Had a fantastic time talking with Dr. Trey Suntrup, Phd in physics and electrical engineering. We did a fairly deep dive into ketosis, redox state, and what that can say about keto-adaptation. We also looked at the potential for the Biosense breath ketone device.
I’ve been super skeptical of these gizmos as there have been some monumental challenges to figure out how to make these things work well and provide the type of feedback that better informs behavior. The Biosense folks have likely cracked that nut.
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Nicki: Welcome to The Healthy Rebellion Radio. This is an episode of Salty Talk, a deep dive into popular and relevant health and performance news pieces mixed with the occasional salty conversation with movers and shakers in the world of research, performance, health and longevity. Healthy Rebellion Radio Salty Talk episodes are brought to you by Drink LMNT, the only electrolyte drink mix that’s salty enough to make a difference in how you look, feel and perform.
Nicki: We co-founded this company to fill a void in the hydration space. We needed an electrolyte drink that actually met the sodium needs of active people, low carb, keto and carnivore adherence without any of the sugar, colors and fillers found in popular commercial products. Health rebels, this is Salty Talk.
Nicki: Now, the thing our attorney advises. The contents of this show are for entertainment and educational purposes only. Nothing in this podcast should be considered medical advice. Please consult your licensed and credentialed functional medicine practitioner before embarking on any health, dietary or fitness change. Given that this is Salty Talk, you should expect the occasional expletive.
Robb: We’ll you’re looking quite salty today, wife.
Nicki: Salty as ever.
Robb: Salty as ever.
Nicki: Salty AF.
Robb: Something like that, yes.
Nicki: Salty and pepper.
Robb: You’re definitely looking salty and pepper.
Nicki: Yes, the hair’s coming in strong.
Robb: It is. I like it. Looking gorgeous.
Nicki: Thank you. I did have somebody make a comment on my… I never post on Instagram, but the post I did like five months ago about my hair, and she said, “You know, there’s nothing wrong with going gray. But if you would give up caffeine, you might find that your hair would grow back normally colored.” I didn’t bother replying to that one.
Robb: No. Given that we fleshed out that your dad started going gray at like age 18 and you were similar.
Nicki: I had my first gray hair before I ever even began drinking coffee. I had a gray hair at 18. One, the little ones that I would just pluck out here and there. Anyway, I don’t know.
Robb: Oh, the helpful internet.
Nicki: I don’t know. Speaking of helpful internet, we had some interesting social media interactions this week. We had Diana… One of the quotes that we adapted for the Healthy Rebellion is a quote from Albert Camus, and it’s the only way to deal with an unfree world is to become so absolutely free, that your very existence is an act of rebellion. We’ve adapted that for the Healthy Rebellion. So, we say the only way to deal with an unhealthy world is to become so absolutely healthy that your very existence is an act of rebellion.
Nicki: Diana Rodgers had posted that quote graphic on her Instagram page talking about the Healthy Rebellion itself, and we’re doing a Sacred Cow book club that’s going to start in there next week, July 28th, I believe. This week, actually, Tuesday, tomorrow. When this airs, it’ll be tomorrow. Anyway, Diana posted that and we had this woman comment that I feel this has notes of ableism in its sentiment, what are your intentions with this quote?
Nicki: Ableism, for those that don’t know is discrimination in favor of able bodied people. This woman read this quote and took it to mean that we were implying that only healthy, or only able bodied people should be striving to be so absolutely healthy that their existence is an act of rebellion.
Robb: We sat and spun on this and clearly in this cancel culture age, you just wonder, do you just fucking ban this person? You just ban them outright, done, don’t engage? But I really felt like there was… One, I felt that there was a huge amount of hubris and a lack of world experience here, life experience. I replied, “If you are implying that we are working to help people improve their lot in life in every way imaginable, then yes, guilty as charged.” Then she replied something to the effect of… She brought up fat shaming. The interesting thing is, she has subsequently deleted all this stuff. She did end up backpedaling at the end of the day.
Nicki: I took a screenshot of the original comment, but then Robb, you had several back and forths with her.
Robb: I had several back and forths with her, and I was being very respectful, but also I was not going to kowtow to this. The direction that this was going was so dangerous in my mind that, just on so many levels and so disconnected from reality so. She mentioned something to the effect, well, this is fat shaming. I said, what’s interesting about this is nowhere in here, did we say anything about weight, anywhere. But even in your own mind, you recognize the connection between weight and health.
Robb: Now, you may be one of these folks who is in the healthy in any weight perspective, which I’m probably going to get myself in trouble even talking about this. But then I said, is this a true statement? Can one be healthy at any weight? Generally, the thought here, it always just goes to people who are “overweight.” And then he said, what about the 16 year old boy who just died from a cardiac arrhythmia due to anorexia? People forget about that side of the spectrum. This is where abandoning science and abandoning just some vestige of logic is ridiculous.
Nicki: Well, and what-
Robb: Let me finish one thing here, there’s a U-curve with virtually everything in biology and being too thin is dangerous. God damn it, being true overweight is dangerous. We now have people in their 20s suffering diabetic complications, amputations going on dialysis. I don’t know how to… Is it ablest saying, “Hey, we might be able to save you from going on dialysis, we might be able to save you from diabetic complications?”
Nicki: She’s also implying that people who have physical disabilities shouldn’t strive to be healthy. Veterans with-
Robb: Bilateral amputations.
Nicki: … bilateral amputations, our friend Kyle Maynard, who was born with a congenital-
Robb: Condition of no arms and no legs.
Nicki: … condition with no arms and no legs who has summited Mount Everest and who has competed in MMA fights and has not let any of his physical disability… He has accomplished more than almost every able bodied person I know.
Robb: That I can think of.
Nicki: I can think of.
Robb: Is his life better and more enriched than our lives are they more enriched for that?
Nicki: Are there people with disabilities that cannot get healthier metabolically and want to maximize their health and their experience in this world? It just… I don’t know-
Robb: It was remarkable. We had a little bit of back and forth. What was interesting was when I brought up the work that we had done with the Chickasaw Nation. I said, “Hey, I did a good amount of work when the folks from the Chickasaw Nation reached out to me because they’ve recognized that remarkable numbers of their people are sick and living lives that are not that good.” Again, like diabetic complications, amputations, dialysis, and they are dying young. Is it ablest for the Chickasaw people to want better for their folks?
Robb: Then this girl just abandoned ship. She was like, “Oh, okay, I just wanted to understand.” What’s really frustrating to me about that is that I just had to play like a minority card. So long as a minority cares about the health of their group, then that’s okay. But then just broadly it’s being ablest. We don’t need to be dicks to people, we don’t need to fat shame people. This is not that fucking slippery slope.
Robb: Again, what is so ridiculous about this current age that we’re in… Again, the show really isn’t supposed to be about politics, but God fucking damn, politics makes its way into everything that we’re doing now. Diana was being called a racist for posting pieces about regenerative agriculture and there’s a whole fucked up story behind that.
Robb: Politics is coming from a very specific direction and it comes exactly the same way, and it’s very similar messages, but it’s just nipping at every bit of logic and science and the foundation of civilization. Again, not advocating for people being horrible pricks to one another, but how many people have we met that they had an autoimmune condition, they had type two diabetes, they’re managing the type one diabetes of their kid poorly, and they didn’t even know that there were options out there? Then they were like, “Oh my God, thank you for doing the work you’re doing. Or other people like R.D Dyckman, and all these folks with the type one grit community.
Robb: The management of type one diabetes in kids is one of these just Hallmark stories where if the current standard of care in managing these type one diabetic kids is appalling, it is criminal, particularly when we have now a couple of randomized control trials looking at a low carb, high protein diet being used in the management of these type one diabetic kids. It’s as if they don’t have type one diabetes, metabolically. They grow to normal height, they don’t have additional complications. Fuck, are we not supposed to talk about that, because that’s somehow shining… If somebody is drowning, do we not throw them a rope? If they go under, flipping us off, it’s like, okay, God bless you, do what you need to do. But if they grab the rope, and they’re like, “Okay, what do I do now?” Then we fucking help them, we help each other.
Robb: But we cannot help each other if we are lopping each other’s heads off every single time that we point out that there might be a deficiency somewhere. This is one of the interesting things, not to drag this thing off a cliff, but jujitsu, if you were fucking something up, if something’s not working, then you have to admit to the fact that you’re probably getting doing something wrong, and somebody, hopefully with more knowledge or more experience will come in and say, “Hey, why don’t you try doing this?” Then all of a sudden, this movement that you were floundering on, if it doesn’t become effortless, it’s like, okay, that works, that makes sense.
Robb: This is just analogous to life writ large. But again, I don’t know, maybe to… At some point, I have this sense that we’re going to throw something out there and then there’s going to be cancel Rob Wolf, cancel Nicki Violetti, cancel everything that we’re doing. I guess when that day happens, we will be the ones that are going underwater, and we flipped the bird as we drift under the surface.
Robb: But what was interesting also about this is I was legitimately scared to even engage with this person. Because we just had another example of people in the paleo scene that had this big public declaration to dox someone, and I’m being a little bit oblique about this, but it was an event that happened a month ago. Then there was a bunch of drama and turmoil that was spun up about this.
Robb: I largely feel like these people were doing it to try to virtue signal hard enough in the hopes that nobody would then come look at whatever dirty laundry they might have. This is just going on and on and on. I’ll tell you, this is going to sound kind of arrogant, but we are comparatively very good at putting out information that helps people, we just are. We’re good at that. We’ve helped a lot of people, we continue to help a lot of people. There’s some people that are remarkably good at math, and physics, or some people that are amazing at playing professional sport.
Robb: The rest of us will never be able to reach the heights of like a Michael Jordan or an Albert Einstein or something like that. These are the people that they have gifts and they have a passion and they put it in this direction. But where all this stuff is going is that people who have a gift for achievement in a particular area, they’re getting so beat down by this cancel culture and this Uber PC scene that people are going to stop doing what they’re doing, and we will stop helping each other. Then things are… To whatever degree, the world is a bucket of shit right now, when people choose to no longer help one another, choose to just take care of their own shit and not try to help anyone else, then it’s going to get worse.
Robb: I’m not even entirely sure what our point is around all that, but it was just a stunning, wet fish against the head when this thing popped up. Again, I guess it resolved reasonably well. But I still in the back of my head, I’m like, if I didn’t have that Chickasaw story to share, would this have just continued to spin and grow because I’m just a white heterosexual male, and so I’m like the root of all evil in the world? Which is an amazing way to feel. Any other thoughts, or should we just delete this thing and not release it?
Nicki: No, I think the whole world could benefit from a lot of breathing and meditation, and… I don’t know because it’s definitely a very trying time on a lot of levels.
Robb: Super trying time. It’s been good for me in a way because where I would be a little bit dismissive and maybe a little bit of a jerk to people, I’m like, “Oh, they just don’t get it.” I might be a little bit of a prick to them. The fear of cancel culture has made me be more polite, more on point and I guess that that’s a good thing, ultimately, that is the way that I should conduct myself whether there’s the danger of retribution or not.
Robb: Nicki has long time said, try to be more like Michael Rowe-
Nicki: Mike Rowe from Dirty Jobs.
Robb: Mike Rowe from Dirty Jobs, and all that. It’s a good thing to aspire to. I’ve seen people say some super, super dodgy stuff to him and his responses are just amazing. He does good verbal jujitsu.
Nicki: Yeah, he does.
Robb: He doesn’t engage with them and he turns it around on his own terms. I don’t know, folks. I would just ask that you all think about some of this stuff. I assume that probably a lot of folks that are listening to us are already on board with this worldview. But if some of what we’re saying you’re kind of like, “I don’t know, you guys do sound like pricks or whatever.” That’s fine, but just give it some thought that maybe we’re driving our collective train off of a cliff here by this just reactionary stuff. I’m not sure what else to say.
Nicki: This is what’s been happening on social media for years-
Robb: For a long time it just has reached a fever pitch.
Nicki: … I just feel like this year has definitely escalated to a point where it’s super ugly.
Robb: The interesting thing… I guess I will… On Facebook, I guess, which was where I hung out more previously, I’ve been, I guess, trying to ring the bell about this stuff, because I had fear that this would become more pervasive in every facet of our life, and it has. Again, this is where… I’m not Nostradamus, I’m not any type of seer, but I’m a decent student of history and economics and social trends and stuff like that. I’ve been wrong about a number of things, but I’ve been pretty on point with a lot of stuff too.
Robb: The direction this stuff is going is so dangerous for our world, for modern civilization, and for people who want to burn down modern civilization. I think I’m reaching a point where I very much am going to want to fight you on that topic. I’m not just going to let you tear down… It doesn’t mean that we can’t change things, it doesn’t mean that we can’t reevaluate things, but people don’t understand what tearing a world down and starting it over in your image, look at the Khmer Rouge, look at Stalinist Russia and where we’ve had these complete resets.
Robb: If folks think that a reset like this, because you guys are benignly in charge, it’s going to be different, it’s not. Everybody thinks that they’re benign and benevolent and have the best interest. Then once power is uniformly consolidated in one spine, ugly shit happens. Even though this is not a political podcast, the irony is that there is just no corner at this point where… We can’t even talk about trying to help people save themselves from the modern industrial food world, when we talk about regenerative agriculture, it is politicized, every fucking thing is politicized at this point, and I’m tired of it. But I also, where I’ve been inclined to keep my head down, I’m really reaching that point where, I’m going to start fighting back and consequences be damned.
Nicki: All righty. This is a salty talk.
Robb: In other news-
Nicki: This is a salty talk, so sometimes they get a little salty.
Robb: They get a little salty.
Nicki: Robb, today you interviewed a gentleman-
Robb: Trey Suntrup.
Nicki: … Trey Suntrup.
Robb: He is a PhD in physics and electrical engineering, and he’s been in the medical devices, specifically the sensors world for a long time. A young guy, but this is where he’s been for the bulk of his career. He got hooked up with a company called Readout Health, which is the broader company name, and then they have a product called Biosense, which is a breath ketone meter.
Robb: They have some interesting patents on basically identifying metabolites that are expired via breath. They have like this very broad reaching patent on this. They started doing some work with Virta Health because Virta was trying to figure out ways of helping people to better manage their ketogenic diet. It’s interesting because the ability to detect ketones via breath has been around for quite some time, but the ability to quantify this has been long in coming. These folks, actually, we talked a ton about ketosis, ketogenic diets, fasting, redox reactions. This one is a pretty technical show. It doesn’t quite hit Peter Attia level, but we’re talking about NADH versus NAD plus and the redox status and different fats and how it can influence that.
Robb: Also, the benefits of being able to test that state multiple times per day, because… These guys, interestingly, they figured out a way of quantifying breath ketone content. It was difficult to correlate that with blood ketone content because there’s a lag time. Within their algorithm… Once blood ketones elevate, then it takes a certain amount of time for that to diffuse into the breath.
Robb: They did some really great testing. I believe Trey said that the one test that they did, increased the published information on this breath ketone topic by 300%. There really wasn’t that much available previously, and it’s because it was a really complex problem trying to figure out, okay, the blood values are this, the breath values are this. You’ve got acetyl acetate, acetone and beta-hydroxybutyrate, they have their own equilibrium constants that are changing.
Robb: There was a lot going on here, and we got to dig into that. It was a fun show, I got to stretch my biochemistry legs a little bit. We also got to dig into… I asked him, I can see how continuous monitoring or more frequent monitoring, like five times a day monitoring can be very informative for people understanding whether or not they’re doing a ketogenic diet right or wrong. How do we avoid the mistakes that people make, which basically like chasing ketones, dropping protein intake, increasing fat intake, just for the sake of elevated ketone levels?
Robb: He had a great answer to that, and I’ll give you a little bit of the secret with that, which is that over the course of time, as people fat adapt in that NAD, NADH ratio changes, our metabolic state changes, our redox state changes, then you don’t need as high of ketones generally. Some people do for neurological conditions, some people do for maybe like cancer interventions, but we already know that, and we know that there are some additional things that we need to tweak on that. But for fat loss, and probably just for the benefits of ketones as a signaling molecule modifying the inflammatory zone, he had a great answer for that.
Robb: It was a cool thing to be able to spend some time with him. Very interesting because there are a lot of folks that are still pretty wary of pricking their finger and taking the tests and this thing could really open up a whole interesting world and we talked about this at the very end, there may be the potential of a breath based test for detecting things like COVID. We dug into that a little bit.
Nicki: Awesome. Well, let’s jump into the interview.
Robb: Cool. Trey, how are you doing?
Trey Suntrup: I’m doing well, Robb, how are you?
Robb: All good, all good, surviving in the age of COVID, and very excited to chat with you today. I have probably three hours worth of questions, and I’m going to try not to spaz out too much on that. But I did a formal introduction with this, but can you give folks a little sense of your background and talk a little bit about Biosense and how you came to be so integral to this really fascinating project?
Trey Suntrup: Yeah, absolutely. First, just thanks so much for having me on. I’m very excited to be here and to talk to you today. My background is in the physical sciences. My PhD is in physics and electrical engineering. I took a little bit of a circuitous route to get here, as you might imagine, with that background, but I worked on devices really my entire career.
Trey Suntrup: After I finished my PhD, I went up to Silicon Valley and then did some product development work in industry up there. Then I kind of… I’m from the Midwest, and Readout, which is the Biosense manufacturer is based in St. Louis, Missouri, as I think you know. I was missing home a little bit. I was gone for about 12 years in school and working and whatnot. I was like, how do I get back home? How do I get into the healthcare space, because I was feeling a little bit disconnected between the work that I was doing and the benefit that it was having for real people. I really wanted to feel that direct benefit. That’s where the healthcare pivot came from.
Trey Suntrup: How do I get a little bit closer to home? How do I get in the healthcare space? I found this fellowship at Washington University around St. Louis, which is a Translational Sciences fellowship in the medical school. As part of that work, I worked with academic faculty there in the medical school, who were interested in commercializing technologies that came out of their labs. They were doing research and then had an inkling like, hey, I think there might be something here, there might be some intellectual property or a product that we could actually spin a company out of.
Trey Suntrup: I was working really with faculty there to take those first steps toward commercialization of their laboratory inventions, essentially. As part of that work, I had worked with a couple of local investors, and one of those investors was an investor in Readout Health, which is the company that makes Biosense. I had worked on behalf of the investor and got to interview everybody in the company and get to know them. This was about, gosh, it was about 15 months ago.
Trey Suntrup: At the end of that period, when the venture capital firm decided to invest, they actually gave me away to the company. It’s kind of an interesting way-
Robb: You get some cash and a PhD.
Trey Suntrup: Yeah, that’s right. They did bundle it together and say, “Here you go.” That’s how I came to be involved.
Robb: Awesome. Kind of a peripheral question, but I’m curious, translational medicine is so hot right now, so important. What do you see as being both the benefits and maybe the challenges of this very translationally focused research and investment area? Because there was this golden age, 1950s, 1960s, where a bunch of money was just dumped into “go, be, achieve”, like study crazy stuff. There’s so many interesting things that spun out of that, but nobody had the idea that it was specifically going to have an application, it was just expand the scientific understanding.
Robb: What’s your sense on, where are we in that story? Are we top heavy on the translational part? I get it, we want things that are going to work, we want things that are going to improve our lot in life. But oftentimes, we don’t even know what questions to ask yet. It was the sense that I have, without pushing that fundamental scientific frontier, we don’t even know what we don’t know yet. What are your thoughts on that?
Trey Suntrup: Yeah, that’s such an interesting question, because of course, without basic research, you’re right, it has a completely irreplaceable place in our world, really. I don’t think anybody who really believes in translational research, or whatever, advocate for decreasing basic science research. But translational research is really a new concept.
Trey Suntrup: It didn’t really come into its own until about 20 years ago, is my understanding. It tackles a really fundamental issue, which is really a handoff problem. Typically, what you have on the one hand, just to explain to the listeners what translational research is, on the one side, you have basic science. You’re saying these are folks who are doing laboratory research, they are doing mouse research or maybe even other preclinical research. Then on the other hand, you’ve got people who run human clinical trials.
Trey Suntrup: In the middle, there’s this sketchy handoff between those two, and that’s really what translational medicine was designed to address is that gap. You really see issues with handoffs in all kinds of places, not just in medicine. I do think it’s tackling something that is a real fundamental issue. I think when I was at WashU, if I’m recalling, the stat that I heard was that it takes something like 17 years for a laboratory discovery to make its way into the clinic. It’s something like totally bananas number.
Trey Suntrup: Of course, there’s some reasons for that related to, we don’t want to be willy nilly and just create things and put them into people. I don’t think anybody’s advocating for an abolishment-
Trey Suntrup: That’s right, of course. Of course, we have to have that. But I think the observation of the translational researchers is that 17 years, not all that is necessary. There’s definitely some fluff built into that. You can bring out some of the inefficiencies in that process. That’s a long answer to your question, but I think it’s still a nascent field and there’s a lot to learn with respect to how we can accelerate that process. But it’s a totally fascinating field, that handoff between basic medical research and clinical research.
Robb: It is, and it’s cool and interesting, within the more strength and conditioning oriented scene, there’s this understanding that the coaches, the frontline coaches, they keep an eye on what’s going on in the research, and that they get in and start doing it. Oftentimes, the coaches are implementing things 10, 15, 20 years ahead of where the scientific literature slides in.
Robb: I guess a good example of that is tinkering with lower carb diets, ketogenic diets, there have been people like Phil Maffetone, Charles Poliquin, that have been advocating for these, and none of these folks have said, “Hey, carbs are 100% the devil, but there might be this alternative way of doing things.” These folks have gone pretty deep into developing metabolic efficiency around lipid metabolism and using ketones as an energy source. But there’s been a major breakdown there in how to quantify or monitor where people are in that story.
Robb: I forget which scientist said you can’t change what you don’t track or something to that effect. We’ve really been in this morass of finger stick, which isn’t the worst thing in the world, but it’s cumbersome. I still have needle anxiety around pinging my finger to do either blood glucose or ketone monitoring. Can you talk a little bit about the potential of being able to circumvent that? How did Readout Health see this opportunity to circumvent the skin environment barrier when we’re talking about monitoring things like ketones?
Trey Suntrup: Yeah. Maybe we should just back up and talk a little bit about the origin story here.
Trey Suntrup: The company was founded by twin brothers, one of whom is based in the Bay Area and one is a professor in Canada. The one in the Bay Area is really a veteran of the national lab system. He’s a biophysicist. He worked in a couple different national labs throughout his career, really on chemical sensing. Some of those projects were actually related to chemical weapons detection for the government and all these government projects and whatnot.
Trey Suntrup: He really is an expert in chemical sensing. He actually has a nephew who is a type one diabetic, who actually had an episode of diabetic ketoacidosis, DKA, when he was a toddler, and it really shocked him into the state of, there’s really not a technology here that can be used to remotely monitor a child like that who has type one diabetes. He thought, wouldn’t it be great if we could send him to school with a device like that, and his mom, for example, could keep tabs on him and keep an eye on him and make sure his numbers aren’t rising?
Trey Suntrup: Fast forward, the company ended up working very closely with Virta Health, it’s a company in the Bay Area, who are reversing type two diabetes with the ketogenic diet. We went from the type one application to the type two and the wellness and dietary application. There was a little bit of a switch there. But really, the basic premise is the way healthcare works now is you go into your visit once or twice a year, you get maybe some blood work done, you get your vitals taken, and your doctor gives you advice based on those numbers.
Trey Suntrup: Meanwhile, you leave for the rest of the year and just are totally unmonitored. How can we possibly expect to be behaving or to be improving health outcomes, particularly in the chronic disease space, if we are basically 99% of what’s going on is untracked? Really, the remote monitoring angle here is, I think, really the driving force for us as a company.
Trey Suntrup: Now, in order to do something like that, you have to have a device that is easy to use, that is accurate, that people don’t have to carry around, bag of supplies with them to do it. Really trying to lower the barrier to measurement, because what we find is, we can talk about this a little bit later, with respect to the clinical trial that we ran last fall, but what you find is there’s a lot of variability throughout the day. Your ketones, your metabolism can change based on any decision that you make, in the course of an hour or two.
Trey Suntrup: This idea that you can do some blood work a couple of times a year or even prick your finger once a week, or even once a day, honestly, is really coming into question based on the data that we’re seeing and the patterns that we’re seeing in our users. It’s really about simple measurements, accurate measurements, so that people can do them many times throughout the day and really find out what’s going on with their body. Because your metabolism is a hidden process in your body, there’s no other way to know what’s going on.
Trey Suntrup: We’re really probing that hidden process and trying to bring those things to light so that you can understand how your body is reacting to these different choices that you’re making.
Robb: It’s so interesting, because it’s the information comparison of a photograph versus a film. You can get a little bit out of a photograph, but there can also be a ton of things taken out of context. Whereas the film, it’s so more represents it, some analog version of real life. It’s interesting, like the gut microbiome testing has been running into this same problem where, okay, we’re going to sequence your gut biome, and here’s your thing. Then all these studies come out that sneezing changes your gut biome, watching a sad movie changes it.
Robb: Clearly dietary activities, getting sunlight, the list is just enormous. It’s basically like, okay, it’s constantly changing. How do you make any sense out of a single snapshot of that story? There have been folks that have been tinkering with breath ketone monitoring for a while, but it’s been really hard to crack the nut of quantification. You guys really appear to have done that in a remarkable way. Could you talk about some of the challenges there? This is a pretty geeky audience. If you want to talk about some of the equilibria associated with acetoacetate, acetone, beta-hydroxybutyrate, folks will definitely be able to keep up with that. Yeah.
Trey Suntrup: Sure. The first thing to say about breath ketone testing is, it’s hard to do. That’s the first thing, to just get out of the way immediately is that it’s not an easy process. The fact that there really hasn’t been a device that’s been able to do it yet is not surprising. It took us, around three, four years of development to get to the point where we were able to do it. That’s just the first thing is that it’s not an easy thing to do. Detecting any anolyte in the breath is not easy to do.
Trey Suntrup: Just to make sure we’re all on the same page with respect to the physiology of what’s going on in your body. Whenever your body starts to metabolize fat, a byproduct of that process is a ketone called a acetoacetate. That’s the first ketone that’s produced in your liver when you start to metabolize fat. That ketone can be converted via an enzyme into beta-hydroxybutyrate. Now, beta-hydroxybutyrate is the one that I think most people are familiar with. It’s one they measure in your blood.
Trey Suntrup: Both of those molecules after they’re created in your liver are released into your bloodstream, all right? You’ve got circulating acetoacetate and beta-hydroxybutyrate. Of course, if you just prick your finger, that test is sensitive to the BHB in your blood, right? The acetoacetate, on the other hand can convert itself into acetone.
Trey Suntrup: This is a spontaneous process. It’s not controlled by an enzyme, it just spontaneously happens at a certain rate. That acetone, because it’s a small molecule and it’s volatile, it actually diffuses into your lung airways, and then you breathe it out. That’s the way that the acetone, the acetoacetate becomes acetone and then ends up in your breath.
Trey Suntrup: Now, the reason why it’s hard to detect that is first of all, for low levels of ketosis, we’re talking about, hundreds of parts per billion concentrations in your breath. For people who are just starting off and they just are getting their first taste of carb restriction, those levels are very well and hard to detect. That’s the first thing. But the way that the device does it and the reason the device has been more successful than any other breath ketone device in the past is this process called deep lung sampling.
Trey Suntrup: Essentially, the way that this works is if you were to just take a breath and exhale, the beginning of that exhalation is just the ambient air that you inhaled in the first place, right? If you imagine taking a breath in, there’s some large component of that air that doesn’t interact with your lung tissue at all. It’s not actually exchanging with your lung tissue. The first part of the air that you exhale is just ambient air. What we actually want to do is we want to ignore that part, because the concentration of acetone is going to be almost zero there, and it’s really not going to tell us anything about the levels of ketones in your blood, because you really want the air that’s exchanging with your lung tissue and therefore exchanging with the blood.
Trey Suntrup: Deep lung sampling is a patented process that we have where we essentially ignore that first part of your breath, we wait until you are getting near the end of your breath, and then the device has a pump inside of it, which kicks on and pulls the sample from the mouthpiece into the guts of the device and into contact with the sensor.
Trey Suntrup: The deep lung sampling part is really the key enabler for why this device is able to detect very low levels of acetone in the breath. The other important component, there’s actually a couple of other important components there is that our device is sealed. We have a sealed flow cell where the sensor is housed that does not come into contact with outside air. If you look into some of the other breath products, you can actually look in the side of the device and see the sensor. Anytime that you’re blowing on it, the sensor is just seeing some random mixture of the air that you’re blowing into it and the outside air because it can easily come into contact with that.
Trey Suntrup: It’s that random mixture a lot of the times, combined with the fact that you’re blowing your whole breath and not just the end, that really creates the random readings that I think people have become accustomed to with some of the breath products. Then the last component is just a very highly selective acetone sensor. Our founder tested many, many, many sensors and found one that’s just highly, highly selective to acetone over other compounds in your breath.
Trey Suntrup: The most common being alcohols, essentially ethanol, but then hydrogen as well. We really just want to hone in on just the acetone part, and to the best of our ability, ignore those other compounds. It’s really all those things put together that enabled this breath ketone product to operate at a level of accuracy that we’ve never been able to achieve before.
Robb: That’s awesome. That’s super cool stuff. I know you guys have some peripheral applications that are brewing, which are super exciting. We will get you back on, when we’re able to dig up some of those things a little bit. How are you guys able to crack the nut of the quantification? We’re looking at acetone, but then having a sense of what that meant with regards to beta-hydroxybutyrate levels, because that’s another thing that folks have been casting around for quite some time, and it’s really impressive what you guys did with that?
Trey Suntrup: Yeah. We knew based on the state of affairs before we hit the scene, that the breath ketone products, frankly, had a bit of a bad reputation. If you just do internet searches, like, what’s the best way to test for ketones? We did this actually, as part of the analyst work that I did on the company, I did a lot of internet searching on this. Almost unanimously, people are like, maybe it gives you an idea of something, but it’s really not a serious tool.
Trey Suntrup: We knew that that was the state before we were going to launch our product. We knew we were going to have to come with some real data if we wanted to be taken seriously. Last fall, we ran a clinical trial with 20 individuals where we had them track their ketones five times a day for two weeks with a blood meter. We use the Abbott Precision Xtra, and our device and just take simultaneous measurements five times per day for two weeks.
Trey Suntrup: The first thing to note about that is if you look at the historical literature comparing the two ketones, what you find is, there’s some research on it, but actually not a ton. There’s maybe somewhere between half a dozen and a dozen studies, and not a ton of data points, because what they’re using to measure breath acetone in those studies are these giant laboratory tools where you have to breathe into a plastic bag, and they have to run it off to the lab.
Trey Suntrup: Because there wasn’t a convenient way to do frequent breath ketone measurements, there’s just not a lot of data comparing blood and breath. But there is some. The first thing to mention about our trial is we generated I think, two and a half times all of the existing data comparing blood and breath ketone with just that one trial. In that one trial, we basically tripled the amount of available data comparing the two. Again, that’s enabled by the fact that, it’s a portable device, and it’s easy to get a lot of measurements, right?
Trey Suntrup: What people have found historically, and what we found is that blood and breath ketones are correlated. They’re correlated with kind of a medium strength. For people who are familiar with the way these things work, the correlation coefficient there, the R squared is about 0.6. This is what you… One being a perfect correlation, and zero being no correlation.
Trey Suntrup: That’s typically considered a medium to high strength correlation, but it’s not a perfect-
Robb: Take it to the bank stuff.
Trey Suntrup: Yeah, that’s right. Previously, there’d been a lot of speculation about why this was, but because we had these traces throughout the day that we could actually look at, we could actually take an individual and plot their breath ketone numbers during the day, and plot their blood ketone numbers during the day and just look at them, just visually look at how they’re evolving. You can find a really interesting phenomenon there, which is that usually breath ketone changes lagged behind blood ketone changes.
Trey Suntrup: There’s a time shift between the changes that you see. If you’re just doing correlation, you’re doing coincident measurement correlation, because of the time shift, it knocks down your correlation. Because you can imagine if your blood ketones are going up, and they’ve risen, but your breath hasn’t risen yet, then you have a high blood measurement and a low breath measurement. Your algorithms think those aren’t correlated.
Trey Suntrup: That’s what knocks your correlation down. If instead of looking at point by point coincident correlation, you actually look at the effect over the entire day. We can do something like looking at the area under the curve. A simple way to think of this, is it’s correcting for the time shift. That’s a very crude way to think of it. The correlation is like 0.83. It’s much, much higher. What this basically told us is that yes, the correlation in breath is moderate. It’s pretty good, but it’s moderate. But the reason for that is because of these lags in the way that the ketones evolve, and the levels change in your body.
Trey Suntrup: That was a totally fascinating thing to actually see. It’s something that people have observed indirectly in the literature, when you’re taking exogenous ketones or doing other types of things-
Trey Suntrup: But it was pretty neat to see so clearly that time delay between the two ketones
Robb: That’s interesting. It’s funny, previously, when I’ve been noodling on this, it’s been, is this three body problem in gravitation or something. Are the dissociation variables between acetoacetate, acetone and beta-hydroxybutyrate is so dynamic from person to person that there’s no way to really get a bead on that. But it wasn’t anything that complex or circuitous, it was just a time lag between once the concentrations in the blood go up, there’s just a certain amount of time before the concentration in the breath is going to go up, and you have to figure out a way for accounting for that.
Trey Suntrup: Right. It is true that there’s a little bit more to it than that. There are certain situations like when you exercise, for example, sometimes it can go the opposite way for your breath drops, and then your blood drops.
Robb: Interesting, okay.
Trey Suntrup: There are other situations where the phenotype of that behavior is a little bit different. Then the other thing is, the ultimate ratio between these ketones depends ultimately on, and now I’m going to get really nerdy here, on the redox potential of your mitochondria.
Trey Suntrup: The balance between NAD plus and NADH in your mitochondria is also going to contribute to that ratio that you see. We actually see something really interesting, that’s very exciting for us because we think we can explain it, which is that there’s a typical ratio, and our device, we should just back up and talk about the units for a second. Our device reports in units called aces, and they’re essentially set up to be 10X the blood BHB equivalent, 10 times.
Trey Suntrup: If you were to prick your finger and get a one millimolar, that would be about a 10 on our device.
Robb: Got you.
Trey Suntrup: Our device goes from zero to 40. That roughly covers the range of zero to four millimolar BHB. That’s the first thing. That 10 to one ratio may not always hold if you have some interesting things going on with the redox potential, or if you’re a very experienced faster or keto dieter. That’s something that we see in folks who write in and they’re like, “Hey, my blood is a 1.2, but I’m actually getting a 20 instead of a 12. I’m supposed to be getting a 12, but I’m getting a 20.” It’s almost invariably, folks that just have a ton of experience being in ketosis.
Robb: Got you.
Trey Suntrup: You start to see these interesting shifts in the redox potential in the mitochondria and how they’re behaving that caused that ratio between acetone and BHB to change a little bit. But once you find that groove for yourself, they really nicely go up and down together. If you’re looking for it to track like, I’m going to start a fast or I’m going to start a new dietary protocol, and I want to see if my ketones go up, it’s a great tool for that. The ultimate ratio between what your blood and your breath would be is a little bit personal, but there’s a range on that. It’s not like it’s going to be totally different for you than me, but there is a little bit of a range surrounding that ratio.
Robb: Got you. I would imagine even like dietary fat sources could skew that a little bit. I don’t know if you would pick it up on this, but all of that is going to have impact on the redox potential eventually. Is it safe to say that in the beginning for someone who’s say, transitioning from a standard American diet to a ketogenic diet, that’s going to be a little bit more tightly correlated then, and then we may see a little bit of drift from that 10 to one as the person gets more fat adapted and the redox potential shifts?
Trey Suntrup: Yeah, I think that’s totally fair. I think that’s absolutely right. Something to just point out here is, because the device was designed in collaboration with Virta, who’s treating type two diabetics who are doing exactly what you’re saying, they’re transitioning off of standard American diet and into this more low carb lifestyle, because that was really initially the target, that’s why you get this just great correlation at these lower levels.
Trey Suntrup: Because we found that from a behavioral health perspective behavior modification perspective, one of the things that’s a big motivation killer for people when they start tracking is if you’re not sensitive at the low end, you can’t tell if you’re moving in the right direction even before you’re in ketosis. This idea that, imagine having a tool that just gives you zero, zero, zero, when you’re not in ketosis, and then all of a sudden you get 10 when you are.
Trey Suntrup: That whole time that you’re getting the zeros at the beginning can be really frustrating, because you’re seeing nothing change. Our device, “ketosis”, starts around five aces. Between zero and five, you can move from a two to a three to a four and still see that you’re moving in the right direction before you even get into “ketosis”.
Robb: Got you.
Trey Suntrup: That’s super motivating for folks when they’re first starting out to detect those small changes at the low end, and understand that, hey, I’m moving in the right direction, even though I’m not quite there yet.
Robb: Now, a quick word from today’s sponsor.
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Robb: Trey, we’ve observed and there hasn’t, to my knowledge been studies on this, although Finian Volak have alluded to this, but we’ve noticed that when people have been fat adapted, keto adapted, sometime years going on decades that their total beta-hydroxybutyrate status tends to trend downward. How do we make sense of that, or what would perhaps be the significance in this situation? How would people think about that? Or how might we see a difference with the Biosense Readout in that scenario, assuming that that’s actually a thing, and it’s fairly broad reaching?
Trey Suntrup: We see that as well, actually. That really explains… Because a lot of folks who are using our device, at the beginning, they want to test their blood. They want to just test it against something that they know, with all the caveats that we’ve already said about why they might not be the same. But those are the folks who are typically registering 20s on our device and like a one BHB.
Trey Suntrup: I do think that that’s similar to what you’re saying. You might feel like you should be in deep ketosis, but you’re getting a one millimolar on your blood. I think that that’s exactly this phenomenon. Really interestingly, we think this is related to that redox potential concept. One of the proposed benefits of the ketogenic diet particularly for the anti-seizure effects that it has for epileptics, is really that it shifts this redox potential and that the additional… I’m pretty sure it’s NAD plus goes up, NAD plus over NADH when you’re on the ketogenic diet for a while, that it’s actually the the excess NAD plus that’s providing the therapeutic benefit.
Trey Suntrup: This is one of the proposed mechanisms of action for the benefit of the ketogenic diet in something like epilepsy is the increase of the NAD plus. Now, how does that connect, or how does that connect back to this issue of low BHB? When the redox potential shifts that way, less of the acetoacetate in your liver is converted into BHB, because having more NAD plus means there’s… In the process of converting, and I might get this wrong. So, fact check me in the show notes-
Robb: You’ll get it better than me, I guarantee.
Trey Suntrup: If I get it wrong, I’ll get it backwards.
Trey Suntrup: I think that in the process of converting acetoacetate to BHB, that takes a… Let’s see, what would it be? That takes a NADH to do that. It turns a NADH into a NAD plus. If you have an excess of NAD plus, over NADH, then that conversion is not happening. If you actually get less of your acetoacetate converted into BHB, which ultimately leads to lower BHB levels in your blood. What you have instead in your blood is more acetoacetate. You’re still very much in ketosis, you’re still very much primarily metabolizing fat for energy, but it’s not showing up as much in your BHB.
Robb: Would there be a case to be made that maybe that’s reflective of better efficiency directly oxidizing lipids versus that needing a little bit of that work around to… Because ketones almost fill like this glucose need to some degree. Particularly with people in that transitional state. Do you think that that’s more reflective of direct fatty acid oxidation versus… That seems like the most credible explanation there.
Trey Suntrup: Yeah, let’s venture into the realm of speculation here. I want to clearly delineate that from how we could talk about the clinical trial or other direct observations that we made, and now we’re shifting into the here’s a hypothesis mode. Really what we think is going on, if you think about… You were talking about the three body problem earlier, which I love because I’m a physicist. But if we start to think about how those different ketones are related to each other, and why, remember before when I was talking about in the blood, you have both a acetoacetate and BHB circulating.
Trey Suntrup: The acetoacetate, as we mentioned degrades into acetone and essentially the acetone is metabolically useless. It’s a great marker. It’s a direct proxy measurement for a acetoacetate, but your body can’t do much with it. That’s part of the reason that it gets dispelled.
Robb: I have heard that it’s important in some seizure control scenarios. People will use Antabuse to boost the acetone concentration. If their epilepsy isn’t resolving, they put them on the Antabuse and acetone goes up, and then it works. But sorry, yeah-
Trey Suntrup: No, that’s fascinating. I would love to-
Robb: I’ll ping you that paper.
Trey Suntrup: Yeah, absolutely. Because I hadn’t heard that. But from a metabolic perspective, I do think there’s a tiny bit of acetone metabolizing, I think I read that somewhere, but it’s really negligible with respect to the other ketones.
Robb: Got you.
Trey Suntrup: The beta-hydroxybutyrate, on the other hand is stable in your blood. It doesn’t degrade into anything. One hypothesis that you can make is that your body does this trick where it converts acetoacetate into BHB so that it doesn’t lose it, right?
Robb: Okay, because it is stable and it’s not going to degrade. Okay.
Trey Suntrup: That’s right. Yeah, exactly. The way that we can tie this back into your question is one mechanism that we can think about as explaining the phenomenon that you mentioned, is that your body is just getting better at titrating the amount of ketones that it needs to produce versus what it’s actually using. If it knows, I have to generate these many ketones because I’m going to use this many, and I know that because of all the experience that I have metabolizing ketones. It may not have to do that conversion into BHB as often, because it’s essentially got it figured out.
Trey Suntrup: Again, that’s speculative, but it would make sense if that was case. We just have to do more research about that.
Robb: Right. A good friend of mine and similar to you, someone much smarter than myself, Marty Kendall, he’s an engineer by training. His wife is a type one diabetic. They were having a devil of a time monitoring what was going on. He did a deep dive with a fresh set of eyes on this problem, and arrived at some very interesting conclusion similar to what you’ve been talking about, but he’s been looking at the total energy concentration of our circulatory system. That as we get metabolically efficient, we should see that be very, very low under say, like resting conditions. But then if we start exercising, we mobilize lipids, we mobilize glucose.
Robb: He’s been looking at it as a total energy need in our chronically overfed state, we just tend to have too much energy of all varieties floating around, versus having that really titrated down precisely. That’s interesting.
Trey Suntrup: Yeah, that sounds along the lines of what we’re talking about.
Robb: Either you guys are right, or we have awesome confirmation bias that’s driving us off a cliff-
Trey Suntrup: It could be either.
Robb: Yeah. Trey, one of the challenges that I see for folks on the coaching and the clinician side of helping folks implement ketogenic diets or lower carb diets, folks do get excited about chasing ketones. The higher the better, to some degree. We see folks do things like reducing protein intake, really loading up on fat intake, to goose that process.
Robb: A better understanding of this backend piece could actually be really helpful in that regard. But it’s like, we want to know for sure that you’re in ketosis, but the absolute magnitude may or may not matter as much, particularly as you’re in this over the long haul. How can we unpack some of this information to help people on that clinical interface so that they could say, “Yeah, we want to make sure to monitor where you are in this ketogenic state.” But more isn’t necessarily better. Particularly over the long haul, this is where we would see people run afoul of this, their ketone levels would start trending down, and then they start cutting protein and upping fat, which is not really helping them. Could you talk about some of that, and maybe how we could think about this at a clinical level?
Trey Suntrup: Yeah, absolutely. First of all, I think it’s important to establish what your goal is, right? I think that’s the most important thing for anybody who’s either doing this on their own or in a clinical program. If your goal is to just switch yourself into a primarily fat metabolizing state, then where you want to be is probably somewhere between five and 10 on our device, which is somewhere between 0.5 and 1 millimolar. If you are more interested in the signaling effects or the anti-inflammatory effects that seem to be associated with elevated BHB, there’s not a ton of human studies on this, I’m actually not sure there’s any human studies on this, but the mouse model suggests that that number is about one millimolar and above.
Robb: Got you, okay.
Trey Suntrup: If you’re interested in the more downregulation of the inflammatory pathways and whatnot. That’s the first thing is establish, what am I after? Am I after just weight loss? Am I after longevity? Try to figure that out. That’s the first thing I would say. The second thing is the device in addition to telling you absolutely where you are on the spectrum, which it definitely does, because as you said, it’s very quantitative, and there are 40 different levels that you can be with our device. Zero to 40 at integer levels. So, it’s very, very precise. It’s not telling you five levels and you’re a three instead of a four. It really does fine grain tracking.
Trey Suntrup: Because we have that, you can really get into insight into the way your decisions affect your metabolism. I think that’s really where the holy grail is for individuals, is learning about their body, and learning about how the choices they’re making affect that metabolism.
Trey Suntrup: One way that we are trying to supplement this, and this is something that we’re really excited to release here very soon, is our device has a connected mobile app, where you can download all your ketone data and view the trends over day, week, month, year, get averages and whatnot. But we’re really excited that we’re about to release an annotation feature where you can actually add meals, exercise and fasting into the app. Ten see, a little icon pops up on your graph with your ketones, so you can actually see, okay, I ate something here, and then you can describe a little bit what that is. Then my ketones changed in this way.
Trey Suntrup: Ultimately, the connection between the decisions you’re making and the outcome that we’re really driving toward, rather than trying to be really prescriptive about the type of level that you should be at. There’s, some absolute things we can say, again, like if you’re interested in weight loss, and you want to be up in the five area, now, you’re not going to get much benefit for weight loss if you were to. We can say that. But I agree that, when it devolves into just chasing the number, I think that that can be a little bit of an unhealthy relationship with the tracking itself, and you don’t want to encourage that.
Robb: Well, that’s great. That’s a really good tool that folks could use, particularly in this kind of coaching scenario, if they’re working with a client or a patient, and they’re trying to help educate them about how they could use Biosense to inform what they’re up to. Again, it’s funny, every time somebody asked me a question, it’s, well what’s your goal? Because that’s the target and then, if we know where we want to go and where we are, then in theory, we can build some sort of a roadmap to get there. This can be really dependent on what that goal is.
Robb: If you have somebody that’s an autoimmune patient or neurodegenerative patient is trying to fight that, they have very different needs than somebody that the only goal is weight loss, for example,
Trey Suntrup: Right. You see that, for example, with people who have epilepsy and are on a ketogenic diet, they are usually elevated ketones, compared to somebody who say, type two and is trying to cut their carbs. They are at opposite ends of the spectrum even. Something I should mention, I think this is on our website now. If it’s not, then it will be soon, we actually have a white paper available that you have to just sign up for with your email to get. That white paper is essentially guidance for clinicians who are interested in using our device and using ketone tracking-
Robb: That is up there, yeah.
Trey Suntrup: Okay, great. You know more than I do, actually.
Trey Suntrup: But in there, it really talks about, what do these numbers mean and for specific ranges of numbers, how does that inform the clinical decision and the feedback that I can give to the patient? Then what knobs do I have to turn as well? It’s not just carbohydrates, there are other knobs you can turn too, to get those numbers to trend in the direction that you want them to.
Trey Suntrup: I do think there’s a little bit of… We’re trying to fill that education gap as well to say, here’s really the specific actions that you can take when you see these different numbers pop up on your patient’s devices.
Robb: Brilliant, nice. We should also put together a course similar to this for those clinicians and probably even a client and patient facing alternative to it so that there’s the written, but also the spoken and maybe some graphics around that to help people really unpack this, because it’s cool that the ketogenic state is one of the rare binary stories to some degree in biology. It’s kind of, you’re in or you’re not.
Robb: It lends itself to discrete tracking. I think that that’s why research in this area has exploded because unlike the Paleo diet, it’s like, well, how much protein? How many carbs? It’s so nebulous what that means. A ketogenic state is fairly easily defined. But then it can also, again, lead people in this direction. They’re like, well, if some ketones are good, then more are better. Then they can make well intentioned but poorly informed decisions around what they’re up to with that.
Trey Suntrup: Yeah, absolutely. We could also say that, the ketogenic diet is not the only way to put yourself into ketosis. This was one of the big revelations that I had when I first joined the company about a year and a half ago, is the chair of our scientific advisory board at the time, we were in a meeting I forget who with and he said something like, anytime your body burns fat, you get ketones.
Trey Suntrup: I was like, wow, that makes a lot sense. It doesn’t necessarily matter how you get there, it’s really just a matter of when you metabolize molecule fat, you’ll get some ketones out, no matter how you arrive at that point. Tat makes the tool really interesting to provide feedback for really any dietary intervention where the target is fat loss or fat metabolism.
Trey Suntrup: Really, I think, the pie in the sky goal here is to think about replacing the scale, because you think about what the scale does, first of all, you can’t step on the scale multiple times a day and get anything meaningful. It’s a maximum once a day, and even that is probably too often. It’s confounded by a bunch of other things. Like maybe you’re losing fat, but you’re also going to the gym and lifting weights. Maybe your weight’s not really changing but you’re burning fat, your body composition is changing, right?
Trey Suntrup: Things like waterway, all this stuff really makes it pretty poor feedback tool. I think that’s something that everyone is familiar with. There’s so much frustration, and such an unhealthy relationship with the scale. I think it’s deserved for that reason is just people can’t draw the tie between the things that they’re doing and what they’re seeing on the scale. I think the idea of really honing in on fat loss, specifically, the rate that your body’s metabolizing fat, and not your way, is a really interesting idea for these programs.
Robb: Right. It’s striking me that even somebody that’s eating, say, a moderate carb intake, but they’re really doing this Maffetone pieced cardio with the emphasis on nasal breathing and fat oxidation, that could be really valuable in that context too, even though their goal isn’t specifically being in a ketogenic state, but they should get some really good feedback about how effectively they’re making that happen versus potentially slightly over into anaerobic work output.
Trey Suntrup: Yeah, absolutely. That’s the other reason why we included exercise annotations into that as well, right? Because it’s obviously, a big part of it is what you’re taking in, what you’re eating, what your dietary macros are, of course. But the other part is, the rate of your metabolism based on the different exercise that you’re doing. It’s really all that creates its own little three body problem. These different things that you’re doing and your ketone levels.
Robb: Right, that’s awesome. Trey, could you think of anybody that isn’t a good fit? If you were to look at the profiles of folks, when they’re thinking about something that’s going to help them in monitoring their health or behavior change, who would not be a particularly good fit for trying something like Biosense? Who just would be outside that demo, or is there not really anybody it would be very specific to goals that just don’t align with it or something like that?
Trey Suntrup: Yeah, I can think of two, offhand. The first is, the device is really not approved for type one diabetics.
Trey Suntrup: That’s something that’s really important to understand. For type ones, they actually don’t want their ketones to go up, but to regulate. There’s an exception to that. Right now, the ketogenic diet and low carb is actually being used in type one to get better glycaemic control. That’s its own little niche area of research, the behind where the type two research is. I definitely don’t want to make any recommendations about that, because it’s still so early.
Trey Suntrup: But in general, I think it’s safe to say, for type ones, who are trying to make sure their ketones don’t go up, we’re really not approved to do that. That’s an area that if you don’t handle it carefully, it can be dangerous. Diabetic ketoacidosis is no joke and people end up in the hospital for that. That’s the first one. The other, this isn’t really somebody that falls out of the scope, but I think there’s some prerequisites for using the device.
Trey Suntrup: I think, anybody who’s listening to you, your audience is going to have all those prerequisites. But I think it’s important to have some basic understanding of metabolism first, so that you can actually understand and interpret what you’re seeing.
Trey Suntrup: Because I do think for people who are just like, I think I’m in ketosis already, because I’ve been following low carb. I’m basically getting this device to confirm it. But they don’t necessarily have the tools and the knowledge along the lines of what we’re talking about here. It doesn’t have to be near as detailed as we’re talking about here, just basic understanding of how glycogen metabolism happens first, and then fat metabolism and then stuff like that.
Trey Suntrup: Then I think when they first start out, and they’re getting low numbers, it can be frustrating. That’s not really a demo that falls outside, but I do think there’s some education that we have to do for these folks before so that they can understand that, hey, if I make a dietary change, it might take three days for that to kick in or five days, before I start to see my ketones go up.
Trey Suntrup: That’s something else that we cover in the white paper as well is, what are some of the patterns that I can expect to see here, and how do I interpret those patterns in terms of the underlying physiology? Because again, I think if you don’t do that, and if you ignore all that, then at the beginning low numbers can be frustrating.
Robb: Got you. Hey, just real quick question, do you… This really gets out in the weeds, and I could crack the biochemistry book myself, but do you have any sense of what electrolyte status does or its influence on redox status? Like sodium, potassium level. That’s getting super out in the weeds and so it could just be something that we handle offline, but we’ve seen really significant benefit with reductions in the keto flu, in that transition process when people are really on point with electrolytes, specifically sodium. I’m just curious if that has an impact on that redox status? Is that facilitating something there, or is it purely just the electrolyte status unto itself?
Trey Suntrup: I’m definitely outside of my area there, but my intuition is to say that they’re not related, but I could be wrong about that.
Robb: Yeah, I’m trying to think of how it would be, even modifying an enzyme activity or something like that. But that’s super reaching. I see this benefit in one area, and so I want to project it on to some other area as well.
Trey Suntrup: It’s interesting that you say that because the other element in the conversion from acetoacetate to BHB where he talks about redox potential, the other is this enzyme, I think it’s beta-hydroxy-butyrate dehydrogenase, and the supply of that. Anything that can modulate the supply of that enzyme could definitely have an effect on that ratio that you see.
Robb: I doubt if sodium potassium levels super drive that. You’re probably getting die one way or the other before that gets driven one way. But, yeah, okay. Well, Trey really a huge honor to have you on the show. I know we’ve been trying to put this together for a bit, but COVID… Oh, you know what, that is one other thing I wanted to ask you about. Given… This maybe gets a little bit political and if we need to cut it, we’ll cut it. I’ll leave it up to you on that.
Robb: But I’ve been so frustrated in this COVID story, because seemingly from day one, there was this reasonably clear suggestion that people in better metabolic health fare better. It’s not 100% get out of jail free card. I don’t know that being implicitly in ketosis is like you’re just going to walk through the SARS-CoV-2 virus and have no ill effects.
Robb: But man, it seems like problems round down to nearly zero if individuals are metabolically healthy. Now, we’re finding all this glucose metabolism problems, lipid metabolism problems with this infection. What is the potential… We put all these eggs in a basket of a vaccine and different things like that, which is all well and good, I guess, unless it doesn’t work. That’s the one thing that we’ve invested in, but it seems like a guarantee that ensuring better metabolic health would help everybody. How could Biosense overlay in this age of COVID to help people manage that part of their health also? Is there any way that that can help inform what they’re doing?
Trey Suntrup: Yeah, absolutely. The first thing I could say about that is we were just circulating a paper that I think came out of China, I don’t know how long ago, maybe only a couple of weeks ago, that basically showed that your fasting blood glucose level when you hit the hospital is super predictive of mortality. I think the odds ratio was like four or something like that. Just super predictive. I do think that that’s becoming more and more clear that that’s the case.
Trey Suntrup: The second thing I would say is, I think so much of the anxiety surrounding COVID is, to diverge into maybe the psychological a little bit here, is this feeling of losing control. I know, at least for myself personally, that was a big part of it. The beginning, it’s like, you’re trapped in your house. This feeling that there’s nothing I can do in a way or even if I do all the things, then there’s no guarantee, and that’s, of course, the case.
Trey Suntrup: But I think something that really helps psychologically, is to focus on those things that you can control. Is to really try to take care of yourself, as well as you can and metabolic health, as you mentioned, and as it seems like all the research is suggesting is a huge component of that. I do think, for immunity, for example, the connection between your metabolic health and your immunity, I think is getting stronger and stronger. That was the case for flu even before COVID.
Trey Suntrup: No, I think you’re absolutely right. I think as folks start to understand that, hey, there’s something I can do here, I can stay active, I can change the way that I’m eating. That can go a very long way toward reducing my mortality. As you said, it’s not a get out of jail free, of course. But it really is something that you can control.
Trey Suntrup: I do think a big part of what the device is designed to do, and this is something that our founders are really clear on is to give that agency back to the individual. I do think, of course, our experts and our physicians and clinicians are so important. As a scientist, I am, obviously, a very firm supporter of them. But ultimately, in the case of a lot of these chronic diseases, we’re going to have to start to take some of that on ourselves as well. There’s just no other way to do it.
Trey Suntrup: I think, trying to change that paradigm a little bit to involve the patient, to involve the individual a little more by empowering them with information so that they can start to make their own decisions and have them be informed decisions is really a core part of what the product is offering. I think that all ties in back with the COVID is like, what can I control? What kind of agency do I have over the situation? I do think the device can play a really important role there.
Robb: I totally agree. It’s one of these things where we’re going to eat no matter what. We’re fortunate enough that pretty much all of us are going to eat. We have amazing agency in what we choose to eat. Even if we’re more or less trapped indoors, we can exercise and the getting sunlight on our skin is a dodgy topic at this point, but we do the best we can with that. But that’s a lot of stuff that can dramatically affect where we are on that metabolic health scale and potentially, what the outcomes are going to be.
Trey Suntrup: Absolutely.
Robb: It’s like, if you were going to go into an MMA fight, would you want to be in good shape or not? Any battle for your life or whatever, you want to be in as good a shape as you can. Literally, every day is a battle for your life on some level.
Trey Suntrup: I just want to mention one more thing just before we tie up here, which is that, our company is, in addition to taking this deep dive into breath ketones, we really consider ourselves to really be a breath technology and breath sensing research company. Along those lines, we actually have some pipeline products in the area of viral detection in the breath.
Robb: I wasn’t sure if we could talk about that. That’s what I alluded to earlier.
Trey Suntrup: Right. We can’t say much about it, because we’re still in very, very early development for that. But that’s something that has enormous potential, and it’s something that we really think, given the intellectual property protection we have, and expertise that we have on our team, that is a really interesting area and a big opportunity to create new tools for viral detection. I’ll just leave it there.
Robb: I’m stoked. I was trying to allude to that earlier without-
Trey Suntrup: I noticed that.
Robb: … without getting my head lopped off. So, yeah. Well, Trey, it was super cool having you on. Would you be game for, we release this maybe a month, month and a half down the road? I’m taking a bunch of listener questions, and then we circle back up and have you back on? Because I know that there’s just going to be a ton of questions that are spawned out of this.
Trey Suntrup: Yeah, that sounds great. Happy to do that.
Robb: Awesome. Cool. Well, thank you so much. It’s really an honor to know you folks, and the work that you’re doing is just really cool. I’ve been in this space for 22 years now, and I never thought I would live to see some of the changes that are happening, what Virta Health is doing, what you folks are doing. It’s really incredible, and it’s super exciting to see where it’s going to go.
Trey Suntrup: Thanks so much, Robb. Great meeting with you.
Robb: Thank you. We’ll talk to you soon.
Trey Suntrup: Sounds good. Bye, bye.
Nicki: That was a good one, hubs. Before we sign off here, I want to make sure folks know that if they are interested in checking out the Biosense, they’ve offered $20 off for our listeners. You folks can go to mybiosense.com, and use the code Salty20 to get that $20 discount.
Robb: Yeah, and I screwed up I wrapped up with Trey. I ran long and he needed to split, and I forgot to get him to say, where can we find you guys on the web? So, mybiosense.com.
Nicki: Yep, that’s where you can go for that. Thanks for joining us. Remember to check out our show sponsor Beekeeper’s Naturals. Grab some B.Chill honey. You can save 15% on your first order by going to beekeepersnaturals.com/thr, and you’ll get 15% off. What else, hubs?
Robb: That’s it. Hopefully we will see you over in the Healthy Rebellion. This Basis Strength challenge is in full effect.
Nicki: Basis Strength Reset is in full effect.
Robb: It is awesome. It’s a combination of really coolly planned strength training and then kinstretch related mobility.
Nicki: Coupled with some smart joint mobility.
Nicki: With the cool kids over at Basis Health and Performance in Chico, California.
Robb: Indeed. At least till we get them to move to Texas.
Nicki: Yeah, something like that. All right, folks, we’ll see you next time. Have a good week.
Robb: Bye, everybody.
Nicki: As always Salty Talk episodes are brought to you by Drink LMNT, the only electrolyte drink mix that’s salty enough to make a difference in how you look, feel and perform. Get salty at drinkelement.com. That’s drink L-M-N-T.com.
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