Special: "Why Now" for Digital Health (with Levels founder Josh Clemente)

0:00 So I would get brand flakes and eat it by not only the bowlful, but also like dump it in smoothies and stuff. And it is probably like the single most reactive substance I was putting into my body. Like it was always way above the diabetes threshold. It was like It was crazy. Welcome to this special episode of Acquired, the podcast about great technology companies and the stories and playbooks behind them. I'm Ben Gilbert and I'm the co-founder and managing director of Seattle based Pioneer Square Labs and our venture fund, PSL Ventures. And I'm David Rosenthal and I am an angel investor based in San Francisco.

0:48 And we Are your hosts. Тудей ви спеш епизод да дивись деплінами. Digital health ecosystem. Especially with the lens.

0:57 on the complete upending of the landscaping with companies going direct to the consumer. Today's episode primarily centers around levels, a new company that's on a mission to make All of us aware of our metabolic health, AKA track your blood glucose with a real time wearable sensor known as a continuous glucose monitor or CGM. Wear mine right now. Me too. We were introduced to the company by two of our LPs and members of the acquired community. Shout out to Michael Mizrahi and Ben Grinall.

1:29 One of our favorite things about the incredible community that has developed in Slack and on our LP calls is that we get to learn about some of the most interesting companies in our ecosystem today. We are joined On this episode. By the founder of Levels, Josh Clemente. Josh has a fascinating background even before starting levels from his days as an early engineer at SpaceX, where he worked on Dragon Capsule as the lead life support systems engineer, and then afterwards at another Elon company, Hyperloop One.

1:59 If you are wondering how the business models behind these new direct to consumer healthcare companies work, Why the time is now for this revolution, or perhaps you just want to be one step closer to being a cyborg. This episode is for you. All right listeners. Now is a great time to talk about a new partner of ours here on Acquired, Lagora.

2:21 The agentic operating system that is redefining how the world's best legal teams work. Yep. It's sort of obvious that AI is gonna completely change the legal industry. I bet most of you listening have dropped a contract into some sort of AI chatbot out there. Legora took that insight and asked the question, what if you really built something with that power from the ground up for the legal industry? So the founders did exactly what great founders do. operate with obsessive customer focus. They embedded inside a massive law firm.

2:53 For months. They sat with the lawyers just watching how the work really gets done. And that's how you get features that customers love, like tabular review, where you drop in a folder of hundreds of contracts and it pulls every key term into a grid a lawyer can actually work with. Legor's Bet here is interesting. Since it lets each lawyer handle more complexity, any given person can increase the quality of their work. And do higher value work. And this means that the pie can grow even as each individual task takes less time. And they recently launched Lagora Agent, offering greater intelligence and performance. The agent lets lawyers set an objective. Then it can handle the planning and the execution and delivery of the final product. Legal teams get to maintain full control and transparency since they're still involved where judgment is required.

3:41 And Lagora works where you already work. You can use it within Microsoft Word while redlining or drafting. The early Lagora numbers essentially speak for themselves. When they have a head to head pilot with their top competitor, they win 70% of the time. Ligora now has over a hundred thousand lawyers on the platform from twelve hundred legal teams in fifty countries. And crazily, they went from one million to a hundred million in ARR. In about.

4:10 Eighteen months. Mm. truly insane numbers. And that is the real test. Plenty of things demo well, but the question is whether a busy associate actually reaches for it during crunch time, or whether a partner trusts it before going into a conversation with a major client. If your legal team wants to check it out, whether you're a law firm or you're in-house at a company, you can learn more at Lagora.com/slash acquired.

4:33 And just tell'em that Ben and David sent you. Now on to our interview with Josh Clemente. From levels. So Josh, welcome to Acquired. Super happy to be here. This is gonna be so fun.

4:45 We're excited to have you. David and I are both right around the one month mark David I think just finished using levels for his first month. Um I'm I'm about to cross that threshold and uh So many insights, so much fun to learn all this. Really cool company you founded.

5:00 And I think you guys are Maybe winning for as a and in the startup category for market share of acquired community members as employees. Super, super fun to do this with you. Well that's a that's a trophy I will hold broadly. Well, Josh, I'd like to start with your background,'cause before levels, you were doing some crazy interesting stuff, and I wanna dive into unpack some of that a little bit,'cause y uh you know, we would like to have you as a guest on acquired, even if you hadn't started levels. So let's start in sort of the the SpaceX and Elon chap of the world, working on Hyperloop.

5:37 First of all, can you explain to us what you worked on at SpaceX? Yeah, I entered SpaceX as a manufacturing engineer. So I was fresh out of school. I Only really wanted to work for Elon.

5:49 when I had graduated and I did not have I didn't have that job lockdown. So I actually sold used cars at Carmax for like three months. And just kinda like hung on to hope and work my network like crazy to try and get Yeah. Wow. Did you did you cold email Elon? Like how I cold emailed everyone, including recruiters at other Elon companies like Tesla. I actually got an internship at Tesla first and then they got DOE funding right as I was about to join.

6:16 And they shut down the design office I was gonna work at and relocated. And basically were like, Sorry, we don't have a space for you, so we'll do this again sometime. And so I was just like, Well, how about SpaceX, you know, can you help me get in there? Um and what's crazy is that I actually out of pure coincidence, my uncle met Elon. He he ended up being Working with

6:36 Talila Riley, Elon's Former wives. father and and he like met Elon and was like oh my My uh you know nephew is really interested in your company. He's like

6:51 And I don't really no, but like at some point that filtered down and I ended up getting a phone call back and I think my uncle like put in uh beyond just that in person, but put in like an email good word as well to to try and get me in there. And anyway, long story short, after three months of selling cars, I I got a call from SpaceX and they were like Here's an entry level manufacturing engineer job, which is

7:13 um primarily focused on taking the concepts uh that have been designed or or like first article has been built and tested and then getting those into production. So figuring out, you know, we were a small company when I started, it was uh I think I was employee like six seventy eight. And it was just a big empty building. Which is ten times smaller than it is today. Yeah.

7:34 So when I left it was probably around fifty five hundred people. And it's now yeah, easily seven thousand. And growing. So It was it was very much the Wild West days. I mean like

7:45 You're you're taking these components that have been uh that they have been designed and tested, but you need to get them into spacecraft form and launched, and most of the stuff had never been done before, so it was all like initial systems and as a manufacturing engineer was it was focused around Designing process.

8:03 training up technicians and putting like work instructions in place. And then also just kind of like building yourself. And so I spent a huge amount of time in that first stage. in the factory, like on the factory floor. I was kind of like a glorified technician and then ended up uh learning a lot from the existing technicians in just like the hands-on process of of building aerospace components. Uh and I spent a ton of time down at Cape Canaveral just getting

8:28 Launch articles so like Once the vehicle was prepared for flight. It was then integrating all the final systems. uh putting it through wet dress, static fire, and then watching it go to space. So it was just Pretty wildly.

8:41 educational. And from there I moved into what's called a responsible engineering position. You're responsible end to end. There is no other individual to point to and say We didn't succeed, it's your fault, you know, it's er the buck stops here type role. Um, and so I worked there. On

8:57 A few structural systems and Finally, about halfway through my career at SpaceX, we started to we had succeeded at getting The cargo vehicle. through its COTS program.

9:09 And we were starting on the the human rated program at SpaceX and so this required a life support system to be developed. And SpaceX had obviously no human rated experience. And I was one of the first four employees who had the opportunity to work in that department.

9:24 And yeah, I I look at that project as for sure the pinnacle of my experience at SpaceX. I mean the team was just unbelievable. Some of the best people I've ever met and had the opportunity to work with. And uh I got to lead the pressurized life support systems team. So this was

9:39 Developing the oxygen breathing system. So the pressuriz tanks that go in the vehicle that That carry high pressure oxygen, distribute it. uh regulate it down to lower pressures into the cabin, into the space suits. sensing oxygen concentrations.

9:54 Keeping the cabin at like environmentally safe pressures and compositions. the fire suppression system, the docking adapting system that that pressurizes kind of the space between international the the international space station and the dragon capsule after docking. Kind of all of these pneumatic. uh pressurization mechanisms and um

10:12 So I was able to lead that. Small team, amazing team. through to completion of the Critical design review phase. That's great. And as we know now, you know.

10:23 Dragon cargo and dragon crew have both uh successfully gone up. So uh must be crazy cool to see. You know, your your work and action there. Yeah, I mean it's pretty surreal. To be honest with you, it felt like an impossible amount of time away always and then all of a sudden it's

10:38 It's happened and it worked and it's just such a huge You know, it's the stress is still high. There's gonna be another flight with four more astronauts later this year. So the stress is still high every time because each system is unique, but as SpaceX develops more experience with reusability and reflight. It just kind of It allows kind of some more confidence and breathing room, I feel like.

10:59 Mm-hmm. Okay, so Josh, before diving into the next chapter of your career and and uh founding levels. We gotta ask like

11:09 Is there a fun Elon story that uh that you've got or something crazy that uh I mean everything that happens when you're working at SpaceX, I'm sure, is crazy, but anything you want to share? I think One moment that always Just reminds me of the Kind of

11:23 unique culture of SpaceX. Was really the first major launch. So I I got to SpaceX just after they flew the Falcon Nine one point oh rocket for the first time. So uh basically SpaceX failed three times to get the Falcon One rocket into orbit. The fourth time it was successful.

11:41 Then on the first try they got the larger Falcon Nine rocket into orbit. So I got there just after that that success. So The second Falcon Nine Rocket was getting ready to launch. And you know, at this time

11:55 The the duration between launches was on the order of years. And so everyone was working full time, basically hand building a a vehicle. So we we had this machine, this entire like integrated First and second stage. On the launch pad.

12:09 And there was an air conditioning event. That Basically condition the interstage. It's basically the

12:18 the hollow space between the first stage and second stage. And the second stage sits on top of it and has this very long vacuum nozzle. So it's designed to give better efficiency to the rocket engine in the vacuum of space. So it's very long and it's very, very thin. It's thin enough that you can tear it with your fingers. And it's metallic. Or it was metallic at the time.

12:37 But it's very well supported. So the skirt it's called is is supported by these rings. And so this air conditioning unit was blowing a high volume of air into the inner stage to keep it purging. And we noticed during inspections that the skirt had actually been fluttering in the high

12:54 Pressure sort of air source. And it actually torn. And this was a really big problem, of course. Uh for a number of reasons. Just Debris and um also efficiency loss in the engine.

13:06 The typical approach in old aerospace would be Break everything down. Deintegrate, push the schedule out. Analyze everything, determine why this failure happened. Press release.

13:17 Redesign. The SpaceX approach was Elon calls up one of the lead technicians in the entire company. His name was Kelly. And he used to basically work on on airplanes.

13:29 and was a an airplane mechanic, but the guy was just an absolute machine and and brilliant. And Elon convinces him to get on an airplane to Cape Canaveral. With a pair of shears. Go up in an extremely tall genie boom. This guy's terrified of heights, by the way. Crawl through a hole in the interstage, which is about

13:47 Yeah big. into an integrated stacked rocket. Right. So you're a hundred plus feet off the ground. There's a second stage above you. And

13:56 Yeah, no, it it wasn't fueled up at the time, but certainly was it was intimidating, I'm sure, to say the least. And then he trimmed the lower edge of the skirt off, removing the tear in the The nozzle. And you know, we did a little bit of

14:16 uh propulsion analysis to ensure that the second stage would have what it took to get to orbit. uh even with the loss of of efficiency with the smaller skirt. But you know, basically Kelly hand trimmed this thing in the interstage, walking around on the on the dome of the the first stage. And climbed out and we launched and we successfully got to orbit. And the whole process was like, I mean, the whole company ground to a halt when this happened. It was a huge scary situation. And

14:39 Kelly pulled it off. P part of the funny thing was that As an airplane mechanic, Kelly was like This is a little bit more Scary actually, but he was terrified to fly. Like he just he hated airplanes. He I I think he's seen too much.

14:52 And that was the biggest problem was like convincing him to go up on the rocket was actually not the hard part. It was convincing him to get on an airplane to go to Cape Canaveral in the first place. But But I think it just speaks to the scrappiness of of everything back then. It was really Wild West. Yeah, I'm sure you've thought about this a lot, but why does that work? Like SpaceX has worked and it's been because of a thousand or ten thousand of decisions like these. Was the industry just too conservative before, or is there something different about SpaceX that makes it possible for them where it wasn't possible for people before? Definitely. I mean I think that

15:25 This kinda goes to psychology generally, but people are are you know there's like this scarcity syndrome that If you have something, you fear losing it. And if you don't yet have something, there's nothing to lose. And and so SpaceX was in a n we have nothing to lose mentality for it. the entirety of its kind of early days.

15:43 And so It's basically like we're either gonna Run out of money. and not get this contract and cease to exist. Or we're gonna slice this thing off with scissors and try. And and that's kind of like the the approach was

15:56 We were always one launch away, one launch failure away from from losing the company, you know, until probably twenty fourteen, once Falcon I one point one flew. Uh, we got a a ton of orders on the books and things started to smooth out a little bit. But up until then it was You know, Elon every single opportunity he got was telling people Look, you personally have to succeed, and if you don't

16:17 Two thousand people are gonna lose their jobs, including you. And I mean he would he would not mince words and I think that old aerospace Had

16:25 kind of been resting on its laurels in a sense, but also combined with the failures of the shuttle program was And the political nature of the you know, the entire program. was worried about losing what they had. They you know any failure was career ending for a politician and any failure was Potentially career ending for the engineer. And so p you know, failure is not an option in old space and it w was always an option for SpaceX and that proliferates the culture all the way through to live streaming explosions of Starship. You know, no other program does that because it's like airing your dirty laundry.

16:58 Yeah, that's such a good point. Yeah, we could talk about this forever, but I I I gotta hear about how levels came to be. So I'm wearing a continuous glucose monitor on my arm. It has a patch with your logo over it. Like Catch me up from you were a SpaceX engineer to you decided to have

17:17 David and I sitting across the the internet from you wearing this. How d how did it come to be? It kinda started at SpaceX. And Partially in a good way, partially in a bad way. But I I I kinda hit a a total burnout wall. In

17:30 The late part of uh the life support program I was working on. And you know, in retrospect, I was burning the candle. in multiple directions at once and you know certainly was Just working.

17:43 was not managing Stress. sleeping very poorly. My average sleep was like probably four to five hours. And My approach to like maintaining wellness was

17:54 working out as hard as possible as a CrossFit. You know, that was a Trainer but I didn't really train people. I've trained myself. I gotta imagine this was pretty

18:02 Common at SpaceX. I would at least uh doesn't look like Elon switch much to this day. Yeah, there's there's definitely one of the Yeah, it's it's a classic I think startup environment where everyone wants to be the hardest worker and y you give a bunch of people who are who don't like to fail an impossible deadline and they're just gonna like

18:21 The failure mode's gonna be them. They're they're just gonna like physically burn out trying to succeed. And that's what it was like at SpaceX, and I think it still is to some extent. But yeah, I I was just You know, kind of Do doing I had been doing this for my entire career at SpaceX, but I think there's a compounding return and we can touch on this, you know, uh as it relates to metabolic health. Um in a little bit. But

18:40 I had gotten to the point where I w I woke up one day and was just like I think I have a terminal illness. Like I I have zero energy. My mood is always low. I I'm not I'm not the optimistic, like sort of happy person I think I am anymore. And I don't know what changed but I just constantly feel irrit feel irritable. And I am struggling to make it through the day in terms of Not just like professional performance, personal performance. Like just keeping my

19:06 siblings from from hating me and my significant other from from walking away. You know, it was that degree of like I something's wrong here. Um and and I was getting these bouts of fatigue. that were truly symptomatic. Like I would be be eleven thirty in the morning, and I would feel this like shakiness and cold sweat and kind of a whole body tingling or itchiness type sensation.

19:28 And I would just need to like sit down. And so I was like, Am I about to pass out? I I had never passed out. I didn't I didn't lose consciousness or anything. But it was just a it was a very real sensation. And so I I'm describing this to my doctor and we ran a bunch of blood panels. Kind of the standard stuff and nothing came up.

19:45 And so anyway I This was kinda going on in the background and I was also working on the life support program. And part of the You know, we were designing a super high pressure oxygen system to deliver breathing gas to to the crew. And

19:59 You know, something that divers and astronauts could potentially face in a failure scenario is a high pressure uh high oxygen concentration environment. And what actually happens there is because oxygen is such a reactive molecule. You can um

20:13 generate a huge amount of uh oxygen toxicity in the brain. It's called central nervous system toxicity. And this can cause neurological shutdown. You can cause seizures, potentially even death. So this is why divers are limited. They can't really just breathe pure oxygen underwater for forever. You know, they they only have a short period of time. So Yeah, I'm kinda thinking about failure scenarios like

20:33 How do we avoid you know anything like this ever happening, obviously? But also what what does happen. And I read a paper just randomly just in my in my kind of side research, uh, from Dominic DiAgostino, who's a ketogenic researcher. at University of South Florida. And this paper described

20:50 a a series of studies he did on rodents. Where they fed rodents a ketogenic diet. Actually gave them exogenous ketones. Um as well as feeding them just a high fat diet. Which for the uninitiated is basically almost zero carbs, zero sugar. The only macronutrients you're eating are are fats and proteins.

21:07 Exactly. So in in a certain macronutrient ratio, which is very high fat. Your body will generate these macronutrient bodies called ketones, which are essentially a water soluble fat molecule. And that's crucial because water soluble means that it can

21:22 cross the blood brain barrier and provide energy for the brain. So typically the brain is fueled by sugar, glucose solely. Um and traditional fatty acids can't cross that barrier. So ketones can. So they are a a brain energy source. And they you know, in this study he gave these rodents a uh ketogenic diet.

21:40 And then submitted them to a high oxygen, high pressure environment. And the result was that These these rats could live up to five times longer without seizure. Just because of the

21:52 ketogenic state they were in. And that completely blew my mind. Because up until this point I was a Calorie is a calorie absolutist. And didn't matter what you ate.

22:03 If you worked out hard enough. It was all just energy in the end. Right. It's all thermodynamics, you know, that i you're in a closed system, so why should uh You know, like you should be able to burn it off. Right.

22:14 Just an equation. And so the although this wasn't in humans, I'm obviously extrapolating to humans and thinking Wait a minute. So the macronutrient selection here is giving these rodents superpowers. Like they can live five times longer in a deadly environment. Um What is going on here? How is this possible?

22:31 And that was like the first moment where I started to think what superpowers can be unlocked with dietary selection and w what am I doing to select for for diet? Like is there any objective data that I'm using? To guide my choices. And I was very unhappy by my findings, which was that I I like

22:48 I have the only reason I eat things is because they taste good or because somebody else told me I should eat them. Like there's no data. So I started to just self experiment. And this is like you know, a as I'm approaching the end of of my time at SpaceX, I'm still getting these like extremely

23:04 kind of stress induced or I I don't know, they were symptomatic episodes. and trying to figure out what's going on and then I come across this paper and I'm like, maybe there's more to it than just the gym. You know, I I work out really hard. I've got a decent amount of muscle, I can run fast, but I don't feel healthy.

23:20 So I you know, clearly there's there's a difference between The way you look and how healthy you you are or perceive yourself to be. Um, and so that's when I started self experimenting. And you know, my goal was to understand You know, where my energy is coming from. And how to to optimize it.

23:36 And so the primary energy molecule in the modern human is glucose. It's uh you know, it's the the sugar byproduct of carbohydrate breakdown. And I started I got a finger prick glucometer, it's called. It's this little And you can get a single data point.

23:52 You're in the uh the equivalent of Elon on the plane back from Russia building the Excel spreadsheet. Yeah, I think Hey guys, I think we can uh I think we can uh put the put something in orbit for a lot less money. Or to be even more obnoxious about the metaphor, like it's as if Fitbit hadn't been invented yet and you're just like, Hey, are you walking right now once a day? Right. Yeah. It it was it was like What is Glucose was was step one and then

24:20 Okay, how how do I gather this information? Into a like An insight. Basically I'm having these energy issues. And

24:28 The energy is coming from these macronutrients. I'm not in a ket ketogenic state, which means my energy is either coming from glucose or it's coming from fat. Those are the two sources that it can be coming from. And I can measure glucose by buying this little device at C V S and pricking my finger. So I'm gonna try to learn something here. started pricking my finger, got very obsessed with it, started doing it like sixty times a day at at one crazy point. And then I was plotting the numbers in Excel to to like kind of emulate a continuous data source.

24:54 The problem was At this point I had started sleeping more, um, as I was tapering down my my SpaceX work and and moving into hyperloop, which we can touch on in a minute, but uh so I was sleeping more I am In meetings, I'm doing work, you know, I'm working out. During those time periods, I can't prick my finger. Right. So I'm I've basically got point cloud in the morning. Point cloud cloud in the evening.

25:14 Nothing in between. And it's not making any sense. It's just like It's stuff, but it's not helpful. And then I read a book called Wired to Eat. Which talks about continuous glucose monitoring. And I was completely unsophisticated about bio sensors. So you know, CGMs

25:32 Continuous glucose miners have been Available in you know, kind of trickling from the research, like lab environment through to just Therapy. Research studies.

25:42 The first one kinda came out actually, it was a an early Dexcom or a Medtronic. Those came out in in the kind of two thousand six to two thousand ten time frame. So they've been out for some time, but there hasn't been a mass market move. until right around this time. So twenty seventeen. the Freestyle Libre from Abbott hit the market. And so this is this is twenty seventeen. It was like just coming out.

26:03 And the price point was good. And there had been Dexcom E G five and G four prior to that, but they were like Yeah. A thousand plus dollars a month minimum and very hard to get. Yeah. And DeckCom is

26:14 It's owned. It was a startup started. to build a continuous glucose monitoring device for A diabetic therapeutic. Exactly.

26:24 At this time, you know, uh really, uh even now, all continuous glucose monitors have been developed for the sole purpose Of measuring blood sugar. So that you can manage Diabetes. DEXCOM i they only do one thing. They develop continuous glucose monitoring sensors for type one diabetes. They're starting to move into type two.

26:42 Um the difference between type one and type two is that Type one's an autoimmune condition, primarily where the pancreas stops producing insulin. And insulin is the hormone that is uh it it acts like a key to open the lock in your cells. And let glucose in. So insulin's a signaling hormone.

26:58 And when the pancreas stops producing it, blood sugar levels start to go very high and it can be in and when glucose gets very high. Similar to that oxygen scenario, it's a reactive molecule, you start getting tissue destruction. So type two diabetes. is considered more of a chronic lifestyle illness.

27:16 So this is where over time you break down the insulin glucose feedback loop. And either your body can't produce enough insulin to keep up with demand. Or you're just kind of outpacing the production of insulin and you create what's called insulin resistance by Amplifying demand to the point where your cells stop responding to it.

27:36 And when you say breaking the feedback loop, this is like I have actively made lifestyle choices in what I'm eating where like the natural feedback loop in my body of hey, I should be producing this much insulin based on what this, you know, what the macronutrients that just came in were, like that just gets all out of whack and you can no longer rely on the natural system to function anymore. Yeah. It seems to be a actually potentially an adaptive response where Your body's kind of design it we we've been historically in a certain range of blood sugar values and that's where y you want to stay.

28:08 And if we're constantly jamming more glucose into the system than it was kind of designed for. You require more insulin than than you're designed for. So The devices have been developed. for this condition, for for diabetes specifically, which is very acute.

28:23 Type one is very acute. Type two is kind of a longer Yeah, sort of. Time frame where it's a spectrum. It's a spectrum, exactly. It can get extremely acute. Totally. I think they're both acute, frankly, but

28:35 Type one is It's a situation where if you If you don't use insulin. exogenously inject it. the damage is happening much faster and

28:46 You know, the effects are very immediate. Type two Tends to be you know, semi controlled in the sense that the glucose levels won't go as high'cause there is still some insulin feedback. Um so the this is where the device is.

28:59 Primarily focused. And so twenty seventeen, I read about this. And I was like, Oh man. I need one of those. Like I'm I'm trying to emulate this with finger pricking, my fingers are black and blue.

29:10 And I still haven't discovered anything. So I went to my doctor And I was like Hey, uh you know, check out my spreadsheet. You know, look I'm pricking my finger at on. Uh I'd love to get a CGM. And he was like Dude, you you are one of the healthiest people I see. If you if you saw the people who need that device, you'd kinda be ashamed to ask for it. Like that's That's for people who have

29:31 Yeah. You're like, Yeah, I'm trying to not get a disorder here. So that was my I was like kinda surprised by that response. I I thought Well Firstly, I mean if you look at systems generally.

29:44 Like you measure what you don't want to fail. Like you you don't just measure the thing. that is broken because that's obviously useless at that point. So in systems engineering, especially complex systems You get as much data as you can and you observe failure modes as they develop.

29:59 And find ways to counter them. And so Having already dove into the research on the you know. kind of the metabolic health crisis that I had d had not known about at the time.

30:10 Or had not not known about prior, but it was aware of at the time. I was like Well, uh this is just you know, it's just me trying to learn more about myself and like understand if there's something going on with my metabolic system. And yeah, my my physician was just totally opposed and and was not willing to to get me access to a CGM. Well this is and this is what we one of the things we really wanted to

30:31 Explore on this episode with you. It's like This disconnect. It feels looking at this industry like this huge disconnect developed between uses in a therapeutic sense as like Medical interventions for uh your your doctor's totally right. Like there were

30:49 There are people out there Who need this way more than you do. Mm-hmm. But that's so zero sum thinking, right? Like, you know, uh just because giving you access to a CGM Isn't gonna prevent somebody else from getting that too. So how d how did the light bulb start going off about like

31:09 Well hey, maybe Maybe this can be a consumer device too. Well I You know, eventually after trying for several months, I was able to get a CGM, but it was through a a friend of mine who Brought one back from elsewhere where they're over the counter.

31:22 So he he actually went to Australia and threw some in his backpack where you can you can buy him just like a glucometer. And You know, I was still just interested. I was like, I wonder what's going on. I'm pricking my finger, didn't have any insights yet. Put the CGM on. And was instantly blown away by how bad things were. My blood sugar was essentially it you know, it it looked much more like a heart rate trace than a er than a uh blood sugar trace and huge spikes.

31:47 Huge crashes. Everything I was doing, all of the meals I was consuming were putting me uh above what would be considered the pre-diabetic postprandial threshold, so where your your glucose should be after a meal. Um and oftentime very often well into the diabetic range. And so I w my body was not

32:04 managing blood sugar spikes effectively. it was able to bring them back. So it's not like I was, you know, diabetic and had lost control. But it seemed to be like blood sugar would go very high. My body would release a ton of insulin, overcompensate, I'd have these precipitous crashes. And I was able to just immediately I you know correlate those crashes with the sensations I I had been having where

32:26 The shakiness, the hunger, the irritability, it was all perfectly sinked. And Just by tuning, I you know, within two weeks I had tuned my approach to die, just like trial and error on On the meals I was eating.

32:38 and was able to bring those huge spikes down to a a minima and you know At the time I still wasn't sophisticated on what the ideal levels would be, and actually much of this remains to be discovered. But I was able to identify that things I was eating that I thought were healthy. Uh.

32:53 large servings of sweet potatoes, brown rice, uh quinoa. I was having huge Yeah. Again, in the diabetic range responses to. which was highly counterintuitive. I I thought, you know, I'm I'm a person who's like

33:06 I I eat the paleo CrossFit style, you know? It's like even though I love sugar, I love candy and I love dessert. Like that's not what I'm eating for dinner. uh anymore. I I was in college, but um so just this realization that Things were going haywire and it was it was the things that I thought I was doing. Well

33:23 that were causing these huge, you know. Inconsistencies. I mean, uh Josh, I'll tell you in my first week of using levels, I was like doing the thing that I think the the setup guide recommends, which is eat your normal diet. Don't try and eat h healthy. You you know, you the goal of this is to see like what your normal stuff does. And I had recently worked in like no sugar, just like

33:45 Steel cut oatmeal into my diet. And uh I think it wasn't actually steel cut. It was like the Quaker whole oat but it was advertised as whole. And like it was wild how much that spiked my blood sugar afterwards. Like it w it was like I just like holy bad. Yeah. threw a ton of gushers in my mouth or something. And I was staring at it like okay, I guess that's not as good for me as I thought it was.

34:09 Absolutely. And and I mean Oatmeal is a prime example. So Google healthiest breakfast and it's like top three, no matter what, is oatmeal. And you know, it's considered hard healthy. Well, last time I checked and it has been a few months, but

34:22 One of the worst foods in the data set was oatmeal. So like something like seventy plus percent of people that were eating oatmeal while using levels. had you know exceeded that That pre diabetes threshold was w we're well into the significant blood sugar spike territory from a food that's described as hard healthy. And the reason that that's interesting is that

34:41 Glucose variability, the number and peak sort of amplitude of blood sugar spikes is closely correlated with cardiovascular disease. So because that's an inflammatory event. the number of these that are happening throughout the day, which is obviously higher for people with diabetes.

34:56 is it's connected with negative heart out outcomes. And so it it draws into Question. How these how that ended up on the oatmeal canister. And you know, we're seeing a lot of these examples. But at the time, you know, it was just

35:12 a realization, you know, I'm using this device, which basically just spits out raw data, gives you like you're at eighty eight right now, and at least gives you an error uh a trend arrow. But it's not telling you anything about what is creating this situation that you're in. It doesn't tell you how nutrition, exercise, sleep, stress are related. And I started to intuit these things through use. And it quickly became the most powerful accountability and education tool about how my body works that I'd ever

35:39 used in my life. And that's that's really the realization was just This thing was hard to get. And it's completely transformed my approach to lifestyle. I'm a person who cares about health. But never knew.

35:50 the effects of cortisol. Right. I I I had been stressed for a few years professionally and and personally. Sitting through a meeting. Stressful meeting. Yeah. Sitting through a stressful meeting with a CGM on. And seeing without calories my blood sugar.

36:04 exceed one hundred and forty five milligrams per deciliter, which is the the postprandial kind of threshold for for kind of a pre diabetic response. changed my perspective on stress in one in one fell swoop. I had never seen anything so serious. Oh man, I'll tell you the That was one of the biggest Lessons for me. The um

36:22 During one of the weeks I was wearing. level wearing a CTM from you guys. Jenny and I were in Texas during the crazy power outages, Ice Starves, not even water, and like my blood sugars during that week versus other weeks. It it was just Unreal to see the data of like like I knew I was feeling bad. Like I was very stressed. I was very unhappy. Much higher, David, or like more spiky. Yeah, much more spiky. Not um Big spikes, big crashes. Uh, and like I saw it in my moon. I'm like, Yeah, I I'm very unhappy. I feel terrible.

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38:47 That Ben and David sent you. Josh, I wanna um Take us at a little bit of a more sort of flash forward direction here. So Folks should know that when you when you are

38:58 uh using levels today. It is an Abbott. Uh freestyle Libre. device. So we're still not to the point where you're you're not like making your own CGM at all. Um, but let's just talk about the scale of the company a little bit. Thousands of people that are customers that are wearing these things, that are using this app, that are entering their food to help understand how to correlate, oh, this meal, you know, uh precipitated this spike. So obviously that it's a company, it's a commercial enterprise now. You started a startup. How did you

39:25 come to the conclusion that hey, I actually there's a startup to be started here and I can be the consumer brand rather than just assuming, oh You know what, Abbott or whoever is gonna the the the makers of the device are gonna be successful in the consumer market. Yeah, I mean, my sort of patient zero experience with the technology was the only reason that I I paid attention here. It was just like this thing has changed my perspective. It's given me confidence in areas that I didn't previously know anything.

39:51 And it's informed me much more than a textbook would have about what's happening behind the scenes. Nutrition, exercise, sleep. and stress all in one device. So this is something that has real potential. Um but there's a huge accessibility problem. Like

40:05 It's not being used for general wellness, it's not being used for education, it's only being used post frankly, post diagnosis when someone's already sick and things have already gotten to a bad place. And the realization that You know, Across society we have an epidemic of metabolic breakdown that has largely caused by chronic lifestyle choices. So

40:26 That is the m is the key unlock is that We are breaking our bodies without feedback on the positive or negative effects of our choices. And This has led to a situation where we have ninety million people in the United States with pre diabetes.

40:41 Seventy percent of whom will convert to type two diabetes. Within their lifetime. And eighty four percent of them don't know. that they have this situation. Um, it's because we're making these chronic choices without feedback. So this was the tool, in my opinion, and and it's it's like it's powerful for post diagnosis to manage a condition, but

40:59 potentially even more powerful to prevent that next wave. So that's kinda where things started to congeal in my mind that This this could really be bring a lot of um solutions into people's lives. But

41:11 The technology alone, like the device alone. requires way too much You know, I had spent hundreds of hours, frankly, at this point pouring over research articles. It was like you can't rely on that for people to get context for what's What's coming out of the device. So it seemed like

41:25 The huge value proposition was Building an insights layer on top of this raw data. So Pull it in.

41:33 You know Aura and and Whoop and others do this now with heart rate and heart rate variability data. You know, you take a An L E D. that costs a few pennies and can measure heart rate. and you transform it into a behavior change tool.

41:47 by adding an insights layer that tells you how what factors have affected your sleep. what a recovery, you know, score looks like and why you should want to to focus, you know, in in this area of your lifestyle in order to improve it. Or another allegory would be there's a huge uh amount of code between the sensor pack that's on the back of my Apple Watch and the rings that Apple is presenting me on, you know, hey, make sure you would go on a seven minute brisk walk before bed. Exactly. Yeah. So it's the it's the difference between that Excel spreadsheet. And a a meal score saying You know, this was a a one or a nine out of ten, helping people just understand, okay.

42:23 large scale, I don't need to know the background data on how, you know, what the optimal blood sugar range is and what milligrams per deciliter are, what a postprandial peak is. I just need to know that that meal is not working as well as this other one. And so that that was the what the insight is that it's really a data science problem. It's Ideally. innovation in hardware is going to be able to drive these sensors down to a more

42:47 Commoditize space. But the value proposition is not going to improve if someone doesn't build the insights layer on top of it. to contextualize and create behavior change. So that that's where things started. It just kinda came together as like what do I wish this experience had been like rather than what it was and go build that.

43:05 Mm-hmm. So you started working on the company in like twenty seventeen, right? Yeah, it was it was actually late twenty seventeen, early twenty eighteen when I when I went full. Full bore on it. And um I'm imagining from the outside

43:18 Just think about what was going on. At that time. That was right around the time of the rise of Hims and hers and Roman and like there was this new idea out there that like hey Things that are.

43:30 You know, locked behind medical prescriptions. But that really aren't dangerous and could be beneficial to large portions of non therapeutic populations. There might be a way to get that to the public. Uh did you guys see that? Like were you thinking the same thing? How how did that Absolutely. Come about for you guys. Yeah, I mean one of the

43:49 One of your earliest issues was like, Okay. Say we build the app that provides insights, you know, can pull in CGM data. Well, nobody has CGMs and there's no way to get your hands on them. So No one's gonna even Google that thing. No one's gonna find that in the app store. We have to get

44:03 the hardware and the software together into the hands of people who want it. And that was a huge it was like Oh man, that's That's a big complicated Harry Ball of the U.S.

44:13 pain to to figure that out. 'Cause it's a you know, these were class three. regulated medical devices prescription only. So that's that's where things started was like actually the accessibility of the hardware is the problem to solve first before we can solve the behavior change issue. And companies like Hims and Roman and and others.

44:30 We're demonstrating a new model. Where you combine Telehealth capability. with um low risk products, medical products into a direct to consumer experience. And it it is a traditional practitioner, licensed physician.

44:45 reviewing information about their patient, developing patient physician relationship, and then uh a mail order pharmacy powering the whole thing. But most of that is is kind of hidden in in an experiential sense from the end user. It feels very much like ordering something online. Which is really convenient. And it you look at Romans' numbers, like, you know, they work in sexual dysfunction for men and they've got massive conversion rates that like No sexual therapeutic

45:09 physician is seeing the number of young men come to them for Viagra. at nearly the rate that Roman is. Like they they've because of the privacy and the sort of stigma, distance between yeah, it's just like there's a lot of stigma there. And so this like convenience factor and the privacy factor has

45:26 probably allowed a lot of people to improve their lives that otherwise wouldn't. So I think like that was a very unique business model that they put together. And it gave us a lot of ideas like Okay, maybe there is a way. Despite the the s sort of onerous regulations.

45:40 There is a way that we can design something that would be elegant and As close to a delightful experience as you can get while still maintaining. Regulatory ethics. And just to put a fine point on it, what you're basically saying is, yeah, people are still totally getting prescribed. The doctor is just

45:55 you know, someone that's sending them a survey and communicating over text and you know, it's happening through a web browser. It feels like an online checkout. A little more friction, as it should have, but not like You know, you don't have to go anywhere. You can do it from your your phone or computer. That's right. Yeah. So we you know, we set about developing a relationship with an independent network of physicians.

46:17 who intellectually are on board with the concept of informational uh biometrics. So using What would otherwise be used for uh management of a condition, but instead for education and awareness.

46:29 Starting there and then building the the sort of platform where we can collect the information necessary and deliver it to the physician who will then uh engage in an asynchronous electronic consultation. With that patient. And and so these are all, you know, inside of the telehealth regulations that have been that have been built and are yes, definitely similar to

46:47 The Hymns, Hers, and Romans. but you know, building it in such a way that was specific and unique to the CGM use use case. Which again this is a device Uh it's minimally invasive. It has a little filament that goes beneath the skin, but it's not a drug. You know, it doesn't have symptoms, side effects, complications, allergy considerations.

47:05 It's uh you know, the risk is quite low, especially given that the user is not managing an acute condition. So there is no situation where someone who who's using levels for in information about their diet. is going to inject insulin and potentially over inject due to faulty data. That's the situation that type one diabetes and CGM is is built upon.

47:26 Oh So what if someone says, Yeah, I am type one diabetic? Like do you say, Well, actually you you should go see a a doctor about this? Yeah, right now the software that we're building is, you know, it's not approved as a medical device. It's not approved for diabetes management. So right now, you know, we although we we are working as quickly as we can to get to the point where we could get this approved.

47:47 for you know therapeutic use as well. Today we aren't there and it's really important that people who are managing an acute condition have a close relationship with their primary care provider and all CGM data is being interpreted in a larger diabetes management context. So very very much

48:03 I think um Yeah, it's a it's a very different implementation for CGM and we will get there and I think there's Tons of lifestyle unlocked to be had. for people with diabetes still and um

48:15 Looking forward to get there, but we're not quite ready. Yeah. And so do I have it right that the regulations didn't necessarily change to enable this. It was just that several people sort of all at the same time. I know Curoogy is one of them in in sort of the uh dermatology space, obviously hi uh him's hers Roman that you've talked about. It was sort of a reinterpretation. or using technology for e to apply to existing regulations, not some new regulation that came about that made it possible.

48:43 Well, there have been some serious changes in the telehealth regulatory space actually since Covid. So much of this was Um it was already Plausible, but it wasn't clear. you know, many systems were, for example, not allowed to be used with telehealth.

48:59 When Covid rolled around Which is a you know, yeah, obviously a little bit after we had launched. We saw a huge number of I think improvements where physicians could be licensed across many states. Right now you have to be state by state licensed even to practice telehealth. You could also use the platform of choice. So if you want to engage in synchronous consultation with a patient. You can use FaceTime, or you can use Google Meet, you can use whatever whatever

49:20 platform is most convenient rather than having to use These Clunky. HIPAA compliant. Yeah, EMRs is what they're called. Yeah, where where you like have a built in web client that It it it's just very old school and it nobody has those platforms. You gotta download an application, et cetera. So we saw a lot of, I think, advancement in just

49:39 in sort of a span of an o an overnight. awareness of how much these onerous regulations are Yeah, sort of. Falling behind the times. But but yeah, prior to that, twenty eighteen, twenty nineteen

49:51 companies I've been building. inside of the those onerous regulations, but primarily leveraging asynchronous capability. So there there is many states do allow um physicians to correspond just through written communication as opposed to having to be synchronous. And that's the most convenient path for someone who

50:10 who's not managing an acute condition, it's the most convenient for them to engage in these sorts of Yeah, sort of Optional. medical product requests. And it feels like

50:21 From just like a business model standpoint, what This in that you and and other companies had uh, you know, around this time, it sort of unlocks uh really a connection of like uh a marketing uh in a whole new class of marketing like A you're marketing to a whole a wholly different customer base than Medical devices in a therapeutic sense were before.

50:42 But that enables You know, advertising is part of it, you know, or you know, but things like you know, you go on lots of podcasts and you can talk to this whole population. And now they have an experience that's not you know, it's not a you watch a T V ad for a drug and it's like talk to your doctor about so and so. It's like, No, do you would this be This is something that could be additive to your life. Just like an Apple Watch. Just like a Fitbit at a like.

51:07 And if you want to experience this product Here's an easy consumer friendly way route to do it. You don't have to go decide Yeah, I'm gonna make an appointment. I'm gonna remember to bring this up. I'm gonna it might be a little embarrassing. My doctor might make me feel weird, like Yeah. I think this goes to the to the why now question of digital health, which is

51:28 Historically. There's two ways to approach health. It's like you're either general wellness and making only general statements. You're just saying like eat healthier and work out more. Or you're going down the route of a medical experience, which is

51:43 As we all know. peppered with regulation, very complicated, inconvenient. There's quite a bit of friction there. And this is how, if you look at the space, this is kind of how the the companies kind of filter out. You've got you know, the the Lavangos and the Almadas and the the onduos and uh these are organizations that once you're past the diagnosis phase.

52:04 Well now you're in the captured audience and so it's like Your insurance will reimburse, your doctor will prescribe. Customer experience. I will say it is amazing. Uh Alertive. There's so much innovation in this space. Even if you're not going the direct consumer route, you guys have gone like what Alertive is sort of showing is. Well what if you just bring these great Like

52:25 and Omada and Lavanga, like these great consumer experiences to that sort of existing funnel population rather than the new unlock. Like th there's sort of like a dual you know, two different paths of innovation going on here. Totally. No doubt about it. There's I I think most of us just kind of avoid like it if it becomes too inconvenient, we just avoid the medical experience altogether. It's like I'll just kick the can down the road. And certain people can't, you know, it's like they have a legitimate condition. It's so it's so challenging to carry on your your day to day life and have

52:56 a healthcare issue because the system is not designed for convenience. Right. But to your point, once you're in that, like you also should have a great experience. Exactly. There's a ton of opportunity there. But You know, so it's been like You have

53:09 Superficial kind of population generalities happening in the digital health space. for the the general wellness group. And then once you're post diagnosis, you get More targeted, more consistent. information, but the friction level is so high and the

53:24 actionability of the data is just not The focus. Again, once you get into the captured I I hate using terminology like this, but it is very true. Like once you're in the captured audience, like You have a payer who's going to reimburse. You have a doctor who is gonna draw from their list of potential treatments and they're gonna diagnose and and

53:44 Prescribe. And then you, the end user, are just going to go through whatever experience has been Built. your feedback, your customer experience, your You know, you're you're frankly

53:58 Process of improvement falls behind I think where any consumer mass market consumer product would be Just because there's so many conflicting incentives in there. Yeah.

54:10 Well, you mentioned, you know, payer for folks in the audience who aren't Yeah, deep in the space, you know, we're talking about insurance companies and mostly and maybe employers, you know, occasionally. And and and the government too, with their Medicare and Medicaid, you know. And this is where You know, that sort of business model. If you're a

54:28 If you're a company, if you're a medical device company, if you're a pharmaceutical company, if you're something that's been historically operating in the therapeutic space, It's a great business. You know, this is this is why biotech, this is why medical device venture has done has been a thing for so many decades. But it's so different than the tech world where it's like you get something, you demonstrate efficacy You prove that to payers, all those categories over a long period of time. And then you basically just have a license to print money.

54:57 Forever. Right. Well it's it's uh it's classic disruptive innovation versus sustaining innovation. If you're working within this existing system, like you can make the patient experience ten times better, but you're still working within insurance companies and billing codes and existing clinics and again. can be a great business. And it takes years to get that set up where you're like, Yep, I got the code from a billing code. Now I'm you know yep. But the levels, hims, hers approach, that's the disruptive innovation. That's the thing where you're saying, like, like it's exactly Josh what what you're talking about. You bring your spreadsheet to your doctor. Or frankly, right now I'm even thinking about, okay, I have my levels data and I I I want to go like figure out if I'm diabetic. Well, I should go talk with a doctor and show him my data. I do get this sense that I'll get kind of laughed at of like, what is this toy that you're like, this is not a medical experience. Like, wa come on, don't come to me with this. Yeah, you know, again it's it comes back to

55:51 The way that the healthcare system is set up here. Is All oriented. And it it wasn't always this way.

55:58 But I've talked to many doctors who believe this is the the root. the insurance coding system changed everything. So once it became a requirement that a physician Enter a diagnostic code in order to proceed with treatment. Everything changed. It went from the nuance of an individual to if you don't fit this bucket

56:15 I can't do anything for you. And this is the reason that no one well this combined with, I think well intentioned, but overreaching Data privacy rules. have led to a situation where

56:28 No one uses their healthcare data to make a decision in their lifestyle ever. Like I can basically make that statement and feel confident about it because It's just true. You d people don't they get their blood work done once a year, maybe. You get a single point, that's extrapolated to define your health overall. And You don't use that to decide what to eat for lunch.

56:47 You y you don't know whether or not you're sleeping well. And so you have companies that are you know, they're once you're in that diagnostic coded section, it's like, all right, I get this amount of reimbursement. It doesn't matter whether my product is ten times better, I'm still gonna get that same reimbursement. So my costs go up, but You know, I don't I certainly don't get a higher Yeah the payer's not gonna pay me more.

57:05 So you have a situation where everyone's forced to conformity and you get one option. And the consumer, no matter how price insensitive they are, if they're using an insurance reimbursal route, they don't have selection choice. So I think the the future is

57:21 a situation where you're hybridizing this and you're taking really high quality information and you're going cash pay only direct to consumer and you're providing the framework to meet the regulatory requirement. But you're you're sort of working outside of the three party system. You're saying This is the this is the premium option. And if you if user experience factors into your healthcare journey or your your general wellness journey.

57:44 This is the the option that I you know, can deliver that that experience, that quality of experience. And That's certainly I think where the entire market like we're going to see

57:54 a move in this direction because that also unlocal market forces. And so now you you can have a situation where you know, economies of scale step in. prices drop and now you're genuinely competing. Like it may start out pricey. But with time, I think we can get to the point where

58:10 These Premium. you know, non reimbursed s options are are actually Price competitive. Yeah, okay, great. So let's talk about

58:19 Your business models. And uh What your guys' vision is for how this works. Well maybe to start. Can it can Can you walk us through the Just from a business model sense, how how levels works today and maybe a little bit what you're thinking about as

58:35 Next step down the road and then after that. For sure. So today we're we're still in development. So we're in what we call our beta mode. Which is invitation only. But The process is

58:46 You you get invited into the beta. And You fill out kind of a an e commerce like checkout experience. So you you pay for the program and then you move into a questionnaire process, which is a a consultation for a prescription consultation.

59:01 Intake form. And so you fill out some of the medical history required there. that gets transmitted to an in state physician. So this physician is part of a network That is wholly independent of levels. And they're licensed in the same state that you reside in.

59:14 They review your consultation form. and they determine whether or not an informational CGM is right for you, the individual. And this is entirely in the physician's hands. Levels has no control over who gets a prescription, who doesn't get a prescription. Um, and that's required for obviously ethical independence and uh the physician doesn't have any you know, requirements or quotas or anything that like that from levels.

59:36 And and so after that process and potentially an exchange of information, uh, you know, the the the physician may have extra questions that You know, they they ask the patient. It's entirely up to them. Uh, once we get a determination from the physician, we then fulfill if a prescription was uh received, we fulfill that order through our mail order pharmacy partner.

59:55 So that whole process feels very seamless to the end user and you end up um getting access to a CGM device if prescribed. And the level software. So then you go through a one month experience. where you you wear the the CGM system, you go about your life

1:00:13 The first week we recommend you don't really make any changes. You just kind of see where you are, how your body's responding to the choices you're making. the nutrition selections, the exercise you're doing, the sleep that that you're currently sustaining, et cetera.

1:00:25 um in the middle two weeks, we recommend you start exploring. So try things you maybe don't normally do. Eat different foods, sleep well, walk after meals, all of these different sort of call metabolic challenges, but Testing the boundary cases. And then the final week, the goal is to string what you've learned together.

1:00:42 into um metabolic optimization. So shoot for like your high scores. And you know, we after that one month period People have developed. metabolic awareness. So for the first time they've closed the loop between the actions they're taking

1:00:57 and the reactions their bodies are experiencing. They've they've sort of been in communication. between body and mind, um, in a way that previously wasn't possible because we don't we don't have a sensory feedback mechanism for the quality of our nutrition. Um and and so that metabolic awareness.

1:01:13 you know, they've only been practicing optimization for a week, but the lessons learned are quickly turned into habits. Um so you you kind of When you first see that a ten, fifteen minute walk after an indulgent meal Can completely modify your body's

1:01:27 ability to process that sugar. that lesson sticks with you in a way that hey You should walk after meals as general advice doesn't. Uh it's specific to you. It's grounded in objective data. And so those are the

1:01:40 Those are the little magic moments that we're looking to uncover as as often as possible. In the one month one month program we've built. Cool. And so so the one month program is a beta But

1:01:51 What I think is so interesting is like so the price to participate in the program is three hundred ninety five dollars, right? Three ninety nine, yeah. So This is what's so fascinating. This unlocks like so much. Like on the one hand, for a consumer product, that's You know, a lot of money. On the other hand.

1:02:07 There's no other way you're gonna get access to this. And is the value of learning that, you know, worth Four hundred dollars. Well, It's up to an individual person.

1:02:17 But you guys, how many you have thousands of people that have done it. twenty, thirty thousand people on a wait list. It turns out there's a large population of people out there that are willing to do this, right? Yeah, so um thus far we've had about seven thousand people go through the through the beta program and we actually have

1:02:34 uh about a hundred and five thousand people on a wait list right now trying to get in. And this is largely, you know, again, we're in we're in beta mode. We're really putting no effort into marketing. We're doing a lot of educational effort. So podcasts and our content platform is a a prime drive of attention. But yeah, the the

1:02:52 The company uh is is currently designed. We have our product effort. our content effort and our research effort. And you know, one of the core issues we're facing is that Metabolism. As a word.

1:03:04 Is not Common. Like nobody is thinking about metabolism, let alone metabolic fitness. Uh, we need to inform The world.

1:03:14 that this is something you should care about. And to do that, you we can't rely on osmosis from product experience, uh, especially if we're in invitation only mode right now. So the education effort is To build a world class content platform that helps people understand. what it means to be metabolically fit. And why that matters. So

1:03:33 You know, your your brain, your body. All the cells in in all of the tissues in you. need energy to survive and to function. And if your energetic

1:03:43 Production systems are failing. you cannot experience mental health. You cannot experience physical health. So it's truly the situation where metabolic fitness underlies physical fitness. It underlies mental fitness. And we talk about the other two, but we don't talk about the foundation. And so the the content effort is in and of itself intended to be the leading source of education about

1:04:05 Yeah, why you should care about metabolism. And then our research effort is then um kind of going to pair with our direct to consumer product to look deeper uh into mechanisms, into efficacy, into effectiveness. And so we'll take

1:04:18 the large data sets, the trends from those from our direct consumer group. We'll take the research findings and looking ahead in in the roadmap. combine that information, you know, about how people who don't yet have a a a metabolic condition to concern themselves with

1:04:34 are still improving the markers of long term risk. Through just simple behavior change in their daily lifestyle. And that I think is how we get to the point where you know, eventually

1:04:45 the consumer product is covered for uh insurance, self insured. employee programs, et cetera. So it's sort of working backwards. Oh, so you think you can get to a point where Payers. Not consumers will also be

1:05:00 Paying for levels. Yeah, you know I think So the way we're the way we're going about it. Is We're definitely

1:05:08 You know, we're starting off with the direct consumer play very deliberately. And you know, a a big part of that is that A, we're going cash pay. We need to unlock the traditional market forces. We need to like get out of the situation where the product is forced into conformity. And then You know, that will allow us to open

1:05:24 those economies of scale and drive price down. That's necessary. We we can get to the socioeconomic considerations. But Uh the second thing is like if we can please a discerning audience for a premium product. We can build an exceptional experience, you know, it's table stakes here. then I think that will ensure that the enterprise offering is well received. If we just design something for B to B

1:05:45 you know, it reimbursed. We we fall into the same trap that so many other products have. That you know, user experience doesn't matter. What matters is selling and organizational uh decision maker that this is something they should add to their offering. So by working backwards, not only will we be able to demonstrate with

1:06:01 the the data we're generating from our pay customers. that this is important and that it is helpful. will also, I think, achieve a quality of experience that we wouldn't get if we worked in the other direction, you know, going from Enterprise product to consumer product. It's almost like uh to just completely beat the Elon analogy to death. It's like

1:06:22 Level's current iteration is the model S. Very expensive. But You know, you guys have double digit millions of, you know, revenue on your wait list sitting there right now.

1:06:32 You can use that. to make the model three to bring the price down. And then you can use that. to launch the Robo Taxi fleet of get, you know, vastly expand access. Yeah, yeah, I I actually think we're even earlier. We're we're kind of

1:06:46 We're in the roadster phase. It it's expensive. It's hard to get out there. We don't have you know, huge scale, we know very well that this is the the mode we're in. But if we can satisfy the roadster crowd. we can then take that success and the the sort of economic foundation that we build Through a a secure higher higher margin business model.

1:07:06 And start to work. work down market. And you know We need to get to the model two stage. Like model three is even too expensive for most people. So looking at the environment of uh or or really the landscape of metabolic dysfunction.

1:07:19 It essentially focuses on lowest socioeconomic groups. Like it's the people who have the least ability to access the levels program who need it the most right now. And we're well aware of that. You know, it's It's a it's going to be a process in order to get to that mass market option where you have real time data informing your decisions every day. We need many things to change. You know, it's gotta be hardware innovation, it's gotta be software intelligence, it's gotta be uh regulatory improvement. Tons of different You know.

1:07:46 very complex systems have to adapt for this to happen. But Similar to what you've seen Tesla do, the entire market's adapted. I mean the whole automotive industry is different now. And that is all sort sort of building inertia towards the zero pollution future for electric vehicles and I think That's what levels hopes to do is like trigger this new market, trigger innovation, make people aware that

1:08:08 Real time data, biometric data, health data being used in our daily lives. Is the key. Two Turning around the sort of frustrating, complex, and failing medical outcomes we're seeing.

1:08:20 All right listeners. Now is a great time to thank our longtime friend of the show, ServiceNow. If you are running a large enterprise, AI agents are likely spread across every team, and deploying them is uh no longer the hard part. Yeah. The hard part is knowing what permissions they have, what employees are using them for, or what decisions AI is making. AI security for an enterprise at scale is not a small concern. Like the risks

1:08:47 Are real. Exactly. And the challenge with AI is governing it, securing it, measuring it, and making sure that it actually delivers value. That is why ServiceNow built the AI control tower. Yep, AI control tower gives enterprises a single place to see, manage, govern, and optimize AI across the entire business. And it works with Any AI, not just theirs. Every device on your network, every permission across every system.

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1:10:04 Go check out service now.com slash acquired and tell'em that Ben and David sent you. So just to play devil's advocate here a little bit like Tesla didn't just make really good software that then got shipped to a bunch of GM and Toyota cars. They redid the whole thing from scratch. So sort of a two headed question here. Like why isn't

1:10:22 Abbott and the device manufacturers building the insights layer and building the consumer platform. And then two Do you think eventually you also need to become a hardware company to really apply best in class research and push the consumer experience that you want to create? Yeah, I mean It's great question. Like

1:10:39 Tesla. kinda did start off with focusing on Taking existed the the concept was we'll take A C propulsion batteries and software, we'll combine them with Lotus. Yeah, T zero. That that didn't pan out, and I think for a number of reasons. But We we're in a better situation where The hardware is really convenient. It's really good. I mean, I've been wearing a CGM from Avidandor Dexcom for going on three years now, continuously.

1:11:03 And the biggest issue remains the insightfulness and actionability of the data. So that's where our core competency, our core focus is is centered is improving the the delta between raw data coming out of a device. And behavior change that needs to happen.

1:11:19 So for right now, I'll although there is ground to be covered on the hardware, no doubt, and I'm also looking to the future where Sensors are not just measuring one analyte, they're measuring multiple and they're doing it uh seamlessly and in combination with say su superficial metrics like pulse and body temperature, et cetera. You know, that is the direction we're moving and I think

1:11:37 We will evaluate all of the options necessary to make sure that that Future comes. True. Um, so we're not gonna stand by and just like Hey, we got great software. Like hey, anyone wanna give us great sensors too? It it'll be a situation where we're gonna joint develop and or you know. I think create the attention necessary that there is a market here.

1:11:56 But innovation has to happen to feed it. Um and certainly being hardware systems background myself. I'm I'm more than happy to get my hands dirty if necessary. I bet. And from a value capture perspective, then Like, as I think through the value chain of you're providing the insights layer and the software and the consumer experience, you're relying on other people to provide the hardware. This hardware has been

1:12:17 in development for a really long time. Like How much of what the consumer ultimately ends up paying do you get to capture versus having to pass along to the device manufacturers? So um as I touched on our program includes access and fulfillment of the CGM sensors. And uh, you know, it's kind of an all inclusive

1:12:35 product experience right now. We have pretty good margins on the order of uh fifty to sixty percent, depending on the specific for the for the one month program. We are also introducing a subscription model, which of course has lower margins driven primarily by price point driven primarily by the censored cost. And you know, and these devices are still fairly expensive. And uh so our subscription model

1:12:57 We don't make any money right now. It's it's a it's kind of a second Tier of of product offering to our our one month. Experience and One of the reasons is that

1:13:06 you know, in development mode, we want to get maximum throughput. We want maximum fresh ex fresh perspectives uh for feedback reasons. And and so we've been biasing towards the one month experience solely. uh we have been slowly but surely, you know, trickling in a subscription offering. And uh again, not making really much on on that product, but it does

1:13:26 really down select for the most intent of our members. So people who are like, I absolutely cannot stop using this. I need to subscribe. They're the ones that find the subscription offering and and get in there. And so for that user group, we're getting such high value information about who they are. why they are subscribing continually. um that that will you know, that'll inform us about

1:13:46 what a subscription has to to be to really have staying power. And we'll be starting to shift in that direction. sort of simultaneously with I expect some improvements in and unit economics for the the hardware, which I think are coming in in the next twelve to eighteen months. And I would imagine too.

1:14:03 The subscription. Part of levels. will become so important over time for for lots of reasons. You know, one just simply from a Ongoing value to your customers.

1:14:16 But also defensibility and, you know, moat uh for you guys. Uh, you know, if all of my data and all of my insights around that over a long period of time are in levels. Well, of course I'm gonna keep using uh levels. But also the it's reminding me of our um big episode on Maitwan, the Chinese super app and

1:14:37 Yeah, one of the most critical factors for Ma Toine and Surviving war on so many fronts against thousands of other companies in China. was uh the Dion Ping their reviews database. You know the the data from all of the reviews

1:14:53 Allows them to drive recommendations and insights and you know, uh of what to order for dinner or where to travel or where to book, so much better than just a flat system. I imagine for you guys too, the more data, the more ongoing data you have, the better your insights layer becomes. Yeah. You guys gotta pry my fitness pal out of uh under armor. That'd be huge to have that that sort of like auto completed auto macro filled in data set. Yeah, you know, right now we're we're definitely biasing towards low overhead for the user to log. So the the goal is actually to connect

1:15:27 The outcomes of your choices with the inputs. to you. So just surfacing a picture. reminds people, okay, what did I eat in what portion, what was the composition of that meal. And then giving them a score along with it.

1:15:39 Helps to educate them very quickly with minimal input requirement. on whether or not that was like positive or negative. And and so Those

1:15:49 Right now, like requiring macro tracking or requiring calorie counting becomes onerous and our adherents drops off quickly. So we've done a bunch of experiments with this, but I agree, like the future is to get more information from those who are willing to volunteer it. In in terms of like the sort of switching cost concept here. I think this is where our competitive advantage really lies. You know, again, we're we're focusing entirely on the data science and on the actionability, the the sort of behavior change platform. So the metrics that we're producing, which are uh composites of a number of

1:16:20 Clinical Well clinically relevant. data points about a blood sugar curve, you know, how your body responds to a meal, how quickly, how high it goes, how long you stay elevated, all of this stuff is packaged into a composite. that is is actually quite sophisticated and getting better All the time.

1:16:36 And so that's where you know the The metrics they they they turn raw data into behavior change opportunity and the majority of the value is there. So I I I do believe that as we continue to dive into the research.

1:16:49 develop the largest data set of its kind. We currently do have By coming up on an order of magnitude, the largest data set ever in non diabetic glucose, especially when paired with with lifestyle information. And we're just we're still in inv invite only beta mode. Like the opportunity when we do go to market is going to be tremendous and it will continue to allow us

1:17:08 Like you said, you know, as the data set enlarges our phenotyping will improve. So we'll be able to identify you're like this group, and these are the recommendations and insights that we can sharpen. to make it more individual, more unique and and ultimately improve. the the outcomes for each person. That's great.

1:17:24 Yeah, I mean that's so uh hey. Incredibly impressive speaks to you guys of you know building a company in a short amount of time. Uh this incredibly complex space getting to market dealing with the regulatory issues, prescriptions, getting seven thousand people through the program. But it speaks even more to just like

1:17:44 the industry and how far behind. I mean CGMs have been around for Over ten years. And that you already have the largest Yeah, CTM.

1:17:56 Data. of a population out there is It's just like that that's crazy. Yeah. It it It is. And one thing that I like to look at is just the historic

1:18:09 kind of bifurcation of the market. We've we've seen so much data generation in these and I this sounds like a derogative Derogatory term, but superficial metrics. It's like This is your your pulse count, your step count. Um, so much of our wearable data is oriented here. I think the reason that

1:18:25 Things are different now and going forward is that We've had a quiet microelectronics revolution. We've had like software eating eating the world. You know, all this stuff's been happening. Big big data analytics are getting better and better. And in the meantime, we've also had more individual individualization. um and personal ownership concepts like bubbling up. And so all this is kind of coming together into a

1:18:46 a a moment where people want to know more about themselves specifically. They don't want to know about averages. There's enough awareness that you know, just looking at twenty three and me where we we thought that a specific gene would tell you enough to to like know what what to eat for lunch. That's just not the case. It's like the uniqueness of the individual. is so multivariate that you really need

1:19:05 real time continuous feedback to know whether things are improving for you. So we're we're seeing a moment where I think all the pieces are in place. where we can decentralize the solution. So by by building large enough data sets uh obviously anonymized in order to to run research and and sharpen insights.

1:19:23 You can decentralize the actor down to the the minimum viable one, which is the individual. So rather than trying to solve Nutrition. you know, with legislation or policy, you can instead have each person solve for themselves, multiply that by enough people. And you fix the social scale problem without having to like pass some

1:19:42 complex administration package, you know what I mean? The food pyramid doesn't work. Yeah. Just look at the way things have been done historically. And all well intentioned. But the the goal is just too broad. It's to try and solve for the average person. And uh there is no such thing as the average person. Th there is the individual.

1:20:01 So Josh, before we wrap up, uh I at least have a one uh question I'm dying to ask your thoughts on. I know you don't have any inside information on on this front. Um You know, the rumor in this space has been for years that Apple is working on bringing this Technology, CGM technology, not invasively to the Apple Watch. Do you think that's gonna happen any time soon?

1:20:24 If it does, I imagine it's a huge unlock. for levels as the insight layer for this. Yeah, I I spend a lot of time diving into the future of the tech and thinking about, you know, how do we How do we set up the chessboard so that the innovations happen that need to happen.

1:20:41 So Apple's dealing with a situation where they can't break the skin. It will destroy the image of what an Apple product is. frankly. And So they have the toughest go at it. You know, we we can work with the hardware that exists, which which does go below the skin and it gives you direct interaction like that filament is interacting with molecules of glucose in your skin. It's the gold standard for measurement in real time.

1:21:03 Apple needs to solve what I consider a mechanical miracle, which is non invasive measurement of a colorless Small water soluble molecule in a fluid which is primarily water. And they have to be able to do it in concentrations and uh r resolution that is useful for people that don't have diabetes. So the fluctuations are smaller.

1:21:23 Concentrations are tight, accuracy is important. I'm hopeful. It's called Ramen spectroscopy is what I think the the technique they're working on is, and it's a light scattering technique. It's complicated. And I I've heard the rumors that, you know, the next generation of the Apple Watch will have it. If they do, I'm gonna absolutely be blown away and I'm gonna be excited because If you look historically, I mean

1:21:42 The Apple Watch is one of the best selling products of all time. And yet Apple typically delivers the hardware before the software solution. So it gives levels, like you said, the opportunity to leverage A prolific, non invasive option. And build the insights layer on top of it.

1:21:57 to help people contextualize. Um and it's something like You know, Apple's had the hardware. necessary to do exceptional sleep tracking for a long time. But they haven't. You know, they they

1:22:08 Put the hardware out there and other companies fill in the gap for for sleep contacts. And uh and so I think we would take We would take the opportunity And very quickly uh leverage that. So I think we're in a good position.

1:22:21 to benefit from really any innovation in the hardware space today. Well just I mean. Historically. Yeah, you'd think it is the best. Like every time these events now come with much less frequency. But back in the day, every time there was an Apple keynote for a new version of the iPhone with new hardware sensors. That just

1:22:39 launched an opportunity for so many companies. I mean Apple adds great cameras to the iPhone. It's like, well, that enables Instagram. You know, yeah, Apple has the camera app, but like uh other companies are gonna be the ones that Real you know, Apple's not gonna build networks on top of this. Apple's not gonna build You know, great dedicated consumer You know, software services on top of this.

1:23:01 Oh. That would be in a massive opportunity. Yeah, I I t I tend to agree and I you know Not to mention the the non invasive measurement of a molecule and that concentration, just like it opens up the space for future analytes tremendously. So that You know, that will strictly be a benefit for

1:23:16 For what we're trying to achieve, which is to uh solve the metabolic health crisis and it requires Yeah, we we didn't really touch on the the global implications, but Estimates are that thirty percent of the global population is pre diabetic and seventy percent of those will

1:23:29 will progress to type two diabetes in their lifetime. So you know, we're talking about billions of people today who are on a path towards on health, uh and and really dramatic degeneration um of their bodies. Over the next.

1:23:42 you know, ten, twenty years. So something has to change. It's gotta change soon. And you know, it's not a situation where Levels wants to like own every th every piece of that process. It's uh it's really a situation similar to the energy crisis where Everyone's gotta go all hands on deck on this thing and and w I would welcome Apple cracking this one because I think you know, we can always refine the insights they provide at scale to better

1:24:05 you know, the the outcomes for specific use cases. Totally. Yeah. Josh, this has been Awesome. Thank you so much for joining us.

1:24:15 And um For listeners, how can they get in touch with you? How can they Interact with levels, how can they get on the wait list? Yeah, um, first off Thanks so much for

1:24:28 Diving into this stuff with me. This is a really exciting conversation. It gets the wheels spinning to dive into the tricky questions. So I love it. Anyone that's interested in levels should definitely jump to the website levelshealth.com. You can sign up for the wait list right there. And also access the blog which is uh it's that

1:24:45 educational opportunity to discover what metabolic awareness is, why it's relevant, and uh kind of follow along as we introduce more um I I think insight into how the product is affecting people today and how it's helping them understand uh themselves better. And then check us out on Twitter and Instagram at Levels. And uh you can follow along, you know, in real time as people

1:25:06 Yeah, roll out their their personal insights. Cool. What about for um Members of the acquired community like uh Like Ben and Miz and others who uh

1:25:15 Might want to come work with you guys. Well, I I would love to be in touch with anyone who is uh who who hears this conversation and gets excited. Uh we do have a careers page at levels.link forward slash careers. But you know, I'll also just reach out to us through either through the acquired community to to Miz or or Ben Grinnall. I'd love to provide my uh my contact info directly to you guys to distribute to your community. So, you know, you'll end up with my email address and uh anyone that's interested, reach out directly to myself um or Sam and we'd love to talk about

1:25:46 the the scaling opportunities that we have, a lot of lot of challenges to be solved. Great. That's awesome. That sounds awesome. All right listeners. Now is a great time to talk about one of our favorite companies, Statsig. Yes, there is a reason why the best product teams rely on Statsig, whether they are iterating on their core product features or shipping AI powered experiences at scale.

1:26:11 Yeah. In the crazy speed of today's AI world. Shipping fast is just table stakes now. It's basically trivial to build and deploy your app constantly. The real advantage is how quickly you learn what changes actually created value for customers and how fast you can use that signal to guide what you ship next. This is where StatsIG comes in. It brings experimentation, feature flags, and product analytics into one unified system so teams can ship safely, test rigorously, and directly link what they changed.

1:26:42 to how users actually behaved. So if you want to make learning your competitive advantage, whether you're building new AI experiences or just evolving your existing core product, go to statsig.com slash acquired to get started. Well, listeners, thank you for coming on this health journey with us. We're excited to be diving into these new New sort of areas, uh onacquired, and hope to do more of it coming up soon.

1:27:05 Thank you guys. Listeners. We will see you next time. We'll see you next time.

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