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

Tue, 06 Apr 2021 03:57

We dive into the fast-changing world of direct-to-consumer digital health, with perhaps the best person in the world: Levels founder Josh Clemente. (Shoutout to Ben Grynol and Michael Mizrahi from our LP community for introducing us!) Levels is on a mission to make consumers everywhere aware of their metabolic health by enabling anyone to track blood glucose levels with a continuous glucose monitor. Josh has had an incredible career, working as an early engineer at SpaceX and later at Hyperloop One before founding Levels out of a very real personal need. Join our conversation as we cover everything from Josh's time at SpaceX to why the market has changed for consumer digital health, and what the future holds for Levels.

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The Levels / Digital Health Playbook:

(also available on our website at )

  1. High risk, high return - having a mentality of "we have nothing to lose" can create the high risk tolerance necessary to achieving high returns.
    • SpaceX had a "we have nothing to lose" mentality for all of its early days. Elon always reminded SpaceX employees that everyone had to personally have to succeed, or "2,000 people including you will lose their jobs."
  2. Internet-based prescription workflows have unlocked a key business model innovation for direct-to-consumer digital health.
    • The unlocking of therapeutic devices and drugs for direct to consumer cases, as pioneered by Hims/Hers, Roman, etc, has created a new age for digital health. This paradigm has shift has allowed businesses to reach patients directly without spending years (and millions of dollars) negotiating agreements with payers to get a coveted "billing code" from insurance.
  3. Often the best startup opportunities come from personal experience.
    • The story of how Josh came to found Levels illustrates the power of being patient zero of the problem you want to solve. Josh didn't start out looking for a company to start, but by self-experiments simply because he had a problem and was curious.
  4. In new categories, starting as a premium product and moving down market as costs come down is often the best strategy.
    • Tesla's "master plan" illustrates this perfectly: start absurdly expensive & impractical (Roadster), then still expensive but more practical (Model S/X), then mass-market viability (Model 3/Y).
  5. Data, data, data.
    • If you listened to our Meituan episode, you'll remember us discussing the power of Meituan's review data. Similarly, Levels moat lies in its data. Amazingly Levels already owns the world's largest collective dataset of non-diabetic glucose monitoring data, and the company is still in beta! As they amass more and more data, they'll be able to generate more personalized insights and health/lifestyle recommendations for customers.


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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 in my body. 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 in our venture fund PSL Ventures. And I'm David Rosenthal and I am an angel investor based in San Francisco. And we are your hosts. Today we have a special episode that dives deep on the dynamic digital health ecosystem, especially with the lens on the complete upending of the landscape happening 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. Where in mind 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 Grindel. 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. If you are wondering how the business models behind these new direct 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. Our presenting sponsor for this episode is not a sponsor but another podcast that we love and want to recommend called the founders podcast. We have seen dozens of tweets that say something like my favorite podcast is acquired and founders so we knew there's a natural fit. We know the host of founders well David Senra. Hi David. Hey Ben. Hey David. Thank you for joining us. Thank you for having me. I like how the group is together and then they say it's like the best curriculum for founders and executives. It really is we use your show for research a lot. I listened to your episode of the story of Akio Maria before we did our Sony episodes this incredible primer. You know he's actually a good example of why people listen to founders into acquired because all of history's greatest entrepreneurs investors they had deep historical knowledge about the work that came before them. So like the founder of Sony who did he influence Steve jobs talked about him over and over again if you do the research and I think this is one of the reasons why people love both of our shows and there's such good. Compliments is on acquired we focus on company histories you tell the histories of the individual people you're the people version of acquired and where the company version of founders listeners the other fun thing to note is David will hit a topic from a bunch of different angle. I just listened to an episode on Edwin land from a biography that David did David it was the third fourth time you've done Polaroid. I've read five biographies of Edwin land and I think I've made eight episodes of them because in my opinion the greatest such a pretty to do it my favorite entrepreneur personally is Steve jobs and if you go back and listen to like a 20 year old Steve jobs he's talking about Edwin lands my hero. So the reason I did that is because I want to find out like I have my heroes who were their heroes and the beauty of this is the people may die but the ideas never do and so Edwin land had passed away way before the apex of apple but Steve was still able to use those ideas and now he's gone and we can use this ideas and so I think what you're doing what founder trying to do as well is find the best ideas in history and push them down the generations make sure they're not lost history love that well listeners go check out the founders podcast after this episode you can search for it in any podcast player lots of companies that David covers that we have yet to dive into here on acquired so for more indulgence on companies and founders go check it out. Now onto our interview with Josh Clemente from levels so Josh welcome to acquired super happy to be here this is going to be so fun were excited to have you David and I are both right around the one month mark David I think just finish using levels for his first month I'm about to cross that threshold and so many insights so much fun to learn all this really cool company founded. And I think you guys are maybe winning for as a 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 trophy I will hold proudly well Josh I'd like to start with your background because before levels you were doing some crazy interesting stuff and I want to dive into unpack some of that a little bit because you know we would like to have you as a guest on acquired even if you're not going to do it. So let's start in sort of the the SpaceX and Elon chapter of the world working on hyper loop. First of all can you explain to us what you worked on at SpaceX. Yeah I entered SpaceX as a manufacturer engineer so I was fresh out of school I only really wanted to work for Elon when I had graduated and I did not have I didn't have that job lock down so I actually sold used cars at car max for like three months and I just kind of like hung on to hope and work my network like crazy to try and get in. Wow did you did you call the email Elon like how I called 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 and they shut down the design office I was going to work at and relocated and basically we're like sorry we don't have a space for you so we'll do this again sometime. So I was just like well how about SpaceX you know can you help me get in there and what's crazy is that I actually out of pure coincidence my uncle met Elon he ended up being working with Toulouse Rylee Elon's former wife's father and he like met Elon and it's like oh my my you know nephew is really interested in your company is like didn't really know who Elon was had no context whatsoever and just like dropped a name and I don't really know but like at some point I was like I'm not sure if I'm going to do it. I know 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 beyond just that in person but put in like an email good word as well 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 primarily focused on taking the concepts that have been designed 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 with I think I was employee like 678 and it was just a big empty building which is 10 times smaller than it is today. Yeah so when I left it was probably around 5500 people and it's now yeah easily 7000 and growing so it was it was very much the Wild West days I mean like you're you're taking these components that have been 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 engineers it was focused around designing process 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 learning a lot from the existing technology. And just like the hands on process of of building aerospace components and I spent a ton of time down at Cape Canaveral just getting launch articles so like once the vehicle was prepared for flight it was then integrating all the final systems putting it through wet dress and static fire and then watching it go to space so it's just pretty wildly educational and from there I moved into what's called a responsible engineering position your responsible and then there is no other individual to point to and so I was going to do that. And so I was able to point to and say we didn't succeed it's your fault you know it's the box stops your type role and so I worked there on a few structural systems and finally about halfway through my career at space X we started to we had succeeded at getting the cargo vehicle through its cots program and we were starting on the human rated program at space X and so this required a life support system to be developed and space X had obviously no human rated experience and I was one of the first four employees who had the opportunity to work in that department and you know I I look at that project as for sure the pinnacle of my experience at space X I mean the team was just unbelievable some of the best people I've ever met and had the opportunity to work with. And I got to lead the pressurized life support systems team so this is developing the oxygen breathing system so the pressurized tanks that go in the vehicle that that carry high pressure oxygen distributed regulated down to lower pressures into the cabin into the space suits sensing oxygen concentrations 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 international space station in the dragon capsule after docking kind of all of these pneumatic pressurization mechanisms and size able to lead that small team amazing team through to completion of the critical design or the phase. That's great and as we know now you know dragon cargo and dragon crew have both successfully gone up so must be crazy cool to see you know your work in action there. Yeah I mean it's pretty surreal to be honest it felt like an impossible amount of time away always and then all of a sudden it's it's happened in a work and it's just such a huge you know it's how bad the stress is still high there's going to 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 in breathing room I feel like. Okay so Josh before diving into the next chapter of your career and and founding levels we got to ask like is there a fun Elon story that that you've got or something crazy that everything that happens when you're working at space at space X I'm sure it's crazy but anything you want to share I think one moment that always just reminds me of the kind of the unique culture of space X was really the first major launch so I got two space X just after they flew the Falcon 9 1.0 rocket for the first time so basically space X failed three times to get the Falcon 1 rocket into orbit the fourth time it was successful then on the first try they got the larger Falcon 9 rocket into orbit so I got there just after that that success so the second Falcon 9 rocket was getting ready to launch and you know at this time the duration between launches was on the order of years and so everyone was working full time basically hand building a vehicle so we we had this machine this entire like integrated first and second stage on the launch that bad and there was an air conditioning vent that basically condition the interstage it's basically the 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 nozzles 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 but it's very well supported this 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 interstage to keep it purging and we noticed during inspections that the skirt had actually been fluttering in the high pressure sort of air source and it actually torn and this was a really big problem of course for a number of reasons just debris and also efficiency loss in the engine the typical approach in old aerospace would be break everything down deintegrate push the schedule out analyze everything determined why this failure happened press release redesign the space X approach was Elon calls up one of the lead technicians in the entire company his name is Kelly and he used to basically work on on airplanes and was an airplane mechanic but the guy was just an absolute machine and brilliant and Elon convinces him to get on an airplane to Cape Canaveral with a pair of sheers go up in an extremely tall genie boom this guy is terrified of ice by the way crawl through a hole in the interstage which is about yay big into an integrated stacked rocket right so you're 100 plus feet off the ground there's a second stage above you and use the essentially bombs below you and bombs above you yeah now it wasn't fueled up at the time but certainly was you know 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 propulsion analysis to ensure that the second stage would have what it took to get to orbit even with the loss of efficiency with the smaller skirt but you know basically Kelly hand trimmed this thing in the interstage walking around on the dome of 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 Kelly pulled it off part of the funny thing was that as an airplane mechanic Kelly was like this is a little bit scary actually but he was terrified to fly like he just he hated airplanes I think he seemed too much 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 to get on an airplane to go to Cape Canaveral in the first but I think it just speaks to the scrappiness 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 10,000 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 this kind of goes to psychology generally but people are are either 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 so SpaceX wasn't a we have nothing to lose mentality for the entirety of its kind of early days and so it's basically like we're either going to run out of money and not get this contract and cease to exist or we're going to slice this thing off with scissors and try and that's kind of like the approach was we were always one launch away one launch failure away from from losing the company you know until probably 2014 once Falcon 9 1.1 flu we got 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 2000 people are going to lose their jobs including you and I mean he would he would not mince words and I think that old aerospace had kind of been resting on its laurels in a sense but also combined with the failures of the shuttle program was in 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 you know failure is not an option in old space and it 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 yeah it's such a good point yeah we can talk about this forever but I I got to 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 David and I sitting across the the internet from you wearing this how did it come to be it kind of started at SpaceX and partially in a good way partially in a bad way but I I kind of hit a total burnout wall in the late part of 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 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 working out as hard as possible as a crossfit you know I was a trainer but I didn't really train people I would just I would train myself and I got to imagine this was pretty common at SpaceX or at least doesn't look like you want to much to this day yeah there's definitely one of the you know it's it's a classic I think startup environment where everyone wants to be the hardest worker and you give a bunch of people who are who don't like to fail an impossible deadline and they're just going to like the failure most going to be them they're just going to 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 was just you know kind of doing I had been doing this for my entire career at SpaceX I think there's a compounding return and we can touch on this you know as it relates to metabolic health in a little bit but I had gotten to the point where I woke up one day and was just like I think I have a terminal illness like I have zero energy my mood is always low I am not I'm not the optimistic like sort of happy person I think I am anymore and I don't know what change but I just constantly 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 siblings from from hating me in my significant other from from walking away you know it was that degree of like something is wrong here and I was getting these bouts of fatigue that were truly symptomatic like I would be 11 30 in the morning and I would feel this like shakiness and cold sweat and kind of a whole body tingling or itchiness type sensation and I would just need to like sit down and so I was like am I about to pass out I had never passed out 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 and so anyway I this was kind of 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 you know something that divers and astronauts could potentially face in the failure scenario is a high pressure high oxygen concentration environment and what actually happens there is because oxygen is such a reactive molecule you can generate a huge amount of 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 forever you know they only have a short period of time so you know I'm kind of thinking about failure scenarios like 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 from Dominic Diagostino who's a ketogenic researcher at University of South Florida and this paper described a series of studies he did on rodents where they fed rodents a ketogenic diet actually gave them exogenous ketones as well as feeding them just a high fat diet and then initiated is basically almost zero carbs zero sugar the only macronutrient reading are our fats and proteins exactly so 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 cross the blood brain barrier so typically the brain is fueled by sugar glucose solely and traditional fatty acids can't cross that barrier so ketones can so they are a brain energy source and they you know in this study he gave these rodents a ketogenic diet and then submitted them to a high oxygen high pressure environment and the result was that these rats could live up to five times longer without seizure just because of the 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 it didn't matter what you ate if you worked out hard enough it was all just energy in the end right it's all thermodynamics you know that you're in a closed system so why should you know like you should be able to burn it off right just an equation and so there 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 what is going on here how is this possible and that was like the first moment where I started to think what superpowers can be unlocked with dietary selection and what am I doing to select 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 like 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 as I'm approaching the end of my time at SpaceX I'm still getting these like extremely weird kind of stress and used or I don't know if 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 work out really hard I've got a decent amount of muscle I can run fast but I don't feel healthy so you know clearly there's there's a difference between the way you look and how healthy you are or perceive yourself to be and so that's when I started self experimenting and you know my goal is to understand you know where my energy is coming from and how to optimize it and so the primary energy molecule in the modern human is glucose it's you know it's the the sugar byproduct of carbohydrate breakdown and I started I got a finger prick glue cometer it's called it's this little device you prick your finger bleed on a strip and you can get a single data point you're in the the equivalent of Elon on the plane back from Russia building the excel spreadsheet yeah I think like hey guys I think we can I think we can put the put something 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 was it was like what is glucose was step one and then okay how do I gather this information into a like an insight basically I'm having these energy issues and the energy is coming from these macronutrients I'm not in the key to ketogenic state which means my energy they're 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 CVS and freaking my finger so I'm going to try to learn something here started freaking my finger got very obsessed with it started doing it like 60 times a day at one crazy point and then I was plotting the numbers in excel to like kind of emulate a continuous data source the problem was at this point I started sleeping more as I was tapering down my my space x work and and moving into hyper loop to can touch on the minute but so 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've basically got point cloud in the morning point cloud in the evening 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 biosensors yeah would they on the market yet or was this still before the Libre index so you know CGMs continuous glucose and I have been available in you know kind of trickling from the research like lab environment through to just therapeutic research studies the first one kind of came out actually is an early Dexcom or a metronik those came out in the kind of 2006 to 2010 time frames they've been out for some time but there hasn't been a mass market move until right around this time so 2017 the freestyle Libre from Abbott hit the market and so this is this is 2017 it was like just coming out and the price point was good and there had been Dexcom G5 and G4 prior to that but they were like you know a thousand plus dollars a month minimum and very hard to get yeah and Dexcom is its own it was a startup started to build a continuous glucose monitoring device for a diabetic therapeutic purpose exactly so at this time you know really even now all continuous glucose monitors have been developed for the sole purpose of measuring blood sugar so that you can manage diabetes Dexcom they only do one thing they develop continuous glucose monitoring sensors for type 1 diabetes they're starting to move into type 2 the difference between type 1 and type 2 is that type 1's an autoimmune condition primarily where the pancreas stops producing insulin and insulin is the hormone that is it acts like a key to open the lock in your cells and let glucose in so insulin is a signaling hormone and when the pancreas stops producing it blood sugar level start to go very high and it can be in when glucose gets very high similar to that oxygen scenario it's a reactive molecule you start getting tissue destruction so type 2 diabetes is considered more of a chronic lifestyle illness 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. 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 actually potentially an adaptive response where your body's kind of designed we've been historically in a certain range of blood sugar values and that's where you want to stay and if we're constantly jamming more glucose into the system then it was kind of designed for the you require more insulin than your design for so the devices have been developed for this condition for for diabetes specifically which is very acute type 1 is very acute type 2 is kind of a longer you know sort of time frame where it's a specter it's a spectrum exactly it can get extremely acute totally I think they're both acute frankly but type 1 is it's a situation where if you if you don't use insulin exogenous injected the damage is happening much faster and you know the effects are very immediate type 2 tends to be you know semi controlled in the sense the glucose levels won't go as high because there is still some insulin feedback. So this is where the devices have been primarily focused and so 2017 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-pricing my fingers are black and blue and I still haven't discovered anything so I went to my doctor and I was like hey you know check out my spreadsheet you know like I'm picking my finger on I'd love to get a CGM and he was like dude you are one of the healthiest people I see if you if you saw the people who need that device you'd kind of be ashamed to ask for it like that's that's for people who have a disorder you're like yeah I'm trying to not get a disorder here so that was my I was like kind of surprised by that response I thought well firstly I mean if you look at systems generally like you measure what you don't want to fail like you don't just measure the thing that is broken because that's obviously useless at that point so in systems in your especially complex systems you get as much data as you can and you observe failure modes as they develop 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 had not known about at the time or had not not known about prior but it was aware of at the time I was like well this is just you know it's just me trying to learn more about myself and like understand if there's something going on in my metabolic system and yeah my my physician was just totally opposed and was not willing to to get me access to a CGM well this is and this is what we what do the things we really wanted to explore on this episode with you is like this disconnects it feels looking at this industry like this huge disconnect developed between uses in a therapeutic sense as like medical interventions for your doctor's totally right like there were there are people out there who need this way more than you do but that's so zero some thinking right like you know just because giving you access to a CGM isn't going to prevent somebody else from getting that to so how did how did the light bulbs start going off about like well hey maybe maybe this can be a consumer device too like well I know eventually after trying for several months I was able to get a CGM but it was through a friend of mine who brought one back from elsewhere where they're over the counter so he he actually went to Australia and through some of the backpack where 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 picking my finger didn't have any insights at put the CGM on and was instantly blown away by how bad things were my blood sugar was essentially you know it looked much more like a heart rate trace than a blood sugar trace and huge spikes huge crashes everything I was doing all of the meals I was consuming were putting me above what would be considered the pre diabetic post-prandial thresholds so where your glucose should be after a meal and oftentimes very often well into the diabetic range and so I my body was not managing blood sugar spikes effectively it was able to bring them back so it's not like I was you know diabetic and I lost control but it seemed to be like blood sugar would go very high body would release a ton of insulin overcompensate I'd have these precipitous crashes and I was able to just immediately I you correlate those crashes with the sensations I have been having where the shaking is the hunger the irritability was all perfectly facing and just by tuning you know within two weeks I had tuned my approach diet just like trial and error on on the meals I was eating and was able to bring those huge spikes down to 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 large servings of sweet potatoes brown rice keenwa I was having huge you know again in the diabetic range responses to which was highly counterintuitive I thought you know I'm a person who's like 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 anymore I was in college but so just this realization that things were going haywire and it was it was the things that I thought I was doing well that we're causing these huge you know inconsistencies I mean 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 healthy you you know the goal of this is to see like what your normal stuff does and I have recently worked in like no sugar just like steel cut oatmeal into my diet and I think it wasn't actually steel cut it was like the quaker hole out but it was advertised as whole and like it was wild how much that spiked my blood sugar afterwards it was like I just like a holy bad yeah through a ton of gushers in my mouth or something and I was staring at like okay I guess that's not as good for me as I thought it was absolutely and I mean oatmeal is a prime example so you 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 one of the worst foods in the data set was oatmeal so like something like 70 plus percent of people that were eating oatmeal well using levels had you know exceeded that that prediabetes threshold was 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 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 is it's connected with negative heart outcomes and so it draws into question how these how hard healthy it really 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 a realization you know I'm using this device which basically just spits out raw data gives you like you're at 88 right now and at least gives you an error 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 is 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 used in my life and that's really the realization was just this thing was hard to get and it's completely transformed my approach to life so I'm a person who cares about health but never knew the effects of cortisol right I had been stressed for a few years and personally sitting through a meeting you don't say the festival meeting sitting through a stressful meeting with the CGM on and seeing without calories my blood sugar exceed 145 milligrams per decilator which is the the post-pran deal kind of threshold for kind of a prediabetic response changed my perspective on stress in one in one fell swoop I'd never seen anything so serious oh man I'll tell you the that was one of the biggest lessons for me the during one of the weeks I was wearing level wearing a CGM for me guys Jenny and I were in Texas during the crazy power out into the ice storm's not even water and like my blood sugar is during that week versus other weeks 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 much more spiky not big spikes big crashes and like I saw it in my moon I'm like yeah I'm very unhappy I feel terrible and like there it is in the data Josh I want to take us in a little bit of a more sort of flash forward direction here so folks should know that when you when you are using levels today it is an habit freestyle Libre device so we're still not to the point where you're not like making your own CGM at all but let's just talk about the scale the company a little bit thousands of people that are customers that are wearing these things are using this app that are entering their food to help understand how to correlate oh this meal you know precipitated this spike so obviously it's a company it's a commercial enterprise now you started to start up how did you come to the conclusion that hey I actually there's a start up to be started here and I can be the consumer brand rather than just assuming oh you know what Abid or whoever is going to the makers of the device are going to 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 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 but there's a huge accessibility problem like 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 is largely caused by chronic lifestyle choices so that is the key unlock is that we are breaking our bodies down over decades without feedback on the positive or negative effects of our choices and this has led to a situation where we have 90 million people in the United States with pre diabetes 70% of whom will convert to type 2 diabetes within their lifetime and 84% of them don't know that they have this situation it's because we're making these chronic choices without feedback so this was the tool in my opinion and it's powerful for post diagnosis to manage a condition but potentially even more powerful to prevent that next wave so that's kind of where things started to congeal in my mind that this could really bring a lot of solutions into people's lives but the technology alone like the device alone requires way too much so I spent hundreds of hours frankly at this point pouring over research articles and it was like you can't rely on that for people to get context for what's coming out of the device so it seemed like the huge value proposition was building an insights layer on top of this raw data so pull it in and you know aura and whoop and others do this now with heart rate and heart rate variability data and led that costs a few pennies and can measure heart rate and you transform it into a behavior change tool 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 focus you know in this area of your lifestyle in order to improve it or another allegory would be there's a huge 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 difference between that Excel spreadsheet and a meal score saying you know this was a one or a nine out of ten helping people just understand okay 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 desk leader are what a post-pran deal 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 the inside is that it's really a data science problem it's ideally innovation and hardware is going to be able to drive these sensors down to a more commoditized 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 just kind of came together as like what do I wish this experience I'd been like rather than what it was and go build that 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 full boring and I'm imagining from the outside just think about what was going on at that time that was right around the time of the rise of hymns and hers and Roman and like there was this new idea out there that like hey things that are 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 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 one of the 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 going to even Google that thing no one's going to find that in the App Store we have to get 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 pain to figure that out because 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 hymns and Roman and others were demonstrating a new model where you combine telehealth capability with low risk products medical products into a direct consumer experience and it is a traditional practitioner licensed physician reviewing information about their patient developing patient physician relationship and then a male 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 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 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 you it's just like there's a lot of stigma there and so this like convenience factor in the privacy factor has probably 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 sub sort of owner's regulations there is a way that we can design something that would be elegant and as close to a delightful experiences you can get while still maintaining regulatory ethics and just to put a fine point at it what you're basically saying is yeah people are still totally getting prescribed the doctor is just you know someone that's sending them a survey and communicating over text and you know it's happening through a web browser that feels like an online checkout 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 who intellectually are on board with the concept of informational biometrics so using what would otherwise be used for management of a condition but instead for education awareness starting there and then building the sort of platform where we can collect the information that's necessary and deliver it to the physician who will then engage in 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 in our yes definitely similar to the hymns hers and romans but you know building it in such a way that was specific and unique to the CGM use case which again this is a device 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 it's you know the risk is quite low especially given that the user is not managing in a cute condition so there is no situation where someone who who's using levels for 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. Oh so what if someone says yeah I am type one diabetic like do you say well actually you you should go see 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 for you know therapeutic use as well today we aren't there and it's really important that people who are managing in a cute 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 I think you know 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 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 cureology is one of them in in sort of the dermatology space obviously him's hers Roman that you've talked about it was sort of a reinterpretation or using technology for to apply to existing regulations not some new regulation that came about that made it possible well there have been some serious changes in the telehealth regulatory space actually since covid so much of this was it was already plausible but it wasn't clear you know many systems were for example not allowed to be used with telehealth when covid rolled around which is a you know 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 platform is most convenient rather than having to use these clunky HIPAA compliant yeah EMRs is what they're called yeah we're where you like have a built-in web client that it's just very old school and nobody has those platforms you got to download an application etc so we saw a lot of I think advancement and just in sort of a span of an overnight awareness of how much these owner regulations are you know sort of falling behind the times but but yeah prior to that 2018 2019 companies had been building inside of the those owner regulations but primarily leveraging asynchronous capability so there is many states do allow physicians to correspond just through written communication as opposed to having to be synchronous and that's the most convenient path for somebody who's not managing in a queue condition it's the most convenient path for them to engage in these sorts of you know sort of optional medical product requests and it feels like from just like a business model standpoint what this in say that you and other companies had a you know around this time it's sort of unlocks really a connection of like a marketing you know a whole new class market like a you're marketing to a whole a wholly different customer base then medical devices in a therapeutic sense were before but that enables you know advertising is part of it you know or you know by things like you know you go on lots of podcasts you can talk to this whole population and now they have an experience that's not you know it's not a you watch TV 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 fit bit of the like 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 going to make an appointment I'm going to remember to bring this up I'm it might be a little embarrassing my doctor might make me feel weird like yeah I mean I think this goes to the to the why now question of digital health which is 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 workout more or you're going down the route of a medical experience which is 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 company's kind of filter out you've got you know the the lavongos and the omadas and the the and duos and these are organizations that once your pass the diagnosis phase will 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 with there's a PSL ventures company that we've invested in and there's so much innovation in this space even if you're not going the direct consumer route you guys have gone like what alert of is sort of showing is well what if you just bring these great like an omada and the long ago like these great consumer experiences to that sort of existing funnel population rather than the new unlock like there's sort of like a dual you know two different paths of innovation going on here totally no about it there's I think most of us just kind of avoid like if it's becomes to an 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 day to day life and have a health care 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 it's so it's been like you have superficial kind of population generalities happening in the digital health space for 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 action ability of the data is just not the focus again once you get into the captured 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 going to draw from their list of potential treatments and they're going to diagnose and and prescribe and then you the end user are just going to go through whatever experience has been built and it's like your feedback your customer experience your you know you're frankly process of improvement falls in the background I think where any consumer mass market consumer product would be just because there's so many conflicting incentives in there yeah well you mentioned you know payer for folks in the audience who aren't deep in this space you know we're talking about insurance companies and mostly and maybe employers you know occasionally and and the government to with your Medicare Medicaid you know and this is where you know that sort of business model if you're a 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 this 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 for right like it's it's it's classic disruptive innovation versus sustain 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 setup for you're like yeah I got the code from the billing code now I'm you know yeah yeah but the level's him's hers approach that's the disruptive innovation that's the thing where you're saying 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 want to go like figure out if I'm diabetic well I should go talk with a doctor and show 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 come on don't come to me with this yeah you know again it's it comes back to the way that the healthcare system is set up here is all oriented and it wasn't always this way but I've talked many doctors who believe this is the the route 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 she went from the nuance of an individual to if you don't fit this bucket 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 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 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 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 sections like all right I get this amount of reimbursement it doesn't matter whether my product is ten times better I'm still going to get that same reimbursement so my costs go up but you know I don't I certainly don't get a higher the payer is not going to pay me more so you have a situation where everyone's forced to conformity and you get one option and the consumer no matter how price and sensitive they are if they're using an insurance reimbursement route they don't have selection choice so I think the the future is a situation where you're hybridizing this and you're taking really high quality information and you're going cash pay only direct 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 health care journey or your general wellness journey 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 a move in this direction because that also unlocks traditional market forces and so now you 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 these premium you know non reimburse options are actually price competitive yeah okay great so let's talk about your business model at levels and what your guys vision is for how this works maybe to start can can can you walk us through just from a business model sent how how levels works today and maybe a little bit what you're thinking about is 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 you get invited into the beta and you fill out kind of an e-commerce like checkout experience so you pay for the program and then you move into a questionnaire process which is a consultation for a prescription consultation 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 their license in the same state that you reside in they review your information 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 and that's required for obviously ethical independence and the physician doesn't have any you know requirements or quotas or anything like that from levels and so after that process and potentially an exchange of information you know the the physician may have extra questions like you know they they ask the patient to entirely up to them once we get a determination from the physician we then fulfill if a prescription was received we fulfill that order through our mail order pharmacy partner so that whole process feels very seamless to the end user and you end up 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 the first week we recommend you don't really make any changes you just kind of see where you are how your body is responding to the choices you're making the nutrition selections the exercise you're doing the sleep that you're currently sustaining etc. 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 metabolic challenges but testing the boundary cases and then the final week the goal is to string what you've learned together into 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 and the reactions their bodies are experiencing they've sort of been in communication between body and mind 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 and and so that metabolic awareness you know they've only been practicing optimization for a week but the lessons learned are quickly turned into habits so you kind of when you first see that a 10-15 minute walk after an indulgent meal can completely modify your body's 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 it's specific to you it's grounded in objective data and so those are the those are the little magic moments that we're looking to uncover as often as possible in the one one one month program we've built. Cool and so the one month program is a beta but what I think is so interesting is like so the price to participate in the program is $395 right 399 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 there's no other way you're going to get access to this and is the value of learning that you know worth $400 well it's up to an individual person but you guys how many you have thousands of people that have done it 2030 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 thus far we've had about 7000 people go through the through the beta program and we actually have about 105 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 prime driver of attention but you know the the company 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 is not common like nobody is thinking about metabolism let alone metabolic fitness we need to inform the world that this is something you should care about and to do that you we can't rely on osmosis from product experience 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 you know your your brain your body all the cells in all of the tissues in you need energy to survive and to function and if your energetic 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 yeah why you should care about metabolism and then our research effort is then kind of going to pair with our direct consumer product to look deeper into mechanisms into efficacy into effectiveness and so we'll take the large data sets the trends from those from our direct consumer group we'll take the research findings and looking ahead in the roadmap combine that information you know about how people who don't yet have a metabolic condition to concern themselves with 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 the consumer product is covered for insurance self-insured employee programs etc so it's sort of working backwards oh so you think you can get to a point where payers not consumers will also be paying for levels yeah you know I think so the way we're the way we're going about it is we're definitely you know we're starting off with the direct consumer play very deliberately and you know a big part of that is that a we're going cash pay we need to unlock the traditional market forces we need like get out of the situation where the product is forced into conformity and then you know that will allow us to open those economies of scale and drive price down that's necessary we can get to the socioeconomic considerations but 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 designed something for B2B you know reimburseal we fall into the same trap that so many other products have that you know user experience doesn't matter what matters is selling an organizational 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 the the data we're generating from our paying 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 a to just completely beat the Elon analogy to death it's like levels current iteration is the Model S very expensive but you know you guys have double digit millions of you know revenue on your weightless sitting there right now you can use that to make the Model 3 to bring the price down and then you can use that to launch the robot taxi fleet of get you know vastly expand access yeah yeah I actually think we're even earlier we're kind of we're in the Roadster phase it's expensive it's hard to get up 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 secure higher margin business model and start to work work down market and you know we need to get to the Model 2 stage like Model 3 is even too expensive for most people so looking at the environment of or really the landscape of metabolic dysfunction it essentially focuses on lowest socio economic 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 got to be hardware innovation it's got to be software intelligence it's got to be regulatory improvement tons of different you know very complex systems have to adapt for this to happen but similar to what you've seen Tesla do the entire markets adapted I mean the whole automotive industry is different now and that is all sort of building inertia towards the zero pollution future for electric vehicles and I think that's what levels up to do is like trigger this new market trigger innovation make people aware that real-time data biometric data health data being used in our daily lives is the key to turning around the sort of frustrating complex and failing medical outcomes we're seeing so just to play devil's advocate here a little bit like Tesla didn't just make really good software that they got shipped to a bunch of GM and Toyota cars they read the whole thing from scratch so sort of a two-headed question here like why isn't 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 a great question like Tesla kind of did start off with focusing on taking the the concept was we'll take AC propulsion batteries and software we'll combine them with Lotus yeah the two zero 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 Abbott and or Dexcom for going on three years now continuously 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 delta between raw data coming out of a device and behavior change that needs to happen so for right now 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 seamlessly and in combination with say superficial metrics like pulse and body temperature etc you know that is the direction we're moving and I think we will evaluate all of the options necessary to make sure that that future comes true so we're not going to stand by and just like hey we've got great software like anyone want to give us great sensors too it'll be a situation where we're going to join develop and or you know I think create the attention necessary that there is a market here but innovation has to happen to feed it and certainly being hardware systems background myself I'm I'm more than happy to get my hands dirty if necessary my bet and from a value capture perspective than like as I think through the value chain of you're providing the insights layer in the software and the consumer experience you're relying on other people to provide the hardware this hardware has been 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 as I touched on our program includes access and fulfillment of the CGM sensors and you know it's kind of an all inclusive product experience right now we have pretty good margins on the order of 50 to 60 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 sensor cost in you know and these devices are still fairly expensive and so our subscription model we don't make any money right now it's it's a it's kind of a second tier of product offering to our one month experience and one of the reasons is that in development mode we want to get maximum throughput we want maximum fresh fresh perspectives for feedback reasons and and so we've been biasing towards the one month experience solely we have been slowly but surely you know trickling in a subscription offering and again not making really much on on that product but it does 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 that that will you know that'll inform us about 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 hardware which I think are coming in in the next 12 to 18 months and I would amend into the subscription part of levels will become so important over time for for lots of reasons you know one just simply from an ongoing value to your customers but also defensibility and you know vote for you guys 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 going to keep using levels but also the it's reminding me of our big episode on me to on the Chinese super app and you know one of the most critical factors for me to on in surviving war on so many fronts against thousands of other companies in China was the DNPing their reviews database you know the the data from all of the reviews allows them to drive recommendations and insights you know what to order for dinner where to travel or where to book so much better than just a flat system I imagine for you guys to the more data the more ongoing data you have the better your insights layer becomes yeah you guys got to pry my fitness pal out of under the huge to have that that sort of like auto completed auto macro filled in data set yeah you know right now we're definitely biasing towards low overhead for the user to log so the the goal is actually to connect the outcomes of your choices with the inputs to you so just surfacing a picture reminds people okay what did I eat and what portion what was the composition of that meal and then giving them a score along with it helps to educate them very quickly with minimal input requirement on whether or not that was like positive or negative and and so those right now like requiring macro tracking or requiring calorie counting becomes onerous and our adherence 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 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 action ability the the sort of behavior change platform so the metrics that we're producing which are composites of a number of 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 and so that's where you know the the metrics they they turn raw data into behavior change opportunity and the majority of the value is there so I I do believe that as we continue to dive into the research 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 in by only beta mode like the opportunity when we do go to market is going to be tremendous and it will continue to allow us like you said you know as the data set enlarges our phenotyping will improve so 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 yeah I mean that's so a incredibly impressive speaks to you guys of field of building a company in a short amount of time this incredibly complex space getting to market dealing with these are the regulatory issues prescriptions getting 7000 people through the program but it speaks even more to just like the industry and how far behind I mean CGMs have been around for over 10 years and that you already have the largest data set of non diabetic CGM 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 kind of bifurcation of the market we've we've seen so much data generation in these and I this sounds like a drug of drugatory term but superficial metrics it's like this is your your pulse count your step count so much of our wearable data is oriented here and I think the reason that 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 data analytics are getting better and better and in the meantime we've also had more individual individualization and personal ownership concepts like bubbling up and so all this is kind of coming together into 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 23 and me where we we thought that a specific gene would tell you enough to like know what what to eat for lunch and that's just not the case it's like the uniqueness of the individual is so multivariate that you really need real time continuous feedback to know whether things are improving for you so 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 obviously anonymized in order to to run research and and sharpen insights you can decentralize the actor down to them 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 complex administration back you know I mean obviously the food pyramid doesn't work yeah yeah you I mean just look at the way things have been done historically and all well intentioned but the goal is just to brought it's to try and solve for the average person and there is no such thing as the average person there is the individual so Josh before we wrap up I at least have a one question I'm dying to ask your thoughts on I know you don't have any inside information on on this front 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 going to happen anytime soon if it does I imagine it's a huge unlock for levels is the inside layer for this yeah 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 so apples 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 interact like that filament is interacting with molecules of glucose in your skin it's the gold standard for measurement in real time 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 resolution that is useful for people that don't have diabetes so the fluctuations are smaller 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 going to absolutely be blown away and I'm going to be excited because if you look historically I mean 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 to help people contextualize and it's something like you know apples had the hardware necessary to do exceptional sleep tracking for a long time but they haven't you know they they put the hardware out there and other companies fill in the gap for for sleep context and and so I think we would take we would take the opportunity and very quickly leverage that so I think we're in a good position to benefit from really any innovation in the hardware space today what just I mean historically you know the kids invest 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 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 other companies are going to be the ones that real you know Apple's not going to build networks on top of this Apple's not going to build you know great dedicated consumer you know software services on top of this that would be a massive opportunity yeah I tend to agree and you know not to mention the non invasive measurement of a molecule in that concentration just like it opens up the space for future analytes tremendously so that you know that will strictly be a benefit for for what we're trying to achieve which is to solve the metabolic health crisis and it requires you know we we didn't really touch on the the global implications but estimates are that 30% of the global population is pre-diabetic and 70% of those will 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 unhealth and and really dramatic degeneration of their bodies over the next you know 10 20 years so something has to change it's got to change soon and you know it's not a situation where levels wants to like own every every piece of that process it's it's really a situation similar to the energy crisis where everyone's got to go all hands on deck on this thing and I would welcome Apple cracking this one because I think you know we can always refine the insights they provide at scale to better you know the the outcomes for specific use cases totally well Josh this has been awesome thank you so much for joining us and 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 first off thanks so much for diving into this stuff with me this is a really exciting conversation it gets the wheel spinning to dive into the tricky questions I love it anyone that's interested in levels should definitely jump to the website you can sign up for the wait list right there and also access the blog which is it's that educational opportunity to discover what metabolic awareness is why it's relevant and kind of follow along as we introduce more I think insight into how the product is affecting people today and how it's helping them understand themselves better and then check us out on Twitter and Instagram at levels and you can follow along you know in real time as people roll out their their personal insights cool what about for members of the acquired community like like band and miss and others who might want to come work with you guys well I I would love to be in touch with anyone who is who who here's this conversation and gets excited we do have a careers page at forward slash careers but you know I'll also just reach out to us through either through the acquired community to to miss or or Ben Grinnell I'd love to provide my my contact info directly to you guys to distribute to your community so you know you'll end up with my email address and anyone that's interested reach out directly to myself or Sam and we'd love to talk about the scaling opportunities that we have a lot of a lot of challenges to be solved great it's awesome that sounds awesome 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 on acquired and we hope to do more of it coming up soon thank you guys listeners we will see you next time we'll see you next time