Empowering Consumers to Make Better Health Decisions - Dr. Taylor Sittler, Head of Research & Development at Levels

Michael Carrese: Hi, everybody, I'm Michael Carrese, and today on Raise the Line we're going to focus on trends that we at Osmosis have had intense interest in for years, and we always love learning more about: direct-to-consumer healthcare and how technology can empower consumers to be active participants in achieving and maintaining their own good health. To help us understand more about all this, I'm delighted to welcome Dr. Taylor Sittler, who, in a relatively short period of time has made a big impact in these areas by starting companies in genetics and women's health to personalize medicine, prevent disease and diagnose infection. 

He's currently the head of Research and Development at Levels, which is a health tech company helping people discover how diet and lifestyle choices impact their metabolic functioning. He also has a special interest in the science of resilience, both from an emotional and physical perspective, so lots of interesting things to talk to you about today, Dr. Sittler, and thanks for coming.

Dr. Taylor Sittler: I'm really happy to be here, looking forward to the conversation. Thanks for having me.

Michael Carrese: Our audience is mostly med students and health professions students and early career professionals, so we always like to start by asking our guests about their own career pathway. 

Dr. Taylor Sittler: Sure. 

Michael Carrese: So what first got you interested in medicine, and then you ended up specializing in pathology…

Dr. Taylor Sittler: Yeah, gosh, it was a bit of a long road. I had thought about going into medicine in college, and then decided not to and went into software development instead, ultimately curved back around. When I was about twenty-five, I started working at Dana Farber in Boston, and then decided that I thought that this was really the way that I could make a difference. I feel like my career has been trying to marry medicine and technology pretty much ever since then.

As I think many folks do, I had a bit of a winding road. But to me, participating in healthcare, and being able to make a difference for people was a big part of what I wanted my career to be about and so that's kind of how I got into medicine and went to UMass Medical School, did a research fellowship. I was working at MIT and then at UC San Diego in systems biology. I was actually thinking about going into emergency medicine, so I had a pretty broad range of things that I was considering. Again, it was just figuring out how to marry those research interests and the technical stuff that I was doing with medicine and ultimately, I settled on pathology as the best way to bring those two things together.

Michael Carrese: So, when did you first develop an interest in the entrepreneurial side of things?

Dr. Taylor Sittler: I think it had kind of always been there. My dad was a bit of an entrepreneur, although it didn't work out very well for him, and I think my mom was always wary of me becoming an entrepreneur. So I think the fact that I was in medicine…I always use that as a defense. I was like, “Look, Mom, I'm gonna be a doctor. You can relax!” But I had always wanted to start a company, I think. I had tried a couple of times, and I'd been part of a startup between medical school and residency. I'd helped spin a company out of Bob Langer's lab at MIT with a couple of friends that actually have become lifelong friends since then. So, I sort of had a couple of run-ins with the entrepreneurial community and once I got to San Francisco -- which is where I did my pathology residency -- I feel like then it was full bore. I was exposed to entrepreneurship everywhere outside of the hospital, and in a way, I think it was just a matter of time before I found the right folks to work with.

Michael Carrese: Your first company that you co-founded was Color Genomics. Tell us about that, how it came about, and what were you trying to address?

Dr. Taylor Sittler: Color really was founded about 10 years ago now and genetics was really just coming online in a big way. There was a really famous graph back in the day of the cost of sequencing dropping faster than Moore's law. This was a graph that was updated monthly by the NHGRI, the National Human Genome Research Institute and we saw that there was going to be a sea change in terms of how people use this information. I think we were trying to figure out how to make a difference for folks and ultimately, what we decided to do -- I think it took us maybe a year to figure out what that product would look like -- but the goal was to make genetics a part of primary care, so we could better personalize medicine. 

The first thing we did is we dropped the cost of sequencing. So, for doing a general genetic test, it used to be about $5,000. We dropped it down to about $250 so that people could actually afford it out-of-pocket. We started in women's health, particularly breast and ovarian cancer genetics which were very well defined and described and there were good treatment options depending on what we found, which is not true in a bunch of other scenarios for genetics. So that was where we started, and I think we made a really big impact. We had a lot of great stories that I was proud of, of women who had basically gotten denied testing by their insurance and because we were able to drop the cost down to a price point that they could afford, they got the testing themselves, found out that they were at risk and were able to get the help they needed. So that was really, I think, my favorite take away from Color, and I think that's what we were trying to do is make genetics accessible and make healthcare more personalized.

Michael Carrese:  Well, right and at the same time, you had consumer genetics companies like 23andMe and Ancestry and those folks coming on line.

Dr. Taylor Sittler: Yeah, there was a whole movement, for sure.

Michael Carrese: But, you know, I'm curious about what you said about integrating this into primary care as baseline information. Do you have any sense of how accepted that has become in the medical community? It seems like a good idea.

Dr. Taylor Sittler: I think we're not quite there yet. I think there is an awareness that we can personalize with genetics, but until it becomes part of the preventive guidelines or the U.S. Preventive Services Task Force we're not going to necessarily see it be listed as a part of primary care. Where I think we're gonna go is, starting at birth, we're going to do a whole genome analysis of someone and right now, most of the states do some kind of genetic testing for the population at large. That will just need to be expanded to a whole genome. From that information, certain things will be taken at birth and certain changes will be made at birth. Then I think we'll revisit your genome when you're about eighteen. Not because your genome changes, but because our understanding of it does and that has some impacts for early adult life. Then I think around thirty-five to thirty-eight, it makes sense to do another personalization round, and this is where we were focused really, a little bit later in life, the risks of cancer, heart disease, stuff like that, that can be related to your genome. So I think that's the model that will develop. I think there's a general understanding that it's important, but it's definitely not fully accepted in primary care yet.

Michael Carrese: Well, as you know, it takes the medical system -- not to be overly critical -- but it does take a long time…I think it's a thirteen-year gap, on average, between introducing something new and having it integrated into healthcare. We'll get there eventually. Let's fast forward and talk about your work now at Levels. It’s probably good to get sort of an overview of the company for folks listening and then what are you trying to achieve? What problem are you trying to solve?

Dr. Taylor Sittler: Levels, right now tells you how food impacts your health. It gives you real time feedback on the food that you're eating and I would say soon it's going to broaden from the food that you're eating to the exercise that you're doing and the sleep that you're getting in order to make better health decisions. I think we all have this idea of interoception, or how you feel about your current situation. Like, how is your body doing? It's more of a feeling and we're adding data to that to enable people to better understand that feeling and better understand what health decisions they should be making. 

So as an example -- the one that we hear all the time and that both Josh and Sam, the co-founders, experienced was - you have a bowl of oatmeal. Oatmeal is supposed to be very healthy, but you see your glucose skyrocket after you've eaten a bowl of oatmeal, and then sometimes come crashing down afterward, and you feel tired and lethargic and things like that. Levels is predominantly helping people interpret that glucose signal that they get and really interpret how this information that's being captured is impacting them. But we don't make the continuous glucose monitors, those are made by Dexcom and Abbott, they're two major manufacturers. What Levels really does is provides an interpretation layer on top of that glucose monitoring.

Michael Carrese: This is really fascinating. At the consumer level, people are getting all kinds of access to healthcare. There's heart monitoring, and so forth and so on. What have you guys seen so far in terms of its impact on behavior? For example, if I know what you just described about the oatmeal thing, maybe I never have oatmeal again and I try to find some breakfast where things are more level and spread out. So, is that happening? Ae people making lifestyle changes based on this?

Dr. Taylor Sittler: Yes, they are, and I think we have a lot of amazing testimonials now from folks. Anywhere from people who have just eliminated simple foods out of their diet to folks who have lost sixty or eighty pounds using the device or using the app. So, I think people are making those health habit changes. One of our core goals over the next year is to really build an application and a product that supports people in those behavior changes, because as we all know, they're difficult, right? Changing how you act is tough, it takes work, it takes multiple tries and so we're really engaged and trying to help people achieve that. I think the first step was just providing the data back to people in a way that they could understand it. The second step is really helping them interpret it and then the third step is helping them take action on it. 

Michael Carrese: What does that look like? How do you plan to do that?

Dr. Taylor Sittler: There are some very simple things that folks can do. For instance, food swaps. If you see a major glucose rise in response to something that you are eating, change it out for another food that might not do that to you. And there are ways to test that. Another thing that can be really helpful is take a walk after you eat. That can help level your glucose out and it's also good for you. There are definitely other health habits that will come in and there are ways to engage people around that. Oh, and there's actually one more simple thing that I'll throw out there: it not only matters what you eat, but in what order. If you're going to have a croissant for breakfast, you might think about having some chia seeds or have some yogurt before you have that croissant. That will actually change your glucose curve and change the way your body processes it. So, there are some very basic things that people can do and we are seeing them do it and we're helping them do it more effectively.

Michael Carrese: What's the user experience like…the interface and so forth?

Dr. Taylor Sittler: Levels is an app that you can download from the App Store or from Android and basically, what it does is it walks you through the interpretation of your glucose data. It's really designed around health and wellness to help people understand their health trends, what things that they're doing that they might be able to improve. It gives you a chart where you can see your glucose over the course of the day, as well as some guidelines and recommendations around that chart. The app is changing very quickly, so I think in order for this to be relevant I'll probably keep it pretty high level, because by the time you download the app, it might actually be a little different from what it's showing today.

Michael Carrese: You know, I would think from a physician's perspective, this is a tremendous tool to help people be compliant with treatment programs between visits. I mean, if you're diabetic, you may not see your doc for weeks and weeks at a time or months and months at a time.

Dr. Taylor Sittler: To be clear, we're not focused on disease states, we're trying to help people stay healthier. But yes, I think this fills a real gap that I've seen in the healthcare industry, which is that doctors get ten or fifteen minutes with a person. They can't stay with them every day to make sure that things are improving and it's one of the reasons that doctors, I think, have so much difficulty helping patients with behavior change. It's because they can't engage with them frequently enough to make that possible and I think the Levels app really does that. It's constantly available for folks that are interested in improving their health.

Michael Carrese: Sounds very interesting. I will just say, if I've ever had this, I would take it off before eating pasta…

Dr. Taylor Sittler: (laughs)

Michael Carrese: …because that has to happen. Regardless of the implications, that red sauce is going to happen. (laughs)

Dr. Taylor Sittler: (laughs)Yeah, totally understood. 

Michael Carrese: I do want to shift to the resilience piece of things. We have focused quite a bit on this show on the physician burnout issue, and just general wellness, helping to support clinicians as they're out there. I mentioned at the beginning that you have this interest in kind of taking a broader look at what resilience means. Why don't you explain that?

Dr. Taylor Sittler: Resilience traditionally was used to describe mostly psychological phenomena. But I think that's where it's so powerful. People come up against these real challenges in life and resilience is kind of a measure of how you deal with it, and how you bounce back, how you recover. What I have found is that this is a phenomenon that we actually use, generally, physiologically. Your brain, just like everything else, is a physiological organ. I'll give some other examples in healthcare that measure resilience. An oral glucose tolerance test is, to me, a measure of resilience. It's basically giving your body a huge slug of glucose, and then seeing how it recovers and how it processes it. Does the glucose level in your bloodstream come down quickly enough that you can be considered, "normal" versus diabetic? A cardiac stress test, where you run on a treadmill for a little while and they hook an EKG up to you to see if there are any changes, that's another measure of resilience. 

So, resilience is actually baked into the idea of the clinical process. It basically involves a stressor and an adaptation. I think the reason that it's helpful to think about resilience now is that we are starting to do continuous monitoring. It will start with glucose and then lactate is starting to be monitored and ketones and you're going to start to see a number of other things that come online. What we do with that data is important and thinking about that data in the context of resilience, I think, tells us a lot about our health. 

As an example, if I were to take a continuous glucose monitor, and take that slug of glucose, I can now watch that entire trace…watch how quickly my glucose rises, how quickly it comes back down, whether there's what we call a biphasic spike, and all of these things tell me about how well my body is responding to this challenge.  I think that's where resilience is really helpful. No matter what continuous stream of information you're monitoring, applying a stressor and then looking for the adaptation tells you a lot about how healthy you are.

Michael Carrese: Then what do you do with that information? Give us sort of a practical scenario.

Dr. Taylor Sittler: What we do with it, I think, will come after we understand it better. We're just at the point that we're starting to understand it. But you know, we can already talk about it in the context of glucose monitoring. If you see your glucose rise very quickly in response to a bowl of oatmeal, maybe you don't eat a bowl of oatmeal, or maybe you eat the chia seeds ahead of time. You can change your behavior to match your response better. Another example that people use a lot is heart rate variability. This is something that's used by athletes in training, and often as people start to train for marathons, their heart rate variability will go up over time. That means your body is able to more rapidly respond to different scenarios. Often, it's also associated with being able to run for longer distances. 

So if you watch your average heart rate variability improve or go down, that is a measure of your resilience. That's a measure of how well you're exercising. I was talking with an ultra- marathoner earlier this week who checks his heart rate, and he says his average heart rate for a given output will actually go down over the weeks that he's training for a long-distance run. Again, that's kind of a measure of your resilience. So, monitoring these things, and seeing how they change over time with respect to a specific stressor, can tell you a lot about health. There are lots of examples of people using this in training. I think we'll also start using this in our daily lives in terms of how we change our diets, how we think about sleep, when we choose to exercise, etc.

Michael Carrese: Staying with resilience for a second and thinking about it in terms of how it applies in a clinical setting, what advice do you have generally for people who are trying to stay strong in the midst of very turbulent, challenging circumstances? Maybe you could even share what works for you?

Dr. Taylor Sittler: It's a great question. I think you need to be able to draw personal boundaries at times and you learn that over the years. When I started med school, I was doing research at MIT while I was going to med school. I wasn't sleeping very much and I was going out to party with my friends, and, you learn where your boundaries are. So, I think setting boundaries is really important. I think that the next thing that I would say, is doing something that gives back to you. A lot of people that go into medicine have a very strong abstract idea of what they want to do. “I'm going to be a neurosurgeon, or I'm going to be this” that they decided ten years prior. I have always found that the things that I do best at are also things that I like to do, and I have to try a few things before I know what that is.  If I try something and I like it, I do it more and that has always served me really well. I think we have these ideas of what we accomplished and they sometimes don't match up to the actual experience, and when they don't -- and they often don't in medicine -- I think it's important to follow your gut to follow the thing that you like,

Michael Carrese: Makes sense. So, Osmosis is an education company as you know, and we love to ask our guests for an idea of something that they would like us to teach. It could be exploding a myth, or it could be just a gap in knowledge related to what we've been talking about or totally unrelated. What would you say? 

Dr. Taylor Sittler: I think -- and Levels has really opened my eyes to this -- I think the biggest thing is understanding insulin resistance. It's still not taught well in med school, and it is probably one of the single biggest contributors to disease across the board. The Levels Health Blog does a fantastic job of talking about a lot of issues related to insulin resistance and metabolic health. Casey Means and Rob Lustig and Ben Bikman -- a bunch of the advisors of the company -- I think also do a great job. There are great resources there. But I don't think that information is making it into med schools yet. This basic concept of eating too many carbs -- refined carbs, particularly -- and constant insulin are fundamental to most of what they originally called the "Diseases of the West" or the sort of developed world diseases. Whether it's diabetes, or cardiovascular disease or Alzheimer's, we're showing some links to cancer…I think understanding insulin resistance would be fantastic. That'd be the one thing I'd love to see more of in med school.

Michael Carrese: Oh, that's a good one. So, you gave good advice already on the resilience side of things, but broadening it out now, what is your general career advice for people who are entering a career in medicine?

Dr. Taylor Sittler: Good question. I guess when I look out there -- and when I did look out there at what I was going to do -- I would tend to look for gaps in what was known. I don't know that this is for everybody, but I think looking at where the field is going is more important than landing the perfect job. I've seen medicine change quite a bit, actually, in the last ten or twenty years and it's been accelerated by COVID. I think with the shortage of doctors, you're seeing states make it easier to practice across borders, you've seen a lot of changes in Medicare and remote treatment. I think there are some big changes to the medical field that have been long overdue that are now coming. So, I expect the profession to look fairly different, actually, in ten or twenty years from what it looks like now.

I think Levels and a lot of the companies that I've been involved in are hopefully capitalizing on some of that change because they're trying to create valuable products in spaces that aren't well served in the medical community. The thing that I have always looked for, and that may be helpful particularly for people who want to be involved in innovation, is look for gaps.  Look for gaps in the way that care is provided and think about how you can create something valuable. Maybe that's the framework I would use. 

Michael Carrese: That's great advice. Some people say, “Skate to where you think the puck is gonna go.” 

Dr. Taylor Sittler: Great. Yes. Excellent.

Michael Carrese: Another way to do it. 

Dr. Taylor Sittler: Exactly, yes.

Michael Carrese: Well, listen, this has been really, really interesting and I'm so glad you had some time to spend with our audience to help them understand what you folks are working on at Levels, and where all this is headed.

Dr. Taylor Sittler: Thanks very much. Appreciate you having me on the podcast.

Michael Carrese: I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to Raise the Line and strengthen the healthcare system. We're all in this together.