at the we're at the very beginning of what will ultimately lead to a data-driven uh very positive feedback-oriented relationship with technology where uh it's not invasive in your lifestyle it's not something that is um i think feeling punishing but i believe it will be very similar our technology will be very similar to having a coach a life coach who's available all the time and is just giving you those gentle nudges saying right now you're not well slept you took a red-eye flight or you were up all night with the baby you should avoid these foods and stick to something more like this and that's based on a personal calibration to how your body functions and those simple nudges are what i think will will be the difference between compounding again over decades in a negative direction and compounding very slightly in a positive direction which is uh you know over again over decades of very large delta in health well so we've talked a lot about the why and why you're doing this the purpose the outcome all of those fantastic things but as well as purpose in the title we've got tech so why don't we talk about the tech tell me how how do what is it and how does it work yeah so the technology itself that levels is implementing is called a continuous glucose monitor and what this device does is it measures sugar molecules in the body in real time now that sounds kind of kind of confusing two of the the primary molecules that the human body gets energy from are fat and sugar and we call the sugar that circulates in our bloodstream and is used by the tissues glucose so during advanced cases of say diabetes or metabolic dysfunction the human the human body kind of loses control over the blood sugar levels that are circulating essentially a hormone called insulin stops functioning effectively and glucose levels start to rise and that causes really significant tissue damages so these for people who have diabetes it's really important that you are well aware of your glucose levels all the time and that you are actively trying to manage them whether through medication or through lifestyle so this this tech was developed in the lab and eventually brought into the medical sphere to to be you know prescribed to people with diabetes for the management of their blood sugar and it's a simple patch a little disc about the size of two coins uh stacked and there's a flexible filament that sits underneath it which is essentially measuring interacting with the glucose molecules in your skin in real time and then that is wirelessly transmitting data to your phone so that's the the origin story of the tech now we've gotten to the point where the accuracy the affordability and the prevalence of the technology has gotten to i think a a sufficient point where we can start to move it out of the specifically therapeutic medical world and into the world of wellness and monitoring for preventative and or just general awareness reasons so levels is taking that original hardware and raw data stream so just just basically an output of blood sugar and we're building a behavior change sort of operating system on top of it so basically taking that raw data in combining it with automatically detected information about your activity and your sleep quality and your meals which you you oftentimes will manually enter a little information about and then we provide you with i think more insightful scores to help you understand just the quality on a scale of 10 for example of a certain decision or how for example a single meal affected you within minutes of finishing it so an example of how this would work is you know i'm going to eat lunch i make myself a meal i take a quick snapshot in the levels app i consume the meal and then for the next two hours my my blood sugar sensor is sending data to my phone which is monitoring how my body is metabolizing that meal two hours later i get a score that pops up that gives me a a rating out of 10 on that meal whether or not that that worked well for me and then it will give me recommendations if it was negative it might say here are some things you can substitute or it might say you know taking a walk after a meal like that can help you metabolize that that glucose spike more effectively and then you get additional scores and insights based on longer durations so over a week over a month how you've improved where the areas of opportunity still are et cetera so we're taking you know similar to how a sleep tracking device might give you a score every morning when you wake up to tell you how well you slept and then track that over time we're building a similar behavior change model on top of this um this previously sort of simple therapeutic device okay so it's kind of understand the input measure understand the output exactly yeah close the feedback loop between the actions we're taking and the reactions our bodies are experiencing and when if you do it in a tight enough time frame so rather than waiting you know days or weeks to tell someone about how how lunch affected them you tell them you know within two hours it's very easy to to create habit that way because again no one wants to make bad decisions and if you're getting that feedback immediately it kind of reinforces those those behavior change pathways yeah and i guess when you give that feedback when they can still feel that as well then that's extra reinforcement do you think you'll ever get to the point where you'll be able to take your levels app and scan a menu and you say actually item 22 is going to be the best one for you i absolutely think that's the direction we'll go and it may be to the to the point where um you know when you're when you're scrolling through your app looking for something to order from from a food delivery service it'll just organize the menu according to those food ingredients that work best for you and there's a huge amount of personalization at stake here and this is something that might be really interesting is that this technology continuous glucose monitoring has been largely used or nearly exclusively used in the diabetic you know the post-diabetic state but some recent research actually the the first landmark study was in 2015 showed in people without diabetes how much variability there is in how you respond to the same foods so so one study they took two sorry they took 800 people without diabetes they put continuous glucose monitors on them and had them consume a variety of foods over a week and that study showed that two people could eat the exact same two foods which in this case were a banana and a cookie made with wheat flour and they could have equal and opposite blood sugar responses to those two foods so the implication there is that not only is blood sugar equal and opposite but the hormones that respond to blood sugar and have to shuttle it into the tissues like insulin will also be equal and opposite which means equal and opposite outcome for those two people now more more research necessary to really demonstrate that that is the case all the way through to the hormonal level but the point is is that early evidence shows just how important it is to know specifically whether it's based on genetics or body composition or or stress levels specifically how your body is responding to the foods you are eating and you know that that personalized menu opportunity in the future i think is the it's the inevitable outcome when we have so much sort of diversity in the human population that's interesting um just as a side note there and i'll edit this bit out but if you've got access to that research please send it and i'll link to it um from the article as well absolutely interesting um okay coming back on so that's interesting and really fascinating and one of the things you know i've got an apple watch and one of the reasons i got it was i was listening to a uh a doctor on a podcast say at some point in the future this data that we're um we're collecting from all of these wearables will be used to solve illnesses we don't yet have in ways we can't yet imagine but if you don't collect that data now you have no kind of baseline or nothing to learn from would you say this is the same another thing that you would recommend another reason why you would recommend collecting this data now so that you can have it when things go wrong as well absolutely you know i think the the future of the patient physician relationship will be data driven it'll be informed by data over long time periods and and so i think that even separately of modifying lifestyle in real time having information about how your body is functioning over longer periods of time is really critical you know i i believe that to to ultimately to find breakthroughs at the individual level and at the population scale that we hadn't discovered before such as the the interesting relationship between cancer and metabolic health uh you know certain certain types of cancer are multiple times higher in prevalence in people with blood sugar irregularities and that that relationship is still not clearly understood but to to understand you know to in order at the individual level and at the the population level to understand those relationships we need more data we need more evidence and i think the side benefit is that you know in the in that future where you have collected uh you know significant data you've been tracking how your body responds to certain things and your sleep quality and your nutrition you'll be able to influence any conversation with your doctor or or initiate it at that sort of position of data you know uh background of data so i can just imagine you know today i walk into a new physician's office because i've moved across the country and they don't have any information about me none of my medical records tend to transfer most people don't don't take their medical records with them and so we're starting from scratch they don't know anything about me they ask a few questions i i may forget what my you know what my decisions were five years ago well if we have this sort of portfolio of data and of course we need to be cautious about privacy and about how this is used in terms of the implications that a lot of people will be concerned about but if we do this effectively we can improve the individual care and and i think maximize the effectiveness of our of our medical system as well wow so having a bit of a kind of a look back and a look forward here um in the last 12 24 months what kind of changes have you seen that both been challenges for for you in the company but also positive and then what do you see happening in the next couple of years and what do you what do you need to change in order to make this what you envision it to be well a few challenges have been of course the you know the world is going through a very tough time right now with with covid and just the implications to society or have been significant you know it's it's been a tough time to to start a business frankly and we've been very lucky in that we're we're focused in an area that is top of mind right now which is health and wellness and um what what happened is you know we we're starting a business here in the united states there are prescription requirements for these cgm devices meaning all of them require a physician's order in order to gain access to um that becomes complicated and of course you know there is an increasing amount of technology being used in the practice of medicine um this is telehealth or telemedicine practice but the ability to just communicate with a physician without having to be there in person it's heavily regulated here in the u.s and and it has historically been quite complicated for a physician to launch their own telehealth practice there are a lot of regulations it's not entirely clear now one of the beneficial byproducts of covet is that it became obvious that people needed to be able to access remote care from a physician without exposing themselves or the the other uh in person and so telehealth overnight transformed here in the united states sort of as a yeah a positive by product of a very unfortunate situation and that has really benefited levels because and i think just society generally telehealth needs to be the the standard of care in the future when we are you know we have high quality data streams available to us we we can exchange information around the world there's no reason that we should have to be co-located for someone to give us uh medical insight so i think the telehealth transformation has been really a positive change and you know i think we're also seeing kind of a revolution happening in data availability about ourselves and this bio-wearable wave you know bringing more data into the conversation about our own health and wellness and um and and for future analytes it's really important that we reconsider many of the i think regulatory assumptions that were made a long time ago prior to uh you know this sort of device and data availability so we we have to kind of push our our medical system our regulatory system our data privacy systems into the 21st century and make it possible for people to access information about themselves to own that information entirely control where it goes and to whom and and then leverage it use it an effective way you know we have to allow big data systems to be able to help us interpret this because it's really challenging for an individual to know what to do with uh you know millions of lines of data points but uh you know some simple software can can assist them so i think looking out say five years uh i believe that we will solve these challenges it's become clear that this is a clear and present danger and people need to have they need to be empowered to make better decisions and and be healthier on their own you can't leave that in the hands of your you know someone's doctor it's it's up to the individual to make better choices so looking ahead i believe we'll see a system that is much more and i i say this tenuously but let's say it's much closer to you know kind of an optimal financial model where you are using your health data every day to make positive educated decisions about you know based on your goals and you are able to project into the future and know the track or with high confidence know the track that you are on in terms of your own health and trending in the right direction and if you need help you can you can get the access to an expert whose perspectives will be based on the data that you have gathered about your specific situation rather than a population average and you know i think the free exchange of information and the individual ownership of it is key to this next wave of bio-wearable technology um so i had a couple of conversations recently with some regulators um people involved in regulation in the medical arena and one of them was uh was saying that one of the challenges with this wave of health tech and med tech and telemedicine is you have a lot of startups coming into the medical environment with um with no understanding of the rigor of the medical device regulation requirements um and there's a big discussion about what's known as intended use so what do you intend this used for and how you know how could it maybe be used for unintended outcomes so what do you what do you think about that are these are there a lot of startups there who are coming into the market and not aware of their regulations and requirements and how could we deal with that moving forward to the greater good yeah it's a really good question you know the prime example is continuous glucose monitoring you know it was developed with the the intended use being for people with diabetes to manage uh acutely their their high glucose levels um high and low and so that's a very high risk population you know it's important that the device works exceptionally well because if somebody is to meter in the wrong amount of medication based on faulty numbers it could be a catastrophic situation for that person now if you look at the the other use case which is the one that levels focuses on where that data is only used as information awareness it's helping the individual understand the effects of you know the lunch that they're eating or the the quality of a walk or better sleep it's a much lower risk scenario because there is no there's no medication there's no acute risk to the individual i think that's a prime example of uh you know you know we are currently working within the regulatory environment and everyone who uses levels uh must communicate with the physician and be granted access to a prescription in order to get that technology so it's it's quite onerous for for the non-diabetic person to get access to the tech and i think we need to kind of be just just be very open to the possibility that technologies that were developed for a higher risk population should be useful for a lower risk population without the same regulatory burden if that makes sense and there may be some simple tweaks that have to be made such as you know if a device were made available based on the same technology without a prescription it should not be available to someone with diabetes just to ensure that we don't you know create something that is sort of at a higher risk of failure that could have life-threatening complications for someone with diabetes if they were to use it for for medication management so certainly being aware of the bidirectional risks but i think opening up the opportunity for innovation and the reason i say that is because you know i genuinely believe that better information at the population level is key to pushing ahead our understanding of how metabolic health or you know and this this applies to basically many industries but how these things progress and if we can better understand the non-diabetic state i think we can improve the therapeutic approach for the diabetic state so i just think that you know we although i you know understand the the need for the regulatory considerations that are in place um i believe that the innovation opportunities are there and companies want to contribute to the the development in these spaces and and really could uh but we need to have an open line of communication with regulators to help us just explain the the use case and rationale a little bit easier it's quite tricky certainly here in the united states to um to navigate regulatory frameworks that didn't i that i believe did not uh anticipate certain business models you know and they may be perfectly beneficial but um it just wasn't contemplated in the original drafting of of the rex so uh i just look forward to i think improving those lines of communication wherever we can thank you josh thank you so much for um spending time with me today on this i've i've learned a lot i've thoroughly enjoyed uh getting to know you and levels and for everybody watching please don't forget to like and subscribe to the youtube channel share this and if there's anybody you think that could benefit um directly from this um please do do let us know josh just the last point on that then if somebody wants to get in touch to register for your product where should they go and what should they do so right now we're we're still in development and we're we're performing an invitation-only beta program um and so what that means is that we we have a wait list which you can you can access at levelself.com you can add your information there and uh we'll be both communicating through our newsletter to to that list but also providing opportunities to to come and join the early access program which is how we're developing sort of co-developing our product with with real-time real customer feedback if you'd like to be a part of that please reach out now the uh the long-term goal of course is to launch this year uh to a wider audience and have have it available to uh in greater numbers and we're doing everything we can to get there so yeah please follow along the the blog at levels health is i think also a really good resource to understand how metabolic health and and metabolic fitness specifically could benefit all of us if we if we start to focus on at a larger scale fantastic i'll put all the links at the bottom so just click on those and follow away so that's it josh thank you so much this has been really really interesting thank you