RHR: Scaling Functional Medicine: The Berkeley Fire Department Wellness Program

In this episode, we discuss:

• The Berkeley Fire Department wellness program overview and team introductions
• Module 1 – Diet and using a continuous glucose monitor
• Module 2 – Stress management and the role it plays in mental and physical performance
• Module 3 – Sleep and happiness
• Module 4 – Sustainability and achieving long term goals
• Nutrino and the technology pieces to the puzzle
• The Oura ring: the most advanced wearable on the market
• Amory Langmo and his inspiration to develop the program
• Continuing education, empowering each other, and creating lasting change 

Show notes:

• 14Four framework plan developed by Chris Kresser
• Buddhify – meditation technique app
• Nutrino – nutrition-related data services, analytics, and technologies
• HeartMath – biofeedback and heart rate variability sensors
• Oura – smart, wearable ring: Use code “VISUALIZE” for $75 off of the generation-two ring, launching next month
• Zenbelly Catering – donated cookbooks and prizes

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Chris Kresser: Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. I’m really excited about today. We are going to talk about how to apply some of these concepts of Functional Medicine and ancestral diet and lifestyle that we talk about so much in a different setting. When I go to conferences and when I speak publicly, I’m often asked, “You know, Functional Medicine’s great, but it’s really expensive if we’re doing it in a one-on-one setting. It’s cost-prohibitive for most people, and we need to get this approach out on a wider scale. We need to start doing it in companies, we need to do it in our communities, and we need to roll this out in a different way than we’ve done so far.”

And that’s exactly what we’re going to be talking about today. So I’m actually going to turn this over to Dr. Sunjya Schweig, my co-director at CCFM, whom you’ve met. He’s been on the podcast several times, and he really headed up this program that we’re going to be talking about today. So I’m going to let him hijack my show and talk about this program and what happened. And we also have several other guests that were a part of this program that Dr. Schweig will introduce. So without further ado, I’ll turn it over to you, Sunjya.

The Berkeley Fire Department wellness program overview and team introductions

Sunjya Schweig: Great, thanks, Chris. Good morning, everybody, and good afternoon, good evening, wherever you are. So today we’re super, super excited to be talking about a pilot project that our clinic took part in and launched with developing a wellness program for the Berkeley Fire Department in the city of Berkeley. And as Chris mentioned, we do have several guests on the line today. I was going to run down who we have with us and we’ll jump in with each of them later.

But we have with us Amory Langmo, apparatus operator from the Berkeley Fire Department. We have David Sprague, the Assistant Training and EMS/EMT chief at Berkeley Fire Department. We have Danielle Cook, our California Center for Functional Medicine registered dietitian and health coach, as well as Tracey O'Shea, our CCFM nurse practitioner. And we have Yaron Hadad, the founder and chief science officer from Nutrino––a very exciting health and nutrition company. And we also have Chuck Hazzard, vice president of sales from Oura, one of the hottest self-tracking devices on the market.

There’s no question that Functional Medicine is the future of medicine—but how do we scale it to a wider audience? In this episode of Revolution Health Radio, we’ll explore one possible answer to that question.

So backing up, and we’ll jump in with each of those people shortly, but backing up, what we were talking about today is again, this wellness project that we took part in and developed for the city of Berkeley, for their fire department. And we were approached last summer by Amory, Amory Langmo, to develop this program for their incoming class of 10 new recruits. So basically, this is a group of 10 young men, all men. Sometimes I do have women who join the department, but this class happened to be all men, and their age range was early to mid-20s to early 30s. Average age was about 26. And we basically walked them through and developed this wellness program for the 20-week academy, training academy, that they were partaking in.

And I want to really give a shout-out to Amory and to the Berkeley Fire Department because again they came to us and it was just so impressive to have their insight and proactive thinking in even considering bringing nutrition information, Functional Medicine, ancestral health information, stress reduction information, how to optimize sleep, all these pieces, and bringing that to their recruits and to their department. And when we were asked, it was a no-brainer. We were so excited and immediately jumped on the opportunity.

And as we started having initial conversations with the department, with Amory, with Chief Sprague, it kind of came down to the basic ideas of what we are targeting. And really, we wanted to teach this class of new recruits skills and techniques for better performance to help them to be able to increase their mental and physical well-being. And also teach them long-term skills that could hopefully reduce injuries, workers’ comp issues, number of sick days that they might have to take, and again, provide them with these long-term tools for sustainability and health. So these new recruits, give them this at the beginning at their entry to the department, and then hopefully provide them with an education that would carry them throughout their careers. And as we’ll see, also the feedback we got from the recruits, it really did seem like that was achieved in a large measure. So really, really exciting.

But the hope also then, was that they would take this information, it would educate them at the start gate, and then they would bring it into the larger department, kind of like a trickle-up theory where, over time, these values and information would take a larger hold and really start to shift the larger culture of the department and bring health to the entire fire department in the city of Berkeley. And then also finally, we were really hoping this was an opportunity to pilot a program that could be a model for a wider rollout across the Berkeley Fire Department, maybe even other departments in the city, and beyond. So a really, really exciting opportunity for all of us involved.

So I want to invite Assistant Training and EMT Chief David Sprague to jump in here and do a little bit of an introduction into what inspired him and the Berkeley Fire Department to approach us with this project in the beginning.

David Sprague: Yeah, thanks for having us. I’m super excited to be here, and this was a really cool experience for us that we’re hoping to continue, and like you said, Doc, take pieces of this and roll it out to our whole department. So essentially the idea was we put our new hires through a 20-week really physically and mentally intensive experience there Monday to Friday, 8 to 5. There's a PT component every morning, and we've done a variety of different kind of exercise regimens, but it's always very intense that starts out the day. And then the rest of the day is a combination of didactic classroom time and a lot of physical manipulative work where they're actually learning the skills of what it's like to be a firefighter and how to pull hose and how to fight fire, and how to use power tools and hand tools.

Needless to say, it's really physically taxing on people. So we've always had a significant number of injuries in our academy, and most of them are strains, sprains. But even those can take somebody out of the game for a couple of days and put them at a significant deficit as related to the rest of the class. And we don't, it's really difficult for us to stop, hit pause and bring them back up to speed. So those are the common injuries and although they don't oftentimes put people off work, they have a huge impact on our instructional schedule. On top of that, once you get out of the academy, which is a really controlled environment, you get into the field and we work odd shifts, 24- or 48-hour shifts. You can be up all night, so you can be, calls coming in all day, so missing meals. Or you're scrambling to get a meal.

And this, over a career, this can lead to poor diet, especially if you don't know how to make a quick meal or grab a quick bite. Interrupted sleep just has a cumulative effect on our health, and it's a stressful job on top of that. So you kind of add all those things up and we realize we had a need to kind of address all of this stuff in the very beginning of somebody's career with some basic education about nutrition, diet, sleep, stress, and look at how we're physically conditioning in the academy to better reduce injuries, maintain flexibility, and create healthy lifestyles that people can learn in the academy and then carry out throughout the rest of their career.

Sunjya Schweig: Yeah, absolutely. Yeah, and again, we were super honored to be able to come in and assist with some of those educational pieces. So, Chief Sprague, again that’s, we’re real excited to be part of this project with you guys, and I really applaud you and your department for this level of forward thinking. And the fact that you were, I think we’re all in the right stage at the right time to bring this to the department. But the fact that you were able to present this information to your fire chief, David Brennigan, and also your deputy fire chief, Abe Roman, and that they were excited and willing to sign off on this, I thought that was really impressive.

David Sprague: Yeah, I agree with you. I think the time is right. This is, I think, something that we’re going to start seeing fire service-wide, and once we push this proposal up the chain with what the work that you and Amory did, it was pretty much a rubber stamp at the top is, yeah, let’s see if we can do something better. We’re all for more education, and we realize, especially, kind of, nutrition, stress management, sleep management is a gap in our knowledge base. It’s a huge issue in the fire service. So let’s talk about it. Let’s experiment and see if we can do better.

Sunjya Schweig: And do you know of any other fire departments that have developed a similar program that bring this type of information to their recruits or their firefighters?

David Sprague: I don't. Amory might have a better handle on that. But I know that especially sleep management and sleep deprivation is a hot topic in the fire service, and improving our wellness specifically around cancer prevention is a big area that people are looking at.

Sunjya Schweig: Yeah, yeah, absolutely. We talked about that a fair amount in terms of considerations for the phase two of this project. So very good, very good point. So again as we develop this program, it was very much within our wheelhouse here at CCFM because we were able to really kind of develop that nutrition piece. And we'll talk about some of the in-depth dietary work and interventions that we did. We also provide robust education around sleep, we’re able to provide tracking and data on that for the recruits, as well as the stress management piece.

So I want to kind of go through some of the nuts and bolts of exactly what this looks like. So the program development happened over the summer, the academy started in October and ran through about mid-March, about a 20-week-long program. Ten new recruits. Again, all male, average age was about 26, almost 27 years of age. So fairly young and healthy. And we broke the program down into four different modules. And I’m going to invite Danielle and Tracey to tell us a little bit about how the modules were organized and implemented, if you guys want to jump in....

Module 1 – Diet and using a continuous glucose monitor

Danielle Cook: I’ll go ahead and jump in. This is Danielle. Thanks for having this. This is great to be talking about it, and it was really a wonderful opportunity to be able to participate in this. The recruits were really fun to work with. So I'm going to just talk about the first module that we did, and that was the nutrition module. And we really wanted to address nutrition as a piece. One, it was one of our requests, but secondly, a lot of the meals are eaten at the station in groups. And so if we could educate new recruits about healthier eating, then that could have, like Dr. Schweig said, it could have a really widespread effect.

So what we did was we used the 14Four framework developed by Chris Kresser, and we used that as our framework for the whole diet program. And what we did was we did an in-person module and presentation on nutrition, and we talked about a whole-foods diet and just general nuts and bolts of healthy eating. And then what we did is we talked to them and taught them about the 14Four reset diet. And what it is, is it's just a whole-foods, nutrient-rich Paleo diet template. And then what we did is we had our recruits follow this diet for a two-week period. And we wanted to see if the diet would make a difference in their blood sugars. So we had them wear what's called a continuous glucose monitor. It's just a little device that they wear on their arms and that measures their blood sugars throughout the day, just continuously.

Sunjya Schweig: Yeah, about every five minutes, right?

Danielle Cook: Yeah, yeah. So we had them wear this monitor, and we had them wear that before they started the diet to get some baseline measurements just to see what their average blood sugars were before starting a diet. And then we had them do that one week into the diet reset. And we had some, we're going to talk about some statistics at the end and just some improvements and pretty impressive improvements we saw in their blood sugar readings just from one week following this reset diet. And then the other thing we had them do was we wanted them to track what they were eating, for several reasons.

One, to see if there was any correlation in what they're eating to what their blood sugar readings were. And the second reason is we wanted to see what they were eating and also bring some awareness to what they were eating. And so what we used was a device or an application, Nutrino, and Yaron is going to be talking about Nutrino a little bit more in depth, and also looking at some of the data that we got from these Nutrino reports. And Tracey, do you want to go ahead and talk about the stress module?

Module 2 – Stress management and the role it plays in mental and physical performance

Tracey O'Shea: Yeah, sure. This is Tracey, and I do want to just reiterate what Danielle and everyone else has said about what an amazing experience this project has been. And it was just really enlightening to be part of. And so we're really excited to see what the future holds. So I’m going to talk about our second module, which talked about stress management, and particularly, we really wanted to give the recruits education and discuss the impact that poorly managed stress has on both mental and physical performance.

And specifically, we really wanted to discuss the role that chronic stress plays, especially in the unique environments of the emergency service occupations and how to kind of work with them on balancing stress response both in the work environment, but also once they go home and they have an opportunity to decompress, and how to do that, and how to be successful and create a sustainable stress management practice.

Sunjya Schweig: Yeah, yeah.

Tracey O'Shea: Yeah. So we gave them tools for balancing stress response and specifically really recommended technology applications where they could use at home on their phone and also something that they could create as a daily practice. And specifically, we were able to provide through generous donations the HeartMath biofeedback and heart rate variability sensors, so that the recruits could have real-time information about how well they are able to kind of bring themselves down from a high-intensity situation, which we've seen in research to be especially important for these emergency service occupations. And we can talk a little bit more about that, but that specifically was what we were trying to do, is find the sustainability and a way to provide these recruits with long-term management tools. We also were able to introduce breathing and meditation techniques that recruits can do on their own, like 4-7-8 breathing and being that they may not necessarily need their phone or need some technological device to get through.

Module 3 – Sleep and happiness

So we provided them with some techniques, and then we also encourage participation in some of these challenges where we asked recruits to incorporate a stress management technique that they liked, that they enjoyed, that they found easy to implement into their life for 30 days at a time. So we could look to see how well their heart rate variability changed before they were really learning these techniques and tools, and then as they were starting to implement them daily. So that was the stress module in itself. And then the third module we moved into was the sleep and happiness module. And as Chief Sprague kind of alluded to, it's difficult when the recruits and firefighters are having odd hours and they never know how many calls they may get in their shift, and sometimes there's a lot of downtime and other times it's just go, go, go, and it's high intensity, and so being able to discuss shift work and how we can provide options for the recruits and firefighters to kind of decompress and get back into a normal sleep pattern once they get home.

So that's really what we focused on in the sleep module. It's how to optimize sleep for emotional well-being. Also daily performance and safety, because as we all know, there's a lot of information out there about poor safety and accidents and things that happen when people are tired and when they have lack of sleep or just not high-quality sleep. So we were really looking for kind of that safety in daily performance as well as overall longevity and vitality and health. So we provided information and different solutions on how to kind of shift from those long hours, high-intensity work with not knowing how much sleep you'll get to kind of getting back into the normal routine in between the days working.

We also encouraged a technology-free zone in the bedroom for 30 days. We really were talking about the impact that technology and certain lights have on your quality of sleep and ability to fall asleep. So we really focused on technology and the impact that that has on sleep. And then we kind of transitioned into the happiness module and how overall attitude and your outlook on life can influence health. And we really discussed neuroplasticity and how experience-dependent neuroplasticity and the things that you do and the actions that you take can really create these positive neural traits and create for more happiness and more enjoyment and kind of overall this practice of gratitude and finding joy in daily activities and how that impacts your health in kind of a more general sense.

Sunjya Schweig: Yeah.

Tracey O'Shea: So those were the stress and sleep modules. I think Danielle was going to kind of jump in for module 4, which was our sustainability and wrap-up module.

Module 4 – Sustainability and achieving long-term goals

Danielle Cook: Yeah. So the last module was a great opportunity for us to sit in front of the recruits and not only review what we had done throughout the program, but also get feedback and hopefully work on improved programs in the future to make them even more effective. And so what we did is we went through each of the modules and just reviewed each of the modules, and we wanted to also develop long-term goals within each of the modules. So a long-term goal for nutrition, stress reduction, optimizing sleep, and practicing a gratitude practice. And so we had them fill out some funnels to do some goal setting.

And the other thing we did is we went through a survey just to assess how they liked the program and how much of the program they enjoyed, what parts of the program they would like to see some improvement or maybe some expansion. And like Tracey mentioned earlier, with sleep and stress, to a high extent is, their work is kind of shift-like and it's really hard to get a regular routine for sleeping. And so that's one of the areas that we definitely want to delve further into in the future and do some more research on that and really get some sort of sustainable plan together and work with the fire department to get a sustainable plan together to really optimize all of their individuals’ or their employees’ sleep. Because that's a huge challenge, and that's one of the things that we found that we wanted to really talk about more. The other thing we did is we reviewed a lot of the data.

So we reviewed the Oura data, which measured heart rate variability and sleep quality, sleep duration. We also reviewed the HeartMath, some of the HeartMath. We didn’t need statistics for that, but just people's experience with HeartMath. And again review how it can be useful, especially and in emergency career-type situations where they’re coming from very high stress and having to then practice some sort of modality to relieve that stress. And HeartMath has been shown in numerous study situations to really be beneficial and effective for that.

And then we also reviewed the Nutrino data and again, Yaron is the expert at this. So he’s going to review some of that data for us today. We reviewed a lot of the high points and talked about how the reports can be useful to them and what kind of information they can glean from those reports to take into their data.

Sunjya Schweig: Yeah. Thanks, Danielle and Tracey. And yeah so it was really a learning process all the way through for both sides, and I just want to touch on that piece. Because we talked a lot in the sleep modules and the stress modules about shift work and the effect that that has on the individual. However, fire department life and lifestyle and work style is a hybrid, where they’re doing this sort of shift work and they’re doing 48 hours on, basically where they can be called at any point in time, and have broken-up nights and broken-up meals and sleep cycles, etc. But then they transition to four days or so of off time.

And so we had to kind of really think our way through that, and I think that that’s something we want to do better on the next round, which is really … And one of the training officers, recruit training officer Dewan Turner, was talking to me about this at the end of the program, where again, you have to be trying to target that circadian rhythm shift work piece for the 48 hours on, and however when they transition then, it’s almost like you have several different stages that happen. They go through a day of kind of reset, they have a couple of “normal days,” and they have a day or so of ramp up before they get back into their on shift. But simple things like, if you're out on a call at two in the morning and you get back at 3:30, you might be tempted to hop on your phone and kind of say well, so I’m all kind of wake up anyways. But really no, you wanted to reset. And some of the meditation techniques and stress reduction techniques, we also used an app called Buddhify, which is one of my favorites for on-demand sort of, as you can do a short meditation in a variety of different real-life settings.

But we really wanted to just train these recruits that the more different time points you touch in and find that relaxation plays that parasympathetic nervous system balance, it becomes easier and easier to find it over time, and more and more effective. And so you can really help your body to reset, shut down, get back to sleep, not be as ruffled by a stressful call, stressful event, or a fire, or a motor vehicle accident that you have to deal with, and get back to your normal routine. So very, very exciting.

I want to touch on some of the data that we gathered as we went through this. And so we did do baseline lab studies for comprehensive metabolic markers, blood sugar inflammation, vitamins, etc. We had hoped to do post-follow-up labs on those as well, but that proved to be difficult. But some of the initial readings that we got, even though these guys are young and healthy, that we did see some abnormal values over the group that really were interesting to us to find because they're the kind of thing where if you intervene early, you can prevent a lot of long-term illness. So, you know, 85 percent of them had low vitamin D, 70 percent of recruits had low B12, all of them had increased markers of inflammation on some level, 71 percent had some markers of blood sugar dysregulation, over half of them, about 57 percent, had abnormal cholesterol markers, and 85 percent had an imbalance in their omega-3 ratios.

So again simple interventions and dietary interventions optimizing nutrient intake, maybe some supplements in a targeted way, body composition balance, etc., really would go a long way. And given what we went through with the program, we’re pretty sure that if we did do those follow-up labs, we’d see some really cool changes and improvements. We also used, again, it’s been mentioned, but Yaron is here with Nutrino. We used the Nutrino app for tracking everything that they were eating, the recruits were eating and drinking, and again, paired this with a continuous glucose monitor measuring blood sugar every five minutes. So that we did this at the baseline and also during this reset diet phase so that we could really see how not only where different foods affecting each individual, but also the shifts as they went through changing their diet.

And then again we used the Oura ring to assess their activity, sleep parameters, different days of sleep, heart rate variability during the nighttime, resting heart rate, etc. Berkeley Fire Department also did a cool thing where they measured, they brought in a body fat, body composition dunk tank and had everyone jump into this tank at the baseline, and again at the end of the program. So we have some cool data looking at things like total weight, for example, the whole group as a whole lost 57.8 pounds. Again, the average was 5.78. The greatest loss, however, was 25.8 pounds. In terms of body fat percentage, the average body fat percent shift was a decrease of 3.5 percent, and the greatest was 6.8 percent. Lean muscle mass gain a total of 31.3, about 31.25 pounds of lean muscle with gain. Average gain was 3.12, and the greatest was 9.6 pounds. Exercise parameters include, they did a 2,000-meter row challenge where they basically got to sit there and row through a distance of 2,000 meters. And the average improvement across the group was 40 seconds, with the greatest being 81 seconds.

And on the diet and blood sugar side, again I just keep coming back to this fact that these are relatively young, relatively healthy guys. But by doing this reset diet we shifted their average A1C from a baseline set point of about 5.2 average for the ones that we could calculate to a post-reset diet of 4.9. And so these are across the board really phenomenal numbers and really, really exciting on our end to see really robust changes in this group of gentlemen. So I want to, if anybody has some comments, a comment or two on that before we move on, I’ll open up the floor for a minute.

Chris Kresser: Well, this is Chris, I just, I mean, just jumping in here. These changes are really, if you think about in terms of risk prevention, then these kinds of reductions in body weight and blood sugar that were observed in this pilot would have a significant impact on reducing the risk of type 2 diabetes and other conditions that are associated with excess weight. We know that these conditions unfold over a long period of time and that even small increases and by extension small decreases add up over time to make a very, very big difference. And cardiovascular disease, heart attack, is still the number one cause of death. High blood sugar and excess body weight are significant contributors to that.

So the fact that we're able to see these pretty significant changes in a relatively short period of time bodes very well not only for the individual health of each of the participants, but also for the impact on the city of Berkeley and the Berkeley Fire Department and organizations in general on preventing, lowering the cost of care for caring for their firefighters over time, which is a really big deal. And I'm sure others can speak better to that like David and Amory. But from a health care perspective, I think this is exactly the kind of change that we need to see where we're scaling these improvements that we all know are possible individually, on a group basis.

David Sprague: Yeah, this is Dave Sprague. I'll jump in with just a quick comment. I think we're in the same boat as everybody else. Healthcare costs are rising significantly every year. It's a crisis for the city. So doing anything we can to reduce the burden on that system by preventative medicine, we get a big thumbs up on. And I think the other, for me, more important part is the personal side of this. Nothing having to do with money, but we work with people for 20, 30 years, and it's really common for folks in our industry to develop mental illness, cardiac problems, other chronic health problems, cancers.

So watching people go through that in the latter years of their career or as soon as they retire is just devastating. So all of this leads to let's get people out the door healthy, let's get them out the door so they can enjoy their retirement, and that, I think, is the core of really why we want to do this. And the cost savings is just a kind of nice add-on.

Nutrino and the technology pieces to the puzzle

Sunjya Schweig: Yeah, absolutely, absolutely. We definitely share that. So I want to transition again to dive a little bit deeper into some of the technology pieces that we were using. Nutrino was with us from the start, and Yaron Hadad, the chief science officer and cofounder of the company is here with us today. And he was instrumental in helping us design that part of the program. So we really appreciate his help. And so basically, again, we tracked everything that the individuals were eating and drinking, and mapped this to continuous glucose monitored data, where we were gathering blood sugar levels every five minutes across the two weeks that the recruits had the device on. And this proved a little bit problematic.

The devices, the little sensors proved difficult to keep them on, given the intensity of the work. We had to call the company who manufactures them, Abbott, at one point, and say, “Hey, what's your take on if this sensor goes into a 200-plus degree environment? The fire department recruits are in a fire environment with all their gear on, etc.” So we had to adjust a little bit according to the unique situation that we were putting the technology through. But I want to invite Yaron on to tell us a little bit about the technology and tell us a little bit about the FoodPrint reports that we developed, that he developed for each person pre- and post-diet.

Yaron Hadad: Great, thank you, Sunjya. So first before I start, I just want to say that this program has been a very unique and wonderful opportunity for us. We also got to learn a lot about the FoodPrint and putting our technology in the hands of people who are going through this very rigorous and extreme physical program, which is really interesting. So Nutrino at its core is a nutrition analytics platform. We developed this concept that we call FoodPrint. FoodPrint, for us, is the signature of how different foods affect a person's body, and our platform is collecting data from over 100 different sensors, wearable devices, medical devices, and other services in order to try and quantify how an individual responds to different foods.

So I always like to say that if we could, we would integrate with, we would try to measure anything that might either be affected by nutrition or affect metabolism. And as this audience knows probably better than anyone, this practically means everything, just because of the complexity of the human body. So we collect information from sleep sensors, activity sensors, the Oura ring being one of those, from continuous glucose monitors. We today integrate with all the continuous glucose monitors on the market, both the Medtronic, Dexcom, and Abbott devices with insulin pumps, blood tests, genetics, and several other things. And we try to help individuals go through this experience where they get to track for a short period of time what they're eating together with data that is streaming from whichever device they might have and then provide them with a simple report that allows them to really see visually how different foods affected their bodies.

And in this case what we did with the Berkeley Fire Department and with you, the California Center of Functional Medicine, we did the program as it was focused around glucose management and nutrition, and we led the Berkeley … the recruits actually collect data about foods that they're eating just by monitoring them using an image. So they all got the Nutrino app, they didn't have any way to even open the app, but just capture images with their normal camera of what they're eating throughout the day and afterwards behind the scenes. We generated this FoodPrint report that visualizes the foods that were eaten together with the glucose responses for each specific food.

Sunjya Schweig: Yeah. So then we're also looking at things like the delta blood sugar, the change in blood sugar and also the insulin area under the curve to try and understand the effect that a given food has, and then your report actually provides a fairly simple visual A through F grade of a given food. Can you talk a little bit about that and what data is contained within that, behind that grade of the food?

Yaron Hadad: Sure. Definitely. So, yes, so the report provides multiple outputs as they relate to the responses to individual foods and also generally about the glucose trends during the time that each report was connected. We take into account today over eight different parameters that allow us to quantify how “good” or “bad” each response was. One of them, for example, is the incremental area under the curve, which is just the area that is between the glucose curve and that base glucose that was at the beginning of the meal.

Generally assuming, and there are quite a bit of studies around this, that it's better to keep the glucose levels balanced. So you want to minimize that area. Other things that we measured include things like average glucose during the two, three hours post-meal. How big was the spike in glucose levels? What percentage of time the individual was actually in a reasonable range? And all these parameters together are obviously very, maybe very difficult to interpret just because there are so many different ways of quantifying post-prandial glucose responses.

So what we do, we combine them together into a very simple A to F score for each specific meal, A being great job, and F being a meal that had a response that was not very good. One of the most important things to realize when reading these reports is that my A won't necessarily be someone else's A. So even those scores are individualized in terms of the individual responses that a person has.

Sunjya Schweig: Yeah, absolutely. So, I mean, there’s a variety of different insights that came out of the reports, however. Things like, that were not surprising, for example, that you know a turkey sandwich or a tuna sandwich with a big bun, that that created a score that was lower, a C or a D score. I’m looking at one of our recruit’s reports right now. So not surprising, a high-carb load, a big chunk of bread, etc. But there are also some insights that were a little bit surprising and also that buried a little bit and we had to kind of dig into a little bit.

For example, one recruit would have just a black coffee or sometimes even with MCT oil in it. And on one day that looks fine, he got an A, and on another day it didn't. It looked more like a D or an F. And so we were really kind of, and as you know better than anybody at this point, Yaron, it gets very complicated, right? Because there’s other factors. Not just what you ate in proximity to that meal, but what your exercise pattern was around that time or previous, or how you slept the night before, or what your cortisol response might be from stressful events the previous day. So how are you guys tackling that going forward with Nutrino in terms of some of the incredible variations that we see within the human organism?

Yaron Hadad: Yeah, definitely. That's a great point. So one of the things that we realized while working on this technology is that there are actually two kinds of variabilities when it comes to the responses people have. One is interpersonal variability, meaning that two people eating the same food under the same conditions often have very different responses. And the second thing is what we call intrapersonal variabilities, meaning that if I’ll eat the same, say, apple under different conditions, I may have different responses to that apple, as you mentioned. And that has to do with other things that may affect glucose levels, like exercise, like lack of sleep the night before.

So we saw, for example, that often when people are not sleeping well, in the following day their glucose responses are being amplified. Things like stress, menstrual cycle, and so on. And this is exactly, to answer your question, one of the reasons that we integrate all these additional inputs into the FoodPrint. And I think that a technology like the Oura ring could be instrumental in that sense because then you could actually put a lot of these responses in the context in which they were generated. And the context here means going beyond the food to other things that may affect it, like sleep, like exercise, and so on.

Sunjya Schweig: Yeah, absolutely. Very exciting, very exciting. It was really, really fun to work with you guys on this project. So thank you again for your involvement.

Yaron Hadad: Thank you. It was fun for us too.

The Oura ring: the most advanced wearable on the market

Sunjya Schweig: Yeah, great. So I want to shift over and talk a little bit about the Oura ring and some of the information that we gathered with that. The Oura ring is, in my opinion, one of the most advanced wearables on the market. And as the name states, it's a ring that you wear on your finger, and it allows us to track activity and sleep through movement and gyroscope accelerometer data, etc. But also allows us to track heart rate, so resting heart rate and heart rate variability.

And heart rate variability is one of the most fascinating parameters, in my opinion, because it gives us this little window into the set point and the balance between the sympathetic nervous system, the fight-or-flight nervous system, and the parasympathetic nervous system or the relaxation part of the nervous system. So by being able to see that and see changes in the heart rate variability over time is a very, very profound marker in terms of just global stress on the person, but also in terms of workouts, in terms of training, as is used a lot in high-level athletics to understand, is today a day when I can go hard and train intensely or am I showing some signs of stress in my body from either a previous training session, or maybe I'm coming down with a cold, or I didn't sleep enough, or I was traveling, or I had some alcohol, etc.

So this marker can give us a window into this, again, that set point of the body’s nervous system. So I want to bring Chuck Hazzard on, but I want to just kind of mention a couple of insights. So basically, we had the recruits wearing these devices, and they can log on to see a dashboard of all their data, but for each recruit I prepared a report just pulling in some insights for a single night. For example, in one recruit, we demonstrated a drop in heart rate variability again. So you want high heart rate variability, and increased heart rate variability is a sign of a physiological nervous system health. So we saw a drop or a decrease, which is not a good thing, after some sleep loss. So a couple of nights of not sleeping, total sleep was low, deep sleep also dropped, and then we see this big drop in the HRV. And we also see a compensatory or simultaneous increase in the temperature for that person, another sign of physiological stress.

We also, another recruit, we’re able to demonstrate this overtraining effect. So where they had this very intense workout the day before, and again these guys are working hard, but there was a variation, there were some days that were harder than others. But after one particularly intense day, this recruit showed low HRV, heart rate variability, elevated resting heart rate, elevated respiratory rate, also signs of physiological stress, a drop in total sleep, and also more awake time during the night. So restless sleep and non-restorative sleep. So this data can also be used to kind of fine-tune training regimens, etc., and make sure that they're optimized for the variations that are happening within that person's physiology.

And finally, we showed one recruit’s total sleep time was okay, had a drop in deep sleep, increased HRV, and respiratory rate, increased temperature. I’m sorry decreased HRV marker dropped and this was a Friday night. And I said, what’s going on? Were you all partying the night before or something? Or not eating anything? And he got a big chuckle and said actually, yeah. So it was showed this response where, with an alcohol intake and staying up a little later than normal routine, that it had this physiological effect. It gets a little Big Brother-y in a way, but on the other hand, it was really cool for the group to see this insight and to understand, it’s fun to go out and have some beers, etc., but to understand the effect that that has on their organism and how it affects their HRV, their nervous system, how it affects their sleep, etc.

So again, very, very cool technology, and we got a lot of great feedback on some of the recruits both using Nutrino and the blood sugar tracking, as well as using the Oura ring and the data that presented. They really liked that. It really resonated; it really helped them understand what was going on and cement some of the more theoretical data that we were presenting in the lectures. So Chuck, why don’t you hop on? Chuck, again, is the vice president of sales for Oura. And I want you to talk about what Oura does, about your company, and any thoughts or insights that you have from our discussion today.

Chuck Hazzard: Okay. You’ve done a pretty good job explaining already what Oura is about. It's a wellness ring, so it's very unintrusive to someone's day to day life. And as you mentioned, we for the most part, we track most of the metrics while you're sleeping at night. So heart rate, heart rate variability, respiration rate, and those attract at a very high sampling rate. So we get clinical grade measurements from that sensor, which are infrared sensors. We also track your temperature.

While you're sleeping, your core temperature and your skin temperature normalize against each other. So you can actually get a good estimate of what your core temperature is while you're sleeping from the skin. And as you mentioned, we have an accelerometer, that gyroscope, to actually measure movement while you're sleeping. And all of that data is combined to give a sleep score, which is an indication of how restorative your sleep was. And that then falls into a lot of the same metrics, give you a recovery or a readiness score, one of which is your heart rate and heart rate variability. And so what we look at is not only when your lowest heart rate occurred during your sleep, I mean what it was when you're sleeping, but also when it occurred.

So in the example of the firefighter that went out drinking, that will always show up as having your lowest heart rate occur later in your sleep because you're revved up, and the consequence of that is you don't get as much deep sleep, which happens earlier in your sleep cycles. And so your sleep is usually not restorative. And that in turn will lower your recovery, and you'll see that in an overall higher heart rate and lower HRV. So the data from the ring is transferred to a smartphone, either iOS or Android, and then we push it up to our cloud, which has a richer dashboard for anybody to look at, as well as we support other companies like Nutrino to hold the data for ring users to their own platform using what's called an API. That’s kind of it in a nutshell.

Sunjya Schweig: Yeah, great, thank you, Chuck. Yeah, so one of my favorite things about the Oura ring … and I think part of is why there's a lot of trackers on the market, a lot of wearables. It’s a hot area. We’re also trying to kind of crack the code on how to really integrate these and develop insights for healthcare and for really shifting people's … what they're doing with their daily routines and health.

But the part of why I think the Oura ring works better than many of them is the fact that the sensors are on the underside of the ring and so are basically in contact with the digital artery in the finger. And it’s much easier to pick up a really high-fidelity signal of the heart rate and therefore using your algorithms to calculate the HRV, heart rate variability, it’s much easier to do that from that point than it is from a wrist-mounted device where it's a lot harder for the sensor to get a read on the pulse. Is that right?

Chuck Hazzard: That's exactly true. The wrist monitors are going against your capillaries and it's really a dirty place to measure data. And there's lots of reasons, I won’t go into all that. But it’s almost impossible, even though they’re getting a better clinical grade signal off your wrist.

Sunjya Schweig: Yeah. So you guys are coming out, we had the first-generation rings that we’re using, but you guys are coming out with your second-generation ring set to launch in about a month. Is that right?

Chuck Hazzard: Yeah, let’s see, the end of, we’ll start shipping the new rings at the end of next month, and yes, it is. It’s more like a man’s wedding band in size, which at least in, we know the firefighters will make it much, much easier to put gloves over it than the original ring. So it’s an easier form factor for a lot of industries including healthcare, where if they’re wearing surgical gloves or something like that.

Sunjya Schweig: Yeah. The form factor is pretty amazing on the next generation ring, and I do really want to give a big thanks to you guys and to your president, Harpreet Rai, who’s a friend of mine over here in San Francisco. But we got his go ahead on this project probably through August, September timeframe. And then by the time it was time for me to bug him and say, “Hey, can I pick up the ring?” you guys had basically gotten a huge amount of international publicity at that point and your whole inventory was basically, dropped down to zero. And it was a little bit of a tricky thing for him to come up with the 10 rings for the recruits, but he pulled through and we're super appreciative because it was a really fun part of our program. So thank you for that.

Chuck Hazzard: Yes. No problem.

Sunjya Schweig: And just for the listeners, we do have a link if you guys want to order an Oura ring, use the code “VISUALIZE”. That’ll get you $75 off of the generation-two ring, which is again launching next month. So I'm really excited about trying to get these onto all of our patients. The dashboard feature was great because I can then log in as a clinician and can just see the trends and see what’s happening in these people and start to understand the physiology between visits. So really, really fun for me. So I want to take a minute, and we did some post-surveys of the recruits, and got some great feedback. But I want to take a minute just to read some of those for everybody and for our audience.

One recruit said, “I really enjoyed the introductions to sleep module. I learned a lot and have been able to improve the quality of my sleep that I'm getting. And I also like the overall tool given to us to monitor our health. Overall, everything was very helpful and will have a long-lasting effect on my daily routines.” Another person said, “I will continue all of these modules in my day-to-day life. I really enjoyed the information that you gave us and I believe this will have a beneficial effect on my career.”

We got a lot of great feedback. Many of the recruits said that they really expected they were going to change their eating habits over the course of their life. For example, one gentleman said, “I’ve learned a lot about nutrition, which will basically change how I eat forever.” So really, I think that in part and in large measure, our goal … Chief Sprague and Amory are bringing this information in at the foundation level and giving people the opportunity to absorb new information that they would take with them and bring it to the department. I'm very excited at this point about that likelihood possibility. So again, really fun stuff. So why don't I open up the floor a little bit if anybody has some thoughts or discussion. Anybody want to jump in?

Amory Langmo and his inspiration to develop the program

Amory Langmo: Hey, Chris, are you able to hear me now?

Chris Kresser: Yeah, I am. Perfect.

Amory Langmo: Awesome, awesome.

Chris Kresser: So, I’d love to get your input and thoughts.

Amory Langmo: Yeah, absolutely.

Amory Langmo: Okay, you just want to hear a background of how I kind of developed the program?

Chris Kresser: Yeah, exactly. What inspired you? What brought you to it? And then talk a little bit about your experience with it.

Amory Langmo: Yeah, absolutely. So when I graduated high school about like 19, I was probably at 260 pounds, like 25 percent body fat, and just stumbled onto the ancestral health kind of model. And now I’ve for the last 10 years been 200 pounds, 13 percent body fat, and just cruising. And so I wanted to share that information with my co-workers and my friends and family, and listening to Robb Wolf’s podcast, I had heard that you had opened up CCFM out of Berkeley and that I also knew that he had done some work with Reno police and fire. So I just wanted to bring that model to the Berkeley Fire Department.

Chris Kresser: Great.

Amory Langmo: Yeah. And I just wanted to touch on fitness, nutrition, and then sleep, and that’s how I kind of developed the three different models that we ended up going with. And then you guys took that and ran with it and added all the awesome technology that I think made it even that much better.

Chris Kresser: Cool. And with this stuff, there’s so many different considerations because when you’re working with an individual, there’s just, and that individual is 100 percent gung ho and on board, that’s one thing. When you’re working with an individual and you encounter some resistance to change, that's one thing. But if you're working with an organization, there are a whole bunch of other considerations, like making sure that all the different stakeholders are on board and dealing with different perhaps political and economic restraints. So what has that process been like for you as the, kind of, one of the champions of this program? Did you meet much resistance? And if so, how did you overcome that? Because I know that other people in organizations around the country and around the world are going to be really curious about this. But also facing some potential obstacles.

Amory Langmo: Yeah, so, I mean, I had initially kind of came up with the idea several years ago. But it's a pretty progressive program, and I just didn’t think that I would get much traction with it. And there was a big push to kind of spend the money on replacing some fitness equipment. But I kind of wanted to use education more than fitness equipment to make the department healthier.

So when Sprague got into training, he sent an email out. I think at the time Sprague was looking for a physical therapist to kind of help people navigate some workers’ comp injuries, and I thought that maybe we should create something that’s a little bit more proactive and less reactive. And so I reached out to you guys and said I wanted to create a new pilot health and wellness program. And we started to get to work from there, and it’s been pretty incredible, the results that have happened from then. Hopefully these guys take it and they’ve got to work until another 30, 40 years in a profession that’s pretty hard.

So hopefully this is … it sticks with them forever. Even if they fall off the horse a little bit, which can, it’s pretty common to get out into the firehouse and there’s always, people make these giant carb-loaded meals and stuff. If they start to gain a little bit of weight, they’ll know how to get back on the horse and get back on track now.

Chris Kresser: Right. I mean, it seems like there’s some unique both challenges and opportunities in a fire department because of that communal aspect where the firefighters are in the … they’re together, they’re preparing meals together. So the upside is if most of the people are on board, then the few folks who might not be on board kind of have to go along for the ride. But the downside is that you have to kind of get buy-in from everybody. If one or two people are just doing it on their own, it can be pretty difficult for them to maintain it in that group environment.

Sunjya Schweig: Yeah, we're seeing that transition right now as we're starting to plan the next phase of this protocol. And Dave Sprague, Chief Sprague and I have been having several conversations back and forth about the recruits, the program that we did with the academy, which we’ll hope to repeat again this fall with the next academy. It's a very unique set up.

These are trainees, they're basically under department control for the nine to five hours of the day and are in this sort of training mentality program. And so we have a lot of leeway, we have a lot of power in some ways to kind of say, okay, here, we’re going to try this and we’re going to do it for this long. And they basically just followed what we asked them to do. But the transitioning of that to the larger department with the power structure as it is, and some people who may be interested like you mentioned, Chris, versus some people who are not interested, it’s going to be an interesting shift to see what kind of change we can still affect for people. And I think both Amory and Dave Sprague were really clear the whole way through that probably a really high value proposition is to do what we're doing, train the recruits and have them bring the information into the department instead of trying to bring it in from the outside and pose it from a kind of a top-down point of view.

The adoption is going to be much higher if there’s somebody saying, “Hey, what are you eating? You made that with an Instant Pot? Like, what do you mean?” Yeah, so, teaching each other, basically “train the trainer” concept. So that's kind of what we're looking at for phase 2.

Continuing education, empowering each other and creating lasting change

David Sprague: This is Dave Sprague. I think, Chris, you kind of touched on an important point that we should talk about a little bit, which is how do you … we all might do these things or some of these things in our personal lives, but then when you get to work and you get in a group environment, the dynamics shift, and maybe you don’t want to talk about what you do because you’re worried people are going to make fun of you.

Or you don’t want people to know that you meditate, or whatever it might be. I think there’s some significant challenges there on successfully implementing a program like that. Like this, what we’re talking about on a larger scale. And honestly, I don’t think we necessarily have the answers. But one of my ideas is that we provide people data about their health. So more in-depth blood panels, data about their heart rate variability, whatever else we can to kind of let them know what we've been talking about this whole time. Where are they at?

And then once we have them, once they've been educated about what the data is, what it means, then we come in with some ideas of like, okay, here are some people and some ideas that can help you make a change. But I think it has to be initiated by the individual. That person has to want to change, right? Or has to want to do something.

Chris Kresser: Absolutely. Of course, we see that individually you can never … well, you learn as a healthcare practitioner, you learn that the easy way or the hard way. If you tell someone to change and they’re not ready to change, it’s not going to be very effective. And this is where I think we can actually employ the tools of health coaching to make a big impact because I would say up until pretty recently, actually, the idea was that just giving people information is all you need to do in order to get them to change.

But we actually know now through a lot of research that that’s not the case. And we don’t even need research to tell us that. I mean, everyone who’s listening to this can reflect upon their own experience and times they’ve been told what to do, and given the information about why they should do that, and not done it. I mean that’s just part of human nature. We, for whatever reason, we naturally resist being told what to do. And there are a ton of methodologies and ways of supporting people to make change that aren’t actually oriented around just providing information.

So an example from what we were just talking about would be the stages of change, which is a framework that was created by a psychologist named Prochaska for helping to understand the different stages people are at in a kind of … if you consider change on like a linear spectrum, where on the far end of the spectrum they're not even contemplating change, they're totally in whatever they're in, and they're not even thinking about change, to well, okay, maybe they're thinking about change but they're not quite ready to do it, all the way to the other end of the spectrum where they're completely ready to change and gung ho about it.

And understanding where people are on that spectrum can lead to creating more effective interventions to move them to the next phase of the spectrum. And then there are techniques like motivational interviewing, which help people to really identify and connect their deeper motivations to behavior change. So, for example, if somebody has almost type 2 diabetic blood sugar, maybe just their own health isn't actually enough of a motivation for them to make that change. But seeing their grandchildren grow up and graduate from college and being able to play a meaningful role in their lives and stay active is enough for them to make that change. And so for that person, connecting that motivation to see their grandchildren get older to their diet change is going to be the key to success. So I think we can use these more evidence-based behavioral interventions to leverage our efforts and our impact as well.

Danielle Cook: This is Danielle. Yeah, I just wanted to emphasize that what Chris said, but also I think we can actually use the groups and the group environment and just the environment in a fire department and leverage that because there's a lot of power in groups. And just working with a group, a group visit-type setting or where you're utilizing some of the coaching techniques, it can be even more powerful in a group setting. So I think over time, as that environment changes, it’s going to become this part of the environment of the fire department over time.

Sunjya Schweig: Yeah, we saw that with this group of recruits because they fed off of each other. They were sort of learning from each other and seeing what diet shifts made and what sleep, or how their sleep changed. And hearing what one of the recruit training officers, Dawan Turner, was saying, “Yeah, I’m using Buddhify, it’s great. I don’t always finish the meditation, but it really helps me.” So just having that level of discussion and acceptance within the department was really, really exciting to see. So I want to thank everybody for joining us today.

And again, big thank you to the Berkeley Fire Department, to Amory Langmo, David Sprague, also to the recruit training officers, Mike Dragovich and Dawan Turner, for all of their help in helping us interface with the recruits. I want to thank Danielle and Tracey on the CCFM side for all their hard work making this program possible. I also really want to thank our practice manager, Khristi Turchi. She really went above and beyond in helping back us up and making this feasible on our end. Thank you to Yaron Hadad, who we heard from today, and the whole team at Nutrino for all their generosity donating the continuous glucose monitors, the FoodPrint reports, and all of their time.

Thank you to Oura, the Oura ring company, Chuck Hazzard, who is with us today, and also to my friend and colleague, Harpreet Rai, who’s the president of Oura. I also want to thank Buddhify for donating codes for free access to their app. Simone Miller of Zenbelly Catering over here in San Francisco, she donated a bunch of cookbooks as prizes that we were able to give out to the recruits. And some of the challenges, we did a technology reset challenge, a meditation challenge, etc., to incentivize them. Also to Chris Kresser for donating books and 14Four memberships. And finally I want to thank Thrive Market, who also donated free subscriptions for the recruits, five-year subscriptions to their online market platform to hopefully help them have an easier time shopping, buying healthy food, stocking their pantries.

This has been an amazing experience for us at the California Center for Functional Medicine. We're very, very grateful and proud to be able to serve the fire department of the city of Berkeley. You guys do such important work and service to the community. And again it was just a huge honor to support the vital work that you’re doing. And we’re super excited about future opportunities to work together as well as future opportunities to expand our wellness program. So thank you again to everybody for joining us, and I’ll stop here.

Chris Kresser: Yeah, I just want to echo what Sunjya said and I think this really is the future of medicine. This is what we have to do, to scale Functional Medicine and these interventions so that they’re available on a much wider scale. Because we know that the current model of just private individual care is not going to be sufficient to reach the numbers of people that we need to reach with this. So I just want to say thanks, everyone involved, and look forward to more collaboration and more exploration about how we can get this really important model out to as wide of an audience as possible.

Thanks again, everybody, for listening. Continue to send in your questions to ChrisKresser.com/podcastquestion and we’ll see you next time.

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