Dr. Ted Naiman is a board-certified family practice physician, who leads a major medical center in Seattle. He not only reads a lot of the literature, but he interfaces with patients. That part is the most valuable, especially when we're thinking about complex systems and how can we help the most amount of people. You have to be able to take the literature and implement it into real-life practice.

In this episode we discuss:

• The ideal ranges for blood markers
• How to really move the needle on body fat
• The most effective ways to change your body composition
• How much protein you should be eating

This episode is brought to you by Inside Tracker and 1st Phorm.

• Ted Naiman - Visit Dr. Naiman's website to get your copy of The P:E Diet
• Twitter - Follow Dr. Naiman on Twitter

Mentioned in this episode:

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Dr Lyon: Dr. Ted Naiman. Welcome to the Dr. Gabrielle Lyon show. Clever name. I know.

Dr Naiman: Wow. so I thank you.

Dr Lyon: I was . I was just saying that you are in very good company, very well deserved company. This is a series on protein, nutrition, and really body composition, the other individuals in your series, which is the first series to be put out are Dr.

Stu Phillips, which of course, you know, Dr. Donald Layman, who you also know know, Dr. Tracy, Anthony, who actually came out of Don layman's lab and yourself, a current practicing physician.

Dr Naiman: Awesome. Love it. Yeah. Well I don't know Tracy, but Phillips and Layman, those guys are amazing. So like I'm so honored.

It just it's just such an honor.

Dr Lyon: And you know, one of the reasons why I really wanted to have you on is out of all the physicians in the space, in the nutritional space, in the medicine space, you and I actually see eye to eye on quite a number of things, which is incredible. And I would love for you to tell the listener, just really in terms of your let's start with your current dietary beliefs, just in general.

Dr Naiman: Gotcha. Yeah. So , well, first of all, you're right. I feel like you and I are separated at birth or identical twins. I don't know if that's possible or whatever, but we do seem to have some very similar belief structures. And I think that myself I've evolved over time about Just not understanding nutrition at all.

And thinking vegetarianism was optimal to being dogmatically low carb and sucked into the whole paleo sphere and keto and all these other things. And now I've arrived at this sort of place where I think I finally have a, just enough knowledge to realize that all of these macros and all of these plants versus animals and carbs as fat things are on U-shaped curves where there's too much or too little or just right.

And now the goal is to try to optimize for the individual, but really, really, really, really big picture. If I'm zooming out, I'm looking at nutritional density versus energy density, if you wanted to really sum it up.

Dr Lyon: So basically from a big picture perspective, you are saying nutrient density, In term versus energy density, which I'm assuming that you're meaning just calories.

Dr Naiman: I'm meaning specifically non-protein energy calories, which is basically carbs and fats. And so all of our problems are basically refined carbs and fats. That's pretty much what we're all afraid of.

Dr Lyon: What, what, what, we're all afraid. Well questionably, cuz at least I see a lot of people also afraid of protein, but I would say you and I both agree that the data really doesn't support that regardless of where you get protein from in your clinic, you do a lot of nutritional recommendations.

Dr Naiman: Yes, absolutely. Yeah. That's a just huge part of what I'm doing. .

Dr Lyon: And what is your foundational recommendations that you give people? Let's say someone walks into your office. She's a perimenopausal woman, and you're gonna give her practical information about what she should be eating.

Dr Naiman: Gotcha. Well, okay.

So like a really, really big picture. Every person who walks in is basically over fat and under muscled period, full stop. They don't know it. It may show up as they don't like the way they look or it may show up in their poor metabolic health or their prediabetes or their dyslipidemia. Uh, But whether they know it or not, they walk in with too much fat and not enough muscle.

And what they're really needing to do is recomp and not just one time recomp, but a permanent lifelong. Sisypheian recomp where every single day, you're trying to get a little bit more skeletal muscle and a little bit more lean mass and a little bit less fat mass. You're basically just constantly recomping at all times, every person who walks in and with the diet side, it really does come down to prioritizing protein higher, which supports your lean mass and minimizing carbs and fats, especially high energy density, refined carbs and fats, which are basically supporting your fat mass.

And so it just kind of comes down to more protein, less non-protein energy in a, in a sustainable fashion. So you can do it forever. And that's the really, really, really, really, really big picture.

Dr Lyon: Right. In terms of percentages, what do you typically recommend people have.

Dr Naiman: Oh, well, okay. Okay. So protein is what I'm focusing on most.

And if you look at worldwide hunter gather macronutrient estimates, you know, they're like 30 ish percent protein, and we have a lot of magical data in the medical literature on 30% protein where you basically cure a hundred percent of prediabetes automatically on ad lib diets and people just automatically get better composition.

So I'm a huge fan of 30% protein on just an ad lib maintenance calorie diet for someone of a medium exercise amount. Now percents are really, really kind of bad because if you are you know, training for an iron man you're burning 5,000 calories a day, that protein percent's gonna go way down and you actually do need way more non-protein energy, but if you're just your average person,

who's just moderately active who needs a long-term maintenance diet that's going to give them pretty good body composition and pretty good metabolic health. I'm usually targeting 30% protein of calories.

Dr Lyon: And I actually agree with you. I think that's really sharp that you brought that up.

So I actually really like that answer.

Dr Naiman: Right. Yeah. And the more active you are, the basically the lower you can get away with on the protein percent, if you're super active, you can just eat the standard American diet at like 12% and you'll actually be fine. But if you're very, very sedentary and your calorie plane is just flying one foot off the ground, you really need a high, much higher protein percentage.

In order to not gain a billion pounds,

Dr Lyon: Yes. A billion pounds would be incredibly uncomfortable. And you know what I think that you're referring to really is there's two ways to stimulate skeletal muscle and that's either exercise or dietary protein, and you have to balance that. The other aspect of that is when you think about protein, is there a gram, a per, is there a gram per pound, ideal body weight?

What kind of recommendations you typically give individuals?

Dr Naiman: Right. Right. So if I was just If I was in running a intergalactic zoo for aliens who had like a couple million humans in a enclosure, and they're like, you just need to come up with a diet that will make all these humans look and feel and perform pretty good.

So they stay alive in our zoo. Right. I would basically be choosing one gram per pound of ideal body weight for the height of the individual as a really rough starting point. So my general advice to most people is a gram per pound of your ideal body weight for your height. And that's not like how much you wanna weigh or how much you do weigh, which could be like 600 pounds or something completely outta whack.

But it's basically what you should weigh if you had like perfect body composition. So that's my target for most people. .

Dr Lyon: And then what about carbohydrates and fats? How do you determine, or do you, let me ask you this, do you determine dietary recommendations for individuals based on caloric consumption?

Do you identify the calories or is, are they eating to satiation? How do you kind of work with the individuals in your clinic?

Dr Naiman: Well the reality is every single human on earth is eating an ad lib, caloric diet, and they have been doing so their whole life, like the whole planet is just an ad lib diet experiment, where everyone eats until they're not hungry.

So I don't care about calorie limits cuz no one's gonna follow those. That's a, like a joke like, so everyone will eat until they're not hungry period. And so I'm infinitely more interested in satiety per calorie. So what diet is going to make you stop eating? At, an appropriate number of calories rather than actually just focusing on the calories.

I mean, calories matter and, you know, obviously have to worry about calories, but instead of like telling someone, this is how many calories you should be eating, it's like, these are the foods you could choose that would give you higher nutrient density, lower energy density, higher satiety per calorie and you would automatically eat the right amount and you would automatically match your intake to your expenditure with these foods.

So if you're working out more, you're gonna eat more and then you're gonna be fine. And so I don't really like to give people a prescribed amount of calories. I really don't.

Dr Lyon: So people always probably ask you, what are you eat in a day?

Dr Naiman: Right.

Dr Lyon: Isn't that so funny, right? Like what do you eat in a day

Dr Naiman: Yeah.

And, yeah, I mean, basically where I'm at is a kind of a very light intermittent fast, like a 16-8, and I, in my eight hour window, I have a whole bunch of protein in the first meal a whole bunch of protein in the last meal. So I'm book, I'm bookending the feeding period with lots of protein. So I have, you know, plenty of aminos flying around for any kind of

muscle.

Dr Lyon: So why do you do that? I'm just curious, where did you...

Dr Naiman: I want, I want amino acids available for muscle protein synthesis basically. And so what I've found is that if you bookend your feeding period with lots of protein, then you can kind of get by with two meals and a snack a day, or maybe three meals a day.

And you know, this is just a really good way to get a little bit of intermittent fasting. So you're more in touch with hunger and fullness and you get to eat larger, more satisfying meals and you get to run your body a little bit on stored body fast. So you're not just tied to you know, glycemic foods all day long.

And so it's a really nice, and again, intermittent fast is on a U-shaped curve where if you just ate once a year, that's not gonna turn out so good. But if you just constantly eat like nonstop, that's not good either. So I, for myself, it's this kind of light 16-8 really larger protein focused first and last meal book ending the window, light snack or a little meal in the middle.

Everything's built around high quality, lean, mostly animal proteins. And my absolute favorites are fish and seafood, anything outta the ocean. Any kind of fermented low-carbon low fat dairy, like Greek yogurt, cottage cheese, or something like that. I'm eating basically fruits and vegetables, and I'm trying to get most of my nutrition in a cellular form rather than acellular.

So I'm eating a lot of actual food, you know lean meat, produce and stuff like that.

Dr Lyon: You know, I think it's very ... I think that we were separated at birth and I'm curious as to number one, how long it took you to come to this realization. So you've been in practice for how long now?

Dr Naiman: Yeah.

Dr Lyon: You look amazing.

Dr Naiman: Oh, thank you.

Dr Lyon: Look amazing. Congratulations. Congratulations.

Dr Naiman: Awesome. Thank you.

Dr Lyon: So the the reason I ask you now, anybody listening would say, wow, When we, as scientists, physicians, people interested in nutrition, we believe one thing when we start and typically, which you and I were talking offline about blood testing, which we'll circle back to is that, you know, we believe one thing and we're very young in practice and then a decade later, some things stay and some things change.

And I'm curious as to now, first of all, number one, I absolutely agree with what you're doing. You are bolusing and bookending protein, which I believe is an incredible way to do it while being able to maintain body composition. And I just find it really interesting. And I'm curious as to how you came up with that strategy for yourself in terms of that protocol first meal of the day, last meal of the day, optimized for muscle protein synthesis at least 50 grams of protein and then a smaller meal.

Was there something that happened? Was there a paper that you read, was there a transition for patients that you saw? That kind of created that for yourself.

Dr Naiman: I mean, honestly, it's just some weird integration of having tried every possible permutation myself and, and seeing patients all day, every day, trying every single permutation.

I owe a lot of this to my patients because they're crazy enough to have tried every single thing, you know extended fasting for weeks. One meal a day for months, you know, these zero carbohydrate carnivore diets, like just pure keto. And then I've got people doing the Dr. McDougal starch solution and I've got, you know, raw vegans and I've got I've just seen every, because I am interested in diet. I basically just get this nonstop supply of patients who've tried every single, crazy diet thing you can think of. And then over time, I just take all of this experience and kind of

Realized that there's some sort of universal principles here and you really want a little bit of every single one of them. And I'm like, oh wow. You actually wanna pull every little lever moderately and be a little bit high protein and a little bit low carb and a little bit low of fat and a little bit higher fiber and a little bit lower energy density and a little bit of intermittent fasting and a little bit of protein timing.

And you just kind of want to each one of these is like a little bit, right. And then people will jump on one thing and have this unifocal over reliance where that's their only strategy, but it's only gonna get you so far when you try to do it harder, you just, things get worse. And so it's all about using every lever a little bit.

Dr Lyon: I, I think that is incredible. And it's so interesting to hear you talk, and again, you are the first physician on that sees patients in the same capacity that I do, and I cannot express how similar our views are, which I think is incredibly unusual. And when you talk about these universal principles, you also mentioned that you have patients in all kind of domains and beliefs, right?

So you have vegans, vegetarians, and you yourself are... sounds even almost pescatarian. Is that where you're falling right now?

Dr Naiman: I mean, I'm definitely not a pescatarian and I do eat other lean meat, but I tend to favor lean meat. So I do eat, you know, I'll eat. Skinless chicken breasts and I'll eat bison and venison and very lean ground beef.

And, but what I think where I'm at is that before I was dogmatically, low carb keto, just eat the fattiest rib I could get.

Dr Lyon: How how long were you?

Dr Naiman: Oh gosh.

Dr Lyon: How long were you dramatically low carb keto?

Dr Naiman: I would say I was just dogmatically low carb for a decade. Yeah.

Dr Lyon: Was there a reason, was there a reason?

Dr Naiman: I think I really just didn't understand everything as well as I do now. And I saw success with low carb. I basically figured, oh, if low carb is good, then zero carb is the best and the lower, the better. And then if low carb is good, high fat must be good. And then you just end up just eating like 100%

lard, and then that's like the, that's the logical final destination of low carb

Dr Lyon: That is hilarious. WE're not suggesting that anybody go on the lard diet Dr. Naiman may be putting out there in the future. But,

Dr Naiman: I mean, but I've literally seen patients, I've seen patients go on fat fasts and that, and actually tried the sorts of things.

And I've seen amazing, crazy, mostly bad stuff that is mind blowing and it's things like that helped me evolve over time and be like less dogmatic and less clueless.

Dr Lyon: Yeah. I think that, that is fascinating when you said, so you said something and you said I understand things differently now. What do you think was the biggest, so there's that global perspective that you said, was there something that.

Like a key paper or something that you read that really kind of changed your understanding that, and by the way, I am not low carb myself. I also came to the conclusion and I was for a decade high driven to be low carb. I was also moderate to low fat. I was never keto. It never really worked for me, but I'm curious, was there a thing that happened?

Was there a paper that you read? Was there an aha moment that changed your insight?

Dr Naiman: There was no one solitary, aha, moment, but the biggest thing for me is having patients do the exact opposite of what I believe and be in amazing shape. Like I would see, you know, high carb, low fat vegan physique athletes who are just crushing it.

And I'm like, wow, this black Swan just punched me directly in the face. I really have to reevaluate. I am like actually totally wrong. And then I'm like I know something about low carb is good. And so it just took a really long time and just seeing all of the opposites and the black swans for me to realize, oh, hey, that's just one possible lever where you can a slightly lower refined carbohydrate and higher density carbs and glycemic index carbs.

And you'll basically improve satiety per calorie. And you improve nutritional density versus energy density and you improve the protein percentage and all of these things. And oh, but hey, over here is a vegan. Just eliminating saturated fat from their diet, which by the way, is completely unnecessary element of in the human diet.

And so I see vegans treating saturated fat the same way. The paleo keto, low carb sphere treats sugar. And in fact, they're actually flip sides of the same coin, like saturated fat and sugar are two things that humans never need to eat. They both give you like in experimental models, you just get some just really horrific, like fatty liver and fattening and all sorts of stuff.

You combine them together and you make the most fat hedonic stuff on earth. And so like I realized, oh, hey, there's this mirror universe that's low fat and avoiding saturated fat, just as hard as I've been low carb and avoiding sugar. And guess what you get the exact same isocaloric results either way.

And so now, and it just took all of this, like being wrong, having things in my face, telling me how wrong I was to really rethink my worldview and just kind of start over. And that's how I got to where I'm at.

Dr Lyon: You know I wanna point out something that may be obvious, but it's incredible, incredibly unusual.

You were so open minded and curious and not stuck in your own bias that I think has allowed you to evolve. I'm sure that you would agree with that. And that in and of itself is incredibly unusual in medicine. And especially in nutritional

sciences. Oh yeah. Yeah. Thank you. Like I'm not afraid to admit that I'm like a total dumb ass and I've been just extraordinarily wrong over and over and over again.

I mean, I was a vegan,

which by the way, I think you were an engineer before, right? You were in some kind of, okay. So for the listener you at, when you joke and call yourself a dumb ass, you were actually an engineer before you were a physician.

Dr Naiman: Well, I did get a mechanical engineering degree and I actually never worked as an engineer.

I just went straight back to medical school.

Dr Lyon: Okay. okay. But an interesting perspective is that you are not afraid. Number one, to question and number two, to be wrong, which I think makes for a profoundly effective and efficient physician or care provider in terms of things that perhaps have changed.

I know right now people talk about calories in calories out the carbohydrate insulin model. Have you kind of thought about the different domains of, shall I say fatness or where we get fat or maybe even a better question would be, where do you think people are really misunderstanding the science to where you see it now after 20 some years?

Dr Naiman: Sure. That's a great question. Now, one of the things for me is that I think understanding personal fat threshold and over fatness, even in very, very thin people helps me to understand that like weight is fairly meaningless. BMI is fairly meaningless and I see people who are just horrifically over fat and diabetic at extraordinarily low body fat percentages because they're over their genetic personal fat threshold.

And I've had I've had the privilege of working with patients with a various amount of lipodystrophy. And when you see someone who looks ripped and jacked and has almost no subcutaneous fat but they're waist circumference at the belly button is bigger than it should. And you do any sort of cross-sectional imaging on them.

And they have whoa, shocking amounts of liver fat and a visceral fat, and their triglycerides are through the roof and they're fully diabetic and you see this enough times and you're like, wow. This is over fatness at any body fat percentage, it literally doesn't matter. And then I realized that triglycerides, for example, I used to think, oh, your triglycerides are high, cuz you either ate too many carbs or drank too much alcohol and that's completely wrong.

Triglyceride is ...triglyceride is fat energy in the bloodstream that has no place to go because your fat cells don't want it cuz they're full. So if you take someone who's very viscerally, lean and way under their personal fat threshold, they're fasting, triglycerides are super low.

And then after an oral fat tolerance test that they only have a slight rise in their triglycerides and the fat cells just suck the triglycerides right out of the bloodstream on the first pass. But then if you have anyone who's over fat, even if they look thin, even if their body fat presents low, their tri fast from triglycerides are really high.

After they eat fat, it goes up really, really high. And you just see all of these triglycerides and has literally nothing to do with carbohydrate intake. I've seen patients on a zero carb, strict ketogenic diet and their triglycerides are in the thousands. And they're just getting more and more diabetic.

And it's seeing things like this that's made me realize has literally nothing to do with carbohydrate, per se. It's just over fatness and every gram of fat that you eat gets stored in your fat cells, unless you happen to burn it off with your activity, which nobody's doing enough of. So like you will just steadily get fatter and more diabetic and more over fat and higher fasting insulin and higher fasting triglycerides,

and eventually diabetes. And so now it's just all on this giant metabolic spectrum of basically how over fat you are on any energy macro, carbs or fat, and at any level of body fat percent, cuz what's really going on is you've filled up what few fat cells you have.

Dr Lyon: Everything.

So, how do you have and I wanna go through kind of the labs that you used to get the labs that you get now in terms of a patient that comes in, who is skinny fat, let's just call them skinny, fat.

You mentioned a personal fat threshold. How does someone determine the, their personal fat threshold? Is that just based on seeing that litany of labs that you had mentioned, or is there some other way to determine a personal fat threshold?

Dr Naiman: Well, you can literally just actually measure your waist at the belly button and it should be less than half of your height.

So your waist circumference at the belly button should be less than half your height. And it's, if it's higher than that, you're almost certainly in some sort of trouble and that's just the low budget way to do it. In terms of lab work, I do love fasting triglycerides. This is a very good way to see if you're over fat.

It kind of the lower, the better on triglycerides. Like I'll see physique athletes who are cutting for a show or something and their triglycerides will be 20. But then I'll see it have a,..

Dr Lyon: That's low by the way. That's very low.

Dr Naiman: Yes, that's extremely low. But then I'll see some just skinny fat person who has a normal BMI.

But they're under muscled. They have some skinny fat, you know, sarcopenic, internal obesity and their triglycerides are 500. And so it's I love triglycerides. Fasting insulin. Is ...

Dr Lyon: so wait, so where's your marker. So where's your threshold for the number? So basically the lower, the better, but would you say triglycerides less than a hundred would be

ideal for you?

Dr Naiman: Correct? Correct. If you have triple digit triglycerides in a ... if you've fasted for nine to 12 hours and your triglycerides are triple digits, you're officially over fat full stop. This is something that, okay. I guess you could do some massive sugar or alcohol overfeeding the day before and have some residual triglyceride issue the next day and not really be over fat.

You just tried to pack too much fat in your liver the day before from sugar and alcohol, but like basically your fasting triglycerides really should be under 100 for everyone. And elite you'd have to be under 70 for me to really give somebody a gold star.

Dr Lyon: oh, I love that. I love that we've got some numbers.

So under a hundred fasted under 70 you had mentioned this post feeding triglyceride challenge. Do you do that?

Dr Naiman: Oh God. No, never like some from a first do no harm principle. I would never give anyone an oral fat tolerance test. I just refer to that, cuz it is in the medical literature where you basically drink heavy cream and they measure your triglycerides every hour or over time afterwards, just like you would consume glucose in a oral glucose tolerance test.

Dr Lyon: Yeah.

And something really interesting to mention about triglycerides for the listener is that exercise and actually aerobic exercise can change triglyceride levels. Even if it's transient. It typically happens one to two days later. And I just think that is so fascinating. And typically you're talking about one hour of moderate intensity.

5-600 calorie type activity which I think is really fascinating that regardless of weight loss, we can actually move transiently at least triglyceride levels. So I just wanna throw that out. There is something very interesting.

Dr Naiman: Yeah. That's basically liver fat. So the very last fat you pack in is in your liver and you can deplete that and just you just do a really heavy workout and you'll be temporarily, nondiabetic just for maybe a few hours until you eat again.

But like it's a very fastest way to fix yourself.

Dr Lyon: Very interesting. It's real. And you and I both really believe in a lot of activity or especially over the years, I'll shoot you message and say, Hey, I have this patient who is very resistant to weight loss and you, do you remember what your answer was to me?

You might not, but it was do more activity. And you were talking about a lot of activity. In terms of how for someone who is weight loss resistant, what kind of activity levels do you typically recommend?

Dr Naiman: Got it. Also if you're really trying to lose weight, you gotta be down maybe 500 calories a day in terms of calorie balance.

And you do not want that all to come from your diet. You really want that 50-50 diet and exercise. You basically want your caloric deficit to be exactly 50% diet and 50% exercise. And I'm talking about general activity here, not specifically resistance training, just focused on maximal muscle tension and muscular hypertrophy.

Like everybody should be doing full body resistance exercise at least twice a week, maybe three times a week. Push pull legs super high intensity of effort. Very high stimulus to fatigue ratio. Just putting the maximum in tension in your muscles for as long as you can to get maximum skeletal muscle.

That's unrelated. I'm talking about just like either walking or doing cardio or any other form of cardio exercise. You pretty much want half of your caloric deficit to come from your diet. Oh. And by the way, on the diet half. Every single calorie of your caloric deficit should come exclusively from carbs and fats, not from protein period.

So like you're basically trying to,

Dr Lyon: and do you wanna

share yes.

Dr Naiman: Right. So you need every bit of protein you're eating now. Yeah. Everyone's eating to satiety. And one of the main things that's getting them there to satiety is the amount of protein and fiber you're currently eating So when you're trying to lose weight, you literally only want to remove non fiber carbs and fat from your diet. And the first thing on the chopping block are the, acellular refined carbs and fats, the added carbs and the added fats. And those need to go, but you need the exact same amount of protein or more and the exact same amount of fiber or more.

So you're literally trying to just have a 250 calorie deficit from. Empty calorie, carbs and fats, which is pretty easy to do in the,

Dr Lyon: I was

just gonna say, that's a great strategy. And then on the, do I want it ..

Yeah, go ahead.

Dr Naiman: Oh, and then on the exercise side, you're asking me like, how much would that take?

That would basically be about a half an hour of really hard cardio a day. If you did a half a, you could do 15 minutes of insane cardio, half an hour of moderate intensity cardio, or an hour of a lighter cardio, and that's pretty much gonna get it done. And anyone who's trying to lose fat, who's not doing at least a half an hour of exercise every day is basically just spinning their wheels.

Dr Lyon: You heard it here at least a half an hour of exercise. These are all really great recommendations and very applicable to anybody who is watching and they make a lot of sense. Circling back to lab values. The labs that you did when you were first in practice. Well, actually let's start with the labs that you're doing now.

We covered triglycerides. And the reason I'm asking this is because right now we have access to so many different labs, right? We do triglycerides, insulin, Homa-IR, particle counts, everything. And I think that the more advanced we get, or the more time we spend seeing patients, it kind of goes back to the, I don't know, the most fundamental.

Would you agree with that? The most fundamental labs?

Dr Naiman: Absolutely. And, and like, honestly, in the past I had a lot of functional medicine training and a lot I've done a lot of advanced lab things in the past where I was doing all of these crazy expensive, ridiculous lab tests. And now, wow. I've gotten to the point where I look at all these labs and I'm like, this is all just completely worthless.

Like all these labs are gonna do is tell me you're over fat and under muscled and your metabolic health sucks. I already knew that just by glancing at somebody when they walked in the door. So what is that gonna really tell? It's not gonna tell me nothing. It's not what I know is they really need to work on diet, work on exercise, give more muscle, less fat.

That's gonna fix every single lab that I didn't like, why am I doing them? They're completely, non-helpful, they're not value added. They're super expensive. And they're basically just to all telling me the exact same thing. The vast majority of labs I used to order I never ever order anymore because I've realized

this is not actionable. This is not value added. This is not telling me anything I didn't already know. And so now I'm just super, super minimalistic because most of that stuff is crap. I hate to say it and I don't wanna be mean or throw anyone under the bus,

Dr Lyon: but which I actually have not heard you do just in other interviews anyway.

So nobody, we're all friends

here.

Dr Naiman: Well, let's put it this way. When I was dumber in the past and just didn't know, I was like, didn't know as much I would order more stuff cuz I kind of really didn't know. And I was just guessing I was just shotgunning things, I'll order every little lab and then maybe something will pop up and I'll kind of get a clue.

And I see people doing that today. And I specifically gonna look at some naturopaths that I interact with. Occasionally I see them ordering just an absurd level of lab testing, like thousands of dollars of labs. And I'm like every single thing on this list is a complete joke. This is a complete non-evidence based,

non-value added. A shotgun approach, ridiculous joke. And they ordered the same panel on everybody. They have this pre-printed lab sheet and they're ordering like $3,000 worth of crap. I'm like, this is all worthless. If you would just just do pushups for 10 minutes and go eat some lean go eat a, you know, some lean protein in a salad.

You'd literally be better off than every test on this sheet. So I'm really pushing back against some of the shotgun lab stuff that's not evidence based value added and I'm super minimalistic now.

Dr Lyon: So let's talk about the minimalistic approach, which I actually really appreciate. We covered number one, triglycerides.

And we said the lower, the better, typically under a hundred. And we also said that you're not doing the provoked triglycerides or fat test. And then you started to mention insulin. And then I had to jump in there and ask you about exercise because it reminded me of a conversation that we'd had, but let's go back to insulin.

I'm assuming that's number two on the list and maybe it's not in a prioritization schedule,

Dr Naiman: but I

almost never order fasting insulin. Okay. I used to order it all the time and I don't like it that much anymore because there's so much. It's so transient and there's so much noise.

Like I could overeat for a day or two and double my fasting insulin very, very easily. Or I could just undereat for a day or two and cut it in half. And so that's a lot of that's way it's way too. Variable way too, transient it's way too dynamic. And I'm like, wow, what would be a less labile? Oh, fasting triglycerides.

Or how about just a fricking waist to height ratio? And now I'm back to a test that's nothing, because that's gonna tell you where you've been at for weeks and months and years. And so fasting insulin. It's fascinating in the ...I love it in the medical literature, cuz I'm, that's what I'm always looking at in studies, because if somebody significantly lowered fasting insulin with an intervention, okay.

I'm paying attention to that, cuz you're literally less fat if you know what I'm saying. And if you look at the, like the. The NHANES data in the us over the past 50 or 60 years of the obesity epidemic. Fasting insulin's just been going up in a straight line. It was like 5, and then it was 8 and then it was 10 and it was 12.

And now this last year, it's 15 and a half, or it's just gone up along with the obesity curve. So it's interesting from a big picture point of view, but I hardly ever do it on individuals because I can just look at your body. I can just glance at your waistline and your fasting triglycerides and have a pretty good idea.

Dr Lyon: Okay.

Well then what would be the next kind of lab that you

ordered?

Dr Naiman: Uh, I do look, I do a lot of A1C. I do like A1C. There are ...

Dr Lyon: Which is a three month measure of where your blood sugar's

been, right?

Dr Naiman: Yeah. Yeah. Hemoglobin A1C. Love hemoglobin A1C. Doing a ton of those now that 52% of adult Americans are prediabetic or diabetic, probably everyone who walks in should get an A1C and it should probably be repeated yearly.

You know, that's, that is something I order a lot of. I do also look at a full, fasting lipid panel and I do like HDL. There are some major problems with HDL. There's a lot of racial and ethnic disparities there where all my patients from Southeast Asia, if they're completely elite and ripped and jacked, their HDL has finally gone up to a 40 and they're in like amazing shape versus like a Eastern European person, Caucasian.

They're gonna start out at a 40, if they're in bad health and then it'll be like a 70 if they're really elite. So there are huge racial and ethnic issues with HDL, but I do like in general triglyceride to HDL ratio, I do look at HDL. I do think that's valuable.

Dr Lyon: The hemoglobin A1C. Where do you like to see people in an ideal world?

Do you have a number?

Dr Naiman: Well, yeah, ideally it's basically sub five okay.

Dr Lyon: Which,

by the way, I have actually never been at sub five,

Dr Naiman: And a lot of people aren't and so that's why there are problems with A1C. So if your red cells are just very long lived

Dr Lyon: and they would be perhaps on a higher

protein diet

Dr Naiman: yeah. You might have a higher A1C, so it's not really quite fair. And then if somebody has any sort of any kind of nutritional deficiencies, B12, folate, iron you're gonna skew the A1C. There are some issues with A1C. There's some hemoglobin patterns that affect it.

And so I have to take it with a grain of salt, but mostly I just wanna see people at least in the normal range and I'm not gonna really ding someone who's in the mid fives. If everything else is great, because I know that there is some variability there.

Dr Lyon: And then the HDL, I really love that you brought that up.

I also think that HDL is very important and can be impacted by exercise, which is amazing. You can increase HDL by exercise and most of the studies have been in aerobic exercise. The number again, there is, it seems as if there's some kind of genetic variability, whether ideally you want.

Probably 50 upper 60s. Would you agree? Do you have kind of a, again, it's very difficult to control and create a linear increase, but you know, I guess beyond 65, there is no more cardioprotective benefits, at least what I've seen in the literature. Do you have a per a number that you really like for each?

Dr Naiman: Yeah, I mean

For most people it's over 50 that I think that's a really good HDL target that's that is racist as hell, because I do have so many patients from Southeast Asia who are just in great shape and they took their HDL from a 20 to like a 45. And now they're just in amazing health, you know what I'm saying?

And so it's just really not quite fair to certain groups, but yeah for the average person I see over 50 would be good.

Dr Lyon: okay. What's next? Anything else? I know you do a CBC and a CMP.

Dr Naiman: I basically

do a CBC and CMP on everybody. On CMP I'm really looking at the transaminases. ALT, AST , which gets screwed up with resistance training.

So if you lifted heavy it's gonna be higher the couple days before you can, like I've had ALT over a hundred, very more than once just from lifting. But you really want, and someone who hasn't done a heavy workout, you want those to be nice and low 20 would be 20s would be good or lower.

And that's something else that's just been steadily going up. The normal range just gone up several times during my career, just because everyone's like a little bit fatter, you know? And I do, I'm looking at blood urea nitrogen and typically higher is better because you're actually eating adequate protein.

Dr Lyon: Amazing. I, again, these are amazing pearls for individuals. So BUN is not necessarily, I mean, of course it depends on the big picture, but what Dr. Naiman is saying, Naiman is saying is that it is a reflection of your dietary protein intake, which is amazing in terms of AST ALT, is there a number where you begin to get concerned?

Is it in the upper 30s, 40s where you're like, Hey, you know, we really need to begin to address this. Do you have a certain threshold for concern with those numbers?

Dr Naiman: Yeah. Anything over a 40 is just clearly really bad.

Dr Lyon: Okay. And as long as you're not training really hard before.

Dr Naiman: Right, right, right.

Which is a big confounder unfortunately,

Dr Lyon: Any other labs that you really think are important?

Dr Naiman: I do CBC on everyone and I'm looking at red cell size for any sort of nutritional deficiencies there. I'm doing comprehensive metabolic panel. I'm looking at blood urea nitrogen.

I'm looking at creatinine, which I actually like a little on the higher side, cuz that's basically muscle mass. So if you're borderline high, BUN and creatinine, I'm actually pretty happy. I'm not calling a nephrologist. I'm just like, oh, Hey, you're lifting the protein. This is great. You're better than the average person.

I'm looking at the Transaminases like you said, if there's an issue with maybe overlap with muscle breakdown from resistance exercise, I'll add on a GGT, which tends to be a little more specific to the liver I'm doing.

Dr Lyon: And the lower, the better for GGT as well? Do you feel the

lower, the better?

Dr Naiman: Yeah, the lower, the better I'm sure if somebody had like liver failure and they had a zero, that would be bad. It's probably a, yeah. A low where it's bad, but not in my everyday practice. Lower is better, pretty much. And so I'm doing I do a lot of A1C. I do check thyroids frequently because we have just an epidemic of, Hashimotos in this country.

It's just a very high percentage of people who come in. So I'm doing a lot of TSHs and that's a that's I do other, I tend to like PSAs in men. I'm also doing some. In older men, I'm looking at testosterone levels, I'm also checking things like that hormonal issues.

But for the most part, it, I'm your average person. I'm just doing like maybe a CBC CMP, A1C, lipid, TSH, that's about it.

Dr Lyon: So you keep it very simplistic and streamlined. That is different than it was before in your practice, which you were getting a substantially, a substantial amount of other blood work, which is interesting.

You've really become a minimalist,

right?

Dr Naiman: Absolutely. Yeah. And, and, in pretty much everything.

Dr Lyon: you know, in terms of medications for weight loss, do you prescribe medications for weight loss? Are there things that are your go-to? What is your perspective in terms of medication?

Dr Naiman: Yeah,

I mean, I prescribe everything.

I prescribe Phentermine, Contrave, Qsymia, Semaglutide I prescribe it all. I'm familiar with it all. I'm using any and again, I'm using any lever I can pull, whether it's bariatric surgery gastric sleeve or medication. Obviously my favorite weight loss drug is Semaglutide, which is basically just same, a satiety hormone it's shockingly expensive.

This is a drug that basically okay. When you eat protein and fiber the digestion is so slow. Let's say you ate three pounds of skinless chicken breast, and asparagus. It's gonna take so long to digest it. It actually distends the mechanically, the lower part of small intestine and your small intestine emits these incretins, this GLP-1 that says, oh, do not eat anything more because you're, it's gonna take us 12 hours to digest this and you are not hungry.

Please do not eat some more. And the Semaglutide is basically just a long acting agonist of this same GLP-1 system. And so you kind of feel like you just ate three pounds of skinless chicken, breast and asparagus a couple hours ago. All day long. It's amazing. And it's very interesting that the best weight loss drug on the planet is really just affecting satiety and satiety per calorie, which has been my focus recently.

And so I do like it and I have to say, it's, you know, $600 a month. Most insurance will not pay for it unless you're have a diagnosis of diabetes. And I will say that you can actually accomplish the same thing by literally eating chicken breast, asparagus multiple times a day, which is cheaper.

Just throwing that out there.

Dr Lyon: It is cheaper. I will also agree with you. Semaglutide is my number one go-to medication. And I think it's important to bring up the fact that there are certain things that are evidence based and work really well. And there's no shame in medication. Obviously you check with your physician, we're not telling you to do it or not do it.

Not giving you medical advice here, but I think that some people carry shame with this idea that they are relying on something external. And from my perspective is you have to minimize the friction, right? This kind of internal friction of any kind of emotional burden that weight is putting on an individual.

So I believe that medication while you definitely, you have to have diet and exercise, but also utilizing a medication. If it suits you can very much alleviate friction for change. So I'm not against it at all. And I, the reason I say that is I think Ted, people really bring it up in a way that they say, oh you should try to do everything all natural and why?

What kind of, what we have modern medicine. Why would we do that?

Dr Naiman: Yeah. And it's just, it's not fair to certain people with certain genetic issues, like, like my patients with basically if you have lipodystrophy, we give you injectable leptin, right? Metreleptin injections and it's life changing.

So this is this is someone who has basically a quasi genetic problem, and you're giving him this drug and they finally just lose a bunch of, they don't lose much weight cuz they didn't weigh too much to begin with, but they lose a couple pounds of liver fat and visceral fat and boom, their diabetes is cured.

It's an incredible, crazily, effective medicine. It doesn't work on your average person by the way. So don't try to go to your doctor and get a leptin injection.

Dr Lyon: Ted's underneath

The table injecting himself. No. I am curious do you have a mentor? Do you have someone that you've learned from again, I just find it so fascinating that we have come to the same place and I just don't know.

Is there someone that's really been inspiring to you or certain scientists that you really kind of collaborated with? Anything like that?

Dr Naiman: Oh, wow. Okay. So I kind of, don't like, I'm so jealous of you and Dr. Layman. Cause if I had Dr. Layman like helping me out, I would've probably gotten to where I'm at faster.

So I'm super jealous. I'm a little bit bitter to be honest. and I don't really have that's. Okay.

Dr Lyon: We're siblings, we're siblings. So it's all an all in good company here, all in good company.

Dr Naiman: And I don't really have any one particular. Person. I mean, there are a bunch of people that I owe a lot to like Keith Frayn. Frayn who wrote the human metabolism textbook Frayn is just amazing guy, like amazing scientist.

I've learned so much from his stuff. It's just unbelievable. And I also feel like I've learned a lot from people like Stu Phillips and people like Don Layman. I owe them a lot. I don't really have, I I know these guys, but I don't have any sort of mentorship relationship with them.

But a lot of what I've learned, I've gotten from certain people in the medical literature that I just read their stuff over and over , you know, Westerterp. I've learned a lot there. Yeah. And doctors Raubenheimer and Simpson are these protein guys are just amazing. And and I've also, I've really learned a lot from like Kevin Hall and people who've forced me to look at black swans and

challenge my beliefs and change my views on things like, you know, the basically carbon insulin hypothesis and things like this. So there are some key science people that I really respect and I really appreciate, and I owe them a lot, but like at kind of more at a distance where I've just been like gleaning their knowledge and I didn't really get that that, that mentorship relationship that you and Layman had that I'm

so jealous of, and I watch you guys and your videos and you're just so adorable and I'm just bitter and angry and I'm just like crying, crying myself to sleep at night.

Dr Lyon: He's the best, he's the best. Right. And for those of you don't know Dr. Don Layman is a OG in the protein field and really his greatest contribution was this meal threshold concept of Leucine and that you require a certain amount of the essential amino acid to stimulate muscle protein synthesis.

Again, he has been in the protein field for, I don't know, 30, 40 years. And yes, you know, Ted, if you're not first you're last, I'm the number one, mentee, just kidding, but not really. I joke, I feel very grateful that he's mentored me and actually he's challenged me. And he would also say that the mark of a good scientist or the mark of any good thinker is an individual who is open to

perspective. And I believe that you've done a really, really great job on that without direct mentorship. It's incredibly unusual, you know, it's incredibly unusual and I'm proud of you. You should be certainly proud of yourself. Oh, well, thank you. One other one other question is those that are really good, read a lot, and I listened to many of your other interviews.

And it seems to me that you read quite a bit. Is

that true?

Dr Naiman: Oh yeah. Yeah, absolutely. I mean like mostly just primary medical literature at this point, but then anything written by any of these people, I really respect and admire. Definitely. .

Dr Lyon: And how often are you reading?

Dr Naiman: Pretty much every day. I'm like, I'm a huge nerd.

I'm a huge geek. I have basically no life. So yeah.

Dr Lyon: Really life of the party. Here's my amino acid book. You know, one of my really good friends, Emily Frascella always teases me. Cuz I have my amino acid book. And I think that you and I are really on the same page there, by the way, it is a really good time because we are taking information from very well vetted scientists thinking about it and being able to really translate the bench to the patient.

And that's very important. A lot of the literature is done in clinical research settings. You know, I used to work at a CRU, which is a unit where it's a metabolic unit, metabolic ward, but the reality is most research takes time to translate to the public. And where I think it becomes very important and very valuable what you're doing Ted is that you're reading it and you're implementing.

So you're taking, you're taking the data and implementing, taking the protocols and actually implementing it to the general population, which in and of itself is incredible. And I know that everybody is very appreciative, so there's that?

Dr Naiman: Oh, well thank you. yeah, that is what I'm trying to do.

Dr Lyon: Yeah. You know?

Where can people find you?

Dr Naiman: Gotcha. Okay. Well I'm on all the socials at Ted Naiman. Twitter, mostly Instagram.

Dr Lyon: Very active on Twitter. Very active on Twitter.

Dr Naiman: Everybody seems to pick one social media platform. That's kind of their... The one they hate the least and they're the most active on.

So for me it is probably Twitter. Yeah. And I think that the, probably the most interesting thing I've produced so far is the book, the PE diet. Which you can get at. Yes. ThePEdiet.com or Tednaiman.com or places like that

Dr Lyon: and the foundation. So it's a protein energy ratio. Do I have that correct?

Dr Naiman: Correct.

Dr Lyon: Okay. Very interesting. Very well done. And I actually have a copy of it. Even if you didn't send it or sign it to me, I still, I have my own copy. It's very well done. it's okay. It's very well done. And it really highlights some of the topics that you talked about in terms of protein, energy, fiber, which is so valuable.

And I'm hoping that you'll come back on. I'm hoping that you'll come back on this podcast. This really is about education and having transparent conversations with individuals whom I really respect. So thank you so much.

Oh, wow. Thank you. No, great to talk to you. And again, we're separated at birth, so it's not very controversial.

No. It's actually, there's something that we don't agree on. You wanna know the one thing that we don't agree on? Sure. Okay. There's one only one principle that we don't agree on. And the one principle that we don't agree on is when I was doing the euglycemic clamps and maybe this has changed for you, but I was doing euglycemic clamps at WashU.

And within those euglycemic clamps, we see the disposal of nutrients and mostly glucose. And obviously they are very high insulin states, right? You're infusing glucose, you're infusing insulin, you're infusing palmitate, you're infusing tracers. And one of the things as a core fundamental belief of mine is that I believe obesity, insulin resistance is a skeletal muscle disease.

And I think that you. I think this is where we have a different perspective. I think, you know, from my perspective, when you eat glucose disposal, I always think about skeletal muscle. I think about liver for liver there's glycogen and then skeletal muscle as it relates to glucose disposal and listening to some of your other interviews, I have a feeling, or at least during those interviews, you believe that obesity is really a adipose tissue site first a a fat issue first.

So there, there's the one thing that we disagree on.

Dr Naiman: Oh, actually

don't think we do disagree on that because for me, in order to be insulin resistant or diabetic, all three depots have to be filled liver, muscle, and fat. And you can actually, as a diabetic, if you just do an hour of hard CrossFit and just this huge glycogen depletion

Protocol you'll literally instantly be non-diabetic temporarily And so yet absolutely muscle is the very fastest way to reverse insulin resistance and metabolic syndrome and diabetes. And you can do it almost instantaneously with a huge workout protocol will deplete, intramuscular triglycerides and glucose, and then all the fuels in your bloodstream just fall into your muscle down a concentration gradient.

It doesn't even take insulin to do that. And so, no, I'm a hundred percent onboard with you. I'm just saying that the, because everybody's so sedentary and nobody ever works out. And everybody eats so much carbs, their muscles are basically a hundred percent full. All day, every day. And so I just don't even think about the muscle part anymore.

And then I'm like, oh, you fill up your fat cells and then you fill up your liver and then you're diabetic. But no the muscle is part of that energy storage depot triad that all three have to be filled for you to be insulin resistant. And you can instantly cure that by depleting muscles, but nobody's working out enough to make that happen.

But no. So I actually agree with you completely, like muscle is absolutely part of that picture. I'm not gonna really say it's first or last because of the timescale is so radically shorter than the time scale for your fat cells.

Dr Lyon: Right? Well, there you go. And I thought we were gonna have our first sibling argument, which we didn't

Dr Naiman: no I'm with you like a hundred percent

Dr Lyon: Again, thank you so much for coming on and I, I really appreciate it.

And I know that the listener will really appreciate it. We'll link everything. I am hoping to have you back when you are in the New York area Don will be coming out to do a series. If you are up for it, I'd love to have you out. And it would be great. So that would be cool. There's that? All right. All right, my friend, thank you so much.

Dr Naiman: Oh, thank you. Great to talk to you.