I am thrilled to have Dr. Ted Naiman, who joined me before for Episode 109, joining me again today.
Dr. Naiman is a board-certified family medicine physician in the Department of Primary Care at a leading medical center in Seattle. He holds an undergraduate degree in engineering and incorporates many of those principles into his clinical practice. In today’s conversation, we get into the most effective strategies for addressing insulin resistance, exploring the U-shaped curve associated with fasting and the potential issues of excessive fasting. We dive into macros, carb restriction, cravings, hedonic eating, weight training, and Zone 2 training, looking at eccentric and isometric training and the negatives of strength training. We explain why calories are of no concern, the difference between animal and plant-based protein, and discuss sarcopenic obesity. Dr. Naiman also shares his take on GLP-1 agonists as a therapeutic approach for weight loss and satiety and answers a series of rapid-fire questions about seed oils, high fructose corn syrup, artificial sweeteners, and anti-nutrients,
I am sure you appreciate and enjoy this conversation!
IN THIS EPISODE YOU WILL LEARN:
Effective ways to address early insulin resistance through exercise
Why you need to increase the weight or resistance gradually when doing strength training
The best way to approach resistance and cardio training
The benefits and risks of fasting
Carbohydrate sources for optimal health and satiety
Dr. Naiman shares strategies for dealing with junk food cravings
Why is protein essential for optimum health?
Are seed oils a problem?
Dr. Naiman shares his views on artificial sweeteners and high fructose corn syrup for weight loss
The best approach to exercise for obese middle-aged females
The benefits of GLP-1 agonists for type 2 diabetes and their potential side-effects
Why diet and exercise are essential when using GLP-1 injectables for weight loss
Bio:
Dr. Ted Naiman is a board-certified Family Medicine physician in the department of Primary Care at a leading major medical center in Seattle. His personal research and medical practice focus on the practical implementation of diet and exercise for health optimization.
He is the author of The P:E Diet.
“In the exercise triangle of intensity, frequency, and duration,
you want a significant amount of all three.”
-Dr. Ted Naiman
Connect with Cynthia Thurlow
Follow on Twitter
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Ted Naiman
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I was joined again by Dr. Ted Naiman. He last joined me in 2020 on Episode 109. He's a board-certified family medicine physician in the Department of Primary Care at a leading major medical center in Seattle. He has an undergraduate degree in engineering and brings a great deal of these principles into his clinical practice. Today, we started a discussion talking about what is the most effective way to address insulin resistance.
[00:00:58] We spoke about the u-shaped curve related to fasting and how over fasting can be problematic, macros and carb restriction, cravings and hedonic eating, the role of weight training, Zone 2 training, eccentric, isometric and negatives in strength training, why calories really don't matter, animal versus plant-based protein, sarcopenic obesity, and rapid-fire questions that ranged from opinions on seed oils, high fructose corn syrup, artificial sweeteners, antinutrients, and then later his opinions on GLP-1 agonists and how they can be a therapeutic strategy for weight loss and satiety. I know you will enjoy this conversation as much as I did recording it.
[00:01:49] Welcome back, Dr. Naiman. It's such a pleasure to reconnect with you. Thanks for coming back to Everyday Wellness.
Dr. Ted Naiman: Oh, yeah, thanks for having me. Great to talk to you.
Cynthia Thurlow: Absolutely. I would love to start the conversation talking about, we know that insulin resistance starts in our muscles, and when you're talking to your patients about navigating middle age and beyond and let's be clear, we're both in this stage ourselves and certainly understand the nuances of being a clinician, also being an adult that's in our middle ages. What do you think are some of the most effective ways to address early insulin resistance? Because I think that for many people, they think about muscle health in the context of phenotypic results or the way that we look, but understanding at a very deep level that muscle health is instrumental in metabolic health.
Dr. Ted Naiman: [00:02:38] Well, yeah, and muscle is key. So, the very fastest way to not be insulin-resistant or diabetic is exercise. So, if you do a glycogen depletion workout where you just wring all the glycogen out of all your muscles, you will transiently be nondiabetic, even if you’re diabetic to start with. I mean, you won’t have type 2 diabetes lets qualify that for all the type 1s out there. But you won’t have an insulin resistance diabetes transiently from just doing a ton of exercise. It’s basically a combination of intensity and volume. So, if you just wring all the glycogen out of all your muscles, you’re nondiabetic. Also, if you do some endurance exercise and get rid of all your intramuscular triglyceride, basically all the stored fuels in your muscles, you will temporarily be nondiabetic.
[00:03:26] So, that is the fastest way to be nondiabetic. Of course, you’re going to replenish that intramuscular glycogen really fast. And then if you were a type 2 diabetic to start with, you’re going to be diabetic again the next time you eat, pretty much. So, that’s very temporary. And in order to really be metabolically healthy, you have to clear all the fuels out of all three of the major storage depots, which is muscle, liver, and most importantly, in my opinion, adipocytes, the fat cells. So, you have to fill all three to be fully type 2 diabetic. And you have to plead all three to be truly metabolically healthy.
Cynthia Thurlow: [00:04:04] Well, and it's interesting to me because I would imagine that people probably don't have issues walking and they probably don't have issues per se going to the gym. But the degree of intensity that you are referring to is where I think most people are mistaken, that it's not just picking up the 5-pound dumbbell. It means the volume that you're putting, whether it's compound exercises, whether it's high intensity interval training. I think for a lot of individuals, they just don't understand that they have to actually push themselves to a degree of, when I say discomfort, I sometimes will say a little bit breathless, not so that you feel like you want to fall over, but you do want to tax your body.
Dr. Ted Naiman: Right, right, right. We were basically looking at a product of intensity times duration. So, it's the volume times, how hard you're going, if you’re going all out, you’re talking a couple of minutes. If you’re just strolling along, that’s an all-day kind of thing. And most people honestly don’t get either one right. They’re not doing enough volume or enough intensity or enough frequency. So, you’ve got the exercise triangle of intensity, frequency and duration, or basically volume. And you really want a significant amount of all three. But you can always do more of one and a little bit less of the other two. You definitely need two out of those three, and ideally all three.
Cynthia Thurlow: [00:05:26] Yeah, it's interesting. I have a family member who's now retired, and I've been talking to her about how important strength training is. As a retiree, they have a lot more free time than they did before and trying to explain that, yes, the 5-pound dumbbells are a good starting point, but you do want to make sure that there's a degree of progression. So, if you're using 5 pounds this week, pushing, so maybe you're doing 7.5 two weeks from now, maybe getting to 10, just getting to a point where you are fatiguing your muscle, where you are getting to a point where you can't do another rep.
[00:05:58] I think this is an important kind of discussion because I would imagine that many individuals listening, they might do the same exercises at the gym every week they go, they're not pushing themselves. They're wondering why they're not seeing results. And to your point, you have to have some degree of adaptation, but you also have to get to a point where you're moving beyond your comfort zone. I'm not indicating anyone should be hurting themselves. I'm not suggesting if you have knee problems, please don't do box jumps. Don't be jumping 2 or 3ft onto a box and wondering why your knee pain is exacerbated, but certainly within a healthy frame of area and exercise. Now, what are your thoughts on Zone 2 training? So, little bit of strength training and intensity, and whether it's neat, which is this non-exercise-induced thermogenesis or Zone 2, where does that fit into your discussion with your patients?
Dr. Ted Naiman: [00:06:49] There's this concept of rep range. If you're doing resistance training, there's this rep range where you could go really heavy and just do singles or doubles or triples, or just do five reps, or you could go way lighter and do 20, 30, 35 reps. And, theoretically, you'll get some similar adaptations on either end. But some people do better at higher rep ranges and some people do better at lower rep ranges. And anytime we do these studies comparing them, you get a waterfall plot and you get an average, and you can know what the mean is. But there are people who have more type 1 or type 2 fibers. They do better at different ends of the rep range, you really don't know.
[00:07:30] So, the best bet is to just shoot the entire rep range. Do some super heavy low rep training out sometimes and do some super light high end training at other times. And you want to run pretty much the whole rep range. And you want to do the same thing with cardio in my opinion. You want the whole rep range. You want some super high end where your heart rate is 90, 95, 95 plus of your theoretical maximum, assuming you don't have an unstable cardiovascular condition, of course, talk to your doctor. You basically want to do the whole cardio rep range as well. You want to be doing some very low end. You want to be doing some high end. You can always trade intensity for duration, so you have to do a lot more of a lower intensity, like Zone 2.
[00:08:13] You don't have to do as much as a higher intensity. Of course, you're way out of your comfort zone with the higher intensities as well, so you couldn't do it for longer. My advice to people is try to run the whole rep range. You want to do at least once a week, some sort of endurance cardio that's at least a half an hour or more. But then you also, at least once a week, want to get close to touching your maximum heart rate and really redlining things and that will probably only be a few minutes. So, I like people to run the whole rep range. The only caveat there is most people, the one thing that they really don't have enough of in life is time, that's the one thing.
[00:08:52] Now that I'm super old, time's the most valuable thing of all, right? [Cynthia laughs] I don't have much time. I'm only going to be alive for another 10 minutes or something. I'm running out of time. And so, for me, I prefer the higher intensities just because it doesn’t take as big a time investment. And like we said, “I ‘m old. I don’t have a lot of time.” But if you have the luxury of time, and that usually means you have more money, because money just buys you time, basically, to do the things you want to do. And if you’ve got plenty of money/time, then you can do all the Zone 2 in the world, and that’s awesome. But you still want to run the whole rep range of cardio, in my opinion.
Cynthia Thurlow: [00:09:31] Yeah, I love that suggestion. One thing that I've started doing, and [laughs] I'm very sore because of it, when I'm doing pullups, as an example, I do a six second decline. And I was saying to my husband that I work with a trainer and she gives me a program and I go off and do it. And these slow repetitions are incredibly effective at activating different parts of the posterior chain for an example, like doing these pull ups, I'm so sore and then I did pikes in Pilates yesterday and my whole back is lit up. So, I think it isn't even that you necessarily have to lift really heavy weight, but sometimes just changing the way that you are lifting, whether you're going a little faster, a little slower, can have a huge impact.
[00:10:14] I have been complaining that I have not been able to progress my back the way that I want to. And she said, okay, we're going to start shaking things up and just doing this slow progression. I'm like two or three days of being not uncomfortably sore, but definitely sore and aware of where I am sore in my back.
Dr. Ted Naiman: [00:10:31] Yeah, that's beautiful. And you can progress any exercise by just accentuating the eccentric, doing a slower eccentric, slower lowering or descent. You can always just use more perfect form, do isometric, hold the top, do a really slow negative, and spend more time on the lengthened position of the muscle portion and just makes it way harder. And so, I love that making things more challenging by just manipulating different parts of the exercise or how long you're taking to do it. So that's great. That's beautiful.
Cynthia Thurlow: [00:11:07] Yeah. And I know that we both share an affinity and we like intermittent fasting. It's something that we use with our patients. It's something we may or may not be using right now for ourselves. But I know that I've seen on social media that you're starting to speak, and I am as well, about the fact that if you're already a lean individual, the over fasting phenomenon that I'm seeing, if a little bit of fasting is good, more is better. Obviously, if you're insulin resistant, obese, really struggling with metabolic health, a little bit longer fasts are probably going to beneficial.
[00:11:39] But for those individuals that are already lean, I don't think more than a 24-hour fast, I don't know where the point at which it's a point of no return, you're going to impact your muscle mass. And I know for being a middle-aged female, I want to preserve what I have and maintain. I don't want to lose any of my muscle mass. And are you starting to see more of an emergence in the metabolic health space that more of us are talking about this the over fasting phenomenon that I really do see, I see a lot of women in particular, that overfast, they over restrict food, they're exercising probably more than they need to, and it's this hormetic stress trying to find the right balance for a lot of individuals seems a bit elusive. Are you seeing that in your clinical practice as well?
Dr. Ted Naiman: [00:12:24] Yeah, absolutely. So, when fasting first hit the scene, it was all like, this is the greatest thing ever. More is better. Let's get extreme. Let's do 24 hours, let's do a week. I think everyone's figured out, especially the scientific community and research, that there's a sweet spot. And you can definitely overdo it. It's definitely a u-shaped curve. You really don't want to go too high. It also, I think, got a little bit overblown in terms of the magnitude of benefit from fasting. So, it's very lightly beneficial. It's one of the smaller rocks in the jar for anyone, and it is helpful for a lot of people. I do like it. Some people will benefit from it more than others. Everyone should experiment with it a little bit, but it has a really hard u-shape to it. And the thinner you are, the less long you should fast.
Cynthia Thurlow: [00:13:17] Yeah, I think this is an important distinction and something I probably haven't spoken enough about on the podcast. Over the past year and a half, I've been experimenting as a 120-pound female, like, let's just put that out there. I'm pretty lean already. So, for me, I've realized that if I have a wider feeding window, I can get in three meals, which means three protein boluses. That has worked better for me in terms of gains in the gym and being able to sleep better. I've been liberalizing my carbohydrates. I think that's another thing that has gotten overblown, that in many ways healthy carbs have been demonized along with the processed carbs.
[00:13:54] And so I'm curious, when you're working with individuals that are perhaps at their goal weight that are already lean, are you encouraging them to liberalize and break their meals into two or three? Because I think for a lot of people in the fasting community, they're very focused on OMAD, or they're doing these 24 hours fasts every other day, or they're doing these 30/16s and an otherwise lean individual I think the cost benefit is narrowing. I just don't see the concerns that I have about the loss of muscle mass, that loss of insulin sensitivity, not properly fueling your bodies, which I think the message of my podcast is making sure people are intuitively eating if they're capable of doing that. But just being cognizant of the fact that we don't want that to be the message that is over restriction message.
Dr. Ted Naiman: [00:14:42] Yeah, yeah absolutely. And personally, for anyone who's reasonably lean and healthy, I don't recommend fasting more than 16 hours. I would do 16/8 at the most. I would not recommend OMAD, I would at a very minimum have two meals bookending you’re eating windows. So, someone like yourself, I would not do more than a 16/8 and I would have at least two sizable meals with large protein boluses bookending that 8-hour feeding window and to be honest, I’m usually not recommending longer fasts for almost anyone because now if someone’s dangerously energy toxic and they just have uncontrolled type 2 diabetes with extreme hyperglycemia and I see like unbelievably crazy stuff.
[00:15:25] I see A1cs that it says over 14 and the lab can’t even read it because it’s so high and people’s blood sugar is just sit in the 500s all the time and this person can fast for a very long time. Thats fine. Let’s actually do that just as a life-saving thing, but only for dangerously energy toxic people that I recommend these longer fasts. And there’s almost no one for whom I recommend fasting within 24 hours. And there’s very, very few people for whom I would recommend more than a 16/8. And I think that you're just running up against the diminishing returns of what intermittent fasting or time-restricted feeding does for people. And there's just not a lot of point to pulling that lever so hard that it breaks off and then you're actually losing lean mass which you can't recover very easily. So, yeah, there's tons of stuff wrong with extended fasting. I'm not a huge fan. I've never told anyone to fast more than 24 hours ever and I really don't recommend more than 8 hours at the most.
Cynthia Thurlow: [00:16:25] Yeah, no that's very helpful.
Dr. Ted Naiman: [00:16:26] I mean 16 hours of fasting. I'm sorry.
Cynthia Thurlow: [00:16:28] No, no, no. And I appreciate that. I knew exactly what you were referring to. And I jokingly always talk about being hospitalized for 13 days and not being able to eat was the longest unintended fast of my life and since then, I have not done more than a 20:4 and don't want to. In fact, my kids know that if I start getting to 20 hours of not eating, I get pretty grumpy. I'm like, “Okay, I know that I'm going to miss having that, the protein bolus.” I don't want to be in a position where I'm breaking down muscle in order to fast longer. In terms of looking at carbs, so carbs seem to be, I think, the most controversial macronutrient right now. I think we can all agree protein is necessary.
[00:17:08] Fats can be beneficial, although you have to carefully balance them. And I know that you speak to this that looking at what lever are we going to pull? So, protein is going to be satiating and then figuring out for the average individual how much fat to include in their diet or carbohydrate. Do you have a threshold around exercise that you like to see, like, if someone's metabolically healthy and they're going to have some carbohydrates before or after exercise in talking about grams of carbohydrates, because I think that is a bit more tangible for listeners being able to get a sense of, is it 15 g? Is it 20? Do you use it as an ergogenic aid? How are you using carbs around exercise?
Dr. Ted Naiman: [00:17:49] Sure. Absolutely. And so, carbohydrate restriction is something else that's on a very hard u-shaped curve. And we’re all like, “Ooh, carbs are bad.” So, less carbs is better and the lower you go, the better you are and the ultimate is zero and now you're a pure carnivore. And unfortunately, there's diminishing returns to carbohydrate restriction, and you actually start going backwards when you hit zero. So, the average person is probably not benefiting a lot by going lower than about 100 g of carbs a day or maybe 20% of their calories from carbohydrate. Why is that? It's because you're missing out on fiber and soluble fiber and a weight and volume to your food and a lot of satiety benefits.
[00:18:31] So, if you're a strict carnivore versus throwing a salad in there, you're probably going to better off from a satiety per calorie perspective and general health perspective, as well as sustainability of your diet from throwing in some carbohydrates. The other thing is you have to make, 50, 60, 70 g of glucose a day just to be alive. And you can do that out of protein, but that's not very protein sparing. So, now you're chewing up some protein just to make enough glucose to be alive. It's probably better to just simply eat some amount of that. Especially if you pick carbohydrate sources, have a high fiber to non-fiber carbohydrate ratio, so you get plenty of weight and volume and satiety per calorie out of those carbs.
[00:19:13] And so it's a mistake, in my opinion, to go too low on the u-shaped curve of carb restriction. Most people, I'm not suggesting they eat under 100 g of carbs for pretty much any adult, I'm typically recommending, I mean, with the caveat that you want the ratio of fiber to non-fiber carbohydrate as high as you can get it reasonably. For the average person off the street, I'm suggesting about a gram of carbohydrate per pound of ideal body weight if you're moderately active, reasonably active. So, I'm 5’10” and I have ideal body weight of 160. And I would suggest 160 g carbs a day with the caveat that the ratio of fiber to non-fiber be as high as I can get it.
[00:19:55] And then of course, if you're doing high intensity exercise, you might burn up to a gram of carbohydrate per minute, a very high intensity exercise, something that’s more than, 80% of your max heart rate or so. If you’re doing an hour of cross-fit and your heart rate is 80-90% of max of the whole time, then yeah, please eat an extra 60 g of carbs or whatever. I don’t think it has to be exact. The nice thing about exercise is as you crank up your caloric burn with physical activity, your body just gets better and better and better at matching intake to expenditure. So, and people doing tons of exercise, they're just perfectly eating the right amount of calories, their body's pulling calories, and they will eat just the right amount and just asymptotically approach their ideal body weight.
[00:20:42] And that's why you see people-- Michael Phelps in the pool all day long eating and burning 8000, 10,000 calories. These people, their body composition is just fine because their ability to match intake with expenditure gets better and better and better. And so, I do like eating extra carbs that you've earned. I think that's a good idea. And you don't have to be exact about it because the more high-end cardio you're doing, the better you're going to be at just eating the right amount.
Cynthia Thurlow: [00:21:10] Yeah, I think this is an important distinction we're talking about this fiber to non-fiber ratio of carbohydrates. So, you're talking about berries and vegetables. You're not talking about the breads, the pastas those are going to be, things that, earn your carbs, but that's not going to be what you're going to be doing every day. Do you have favorite carbohydrates that you recommend or lean into, like root vegetables, sweet potatoes, things like that are a bit more accessible and you can add fat to them to make them more palatable?
Dr. Ted Naiman: [00:21:40] Yeah, absolutely. So, my favorite carbohydrate source is fruit. And you have fruits that are higher in fiber to non-fiber ratio. Berries are the very best. Berries are my favorite, love berries. Apples are quite good, a lot of soluble fiber, pretty good satiety per calorie. They're cheap. They're everywhere. Citrus is actually great as well, oranges and these sorts of things. So, love fruit, any of your low-sugar fruits are spectacular. And these are things that most people classify as a vegetable. And that's your peppers and your cucumbers and your tomatoes and those sorts of basically botanically fruit, vegetable-type things. So, the top of my list is fruit, basically. I also like tubers, carrots, amazing huge weight and volume for the calories in there a lot of satiety for calorie.
[00:22:29] Potatoes, if you're not adding a ton of that, didn’t add your loaded baked potato with the sour cream [Cynthia laughs] and the bacon and the cheese is like buttery. You could make that pretty bad. But if you're just air frying some sliced up potatoes, which I do all the time, very high satiety per calorie. Quite reasonable. Really not too bad. Now, of course, these are low-protein foods, so you're accompanying, hopefully some awesome, properly raised lean protein, as the main focus of that meal or snack. But these are my favorite carbs. It's basically fruit, tubers, and then maybe some whole grains as well, air popped popcorn, really like it, brown rice, wild rice. Some of these grains are pretty reasonable. Oatmeal, very high soluble fiber, tons of satiety per calorie. There's a reason why these bodybuilders are eating that, but they're combining it with a crap ton of protein like egg white scramble or a whey shake or a Greek yogurt or something. Just super high protein. So, yeah, as accompaniment to protein, love all these basically fruit, tubers, whole grains, yeah.
Cynthia Thurlow: [00:23:35] Yeah, those are all really good options. And when you're working with individuals that are energy toxic, they're hyperinsulinemic, they're telling you I'm not interested in vegetables I like my hyper-processed foods. How do you help reset their dopamine? So, these are individuals that are eating out of a sense of, they're craving food. They're maybe leptin resistant, obviously insulin resistant. What are some of the workarounds when you're talking to them about macros?
Dr. Ted Naiman: [00:24:04] There’s basically two things you can do with some of these people, and these are people who eat so much hedonic junk food that every time they eat, it has to be 10/10. They’ll look at the menu and they’ll only eat whatever looks like a dessert for a meal or its just some incredible calorie bomb. Everything they eat has to be 10/10 Häagen-Dazs, chocolate cake, super decadent. Strategy one is risk reduction by you figure out what foods they like and then you have them make a version of it that's just slightly better, a little higher protein, a little higher fiber, a little less carbs and fats, a little bit.
[00:24:42] So, if they like burritos, you show them how to make burritos with low-carb tortilla and a leaner protein source and low-fat cheese. And you're getting refried beans that don't have any added fat and you're just trying to tweak down the carbs and the fats and up the fiber and the protein and the weight and the volume and the satiety per calorie. And that's one option. It's like little substitutions. Everything you eat, you try to swap it out for a version that's just slightly higher satiety per calorie. Option two is hedonic reset. Okay, this is where like for three days you just eat fish, any kind of fish, and a salad, with spinach or raw spinach and just Balsamic vinegar for a dressing and that's it.
[00:25:28] And like this is people have to be like, “Oh, this is so restrictive and so horrible and I hate it.” But after you do a couple days of that, you really do get a dopamine reset and hedonic reset. And I don't like that strategy as well. Because it's like a juice cleanse or one of these short-term crash diet things that has a stop date. And in general, I don't like anything with a stop date. I'm like, why don't you just start eating now the way you want to eat long term? So, I like the more gradual, progressive overload. Today, we're just going to swap out your tortilla for a low-carb tortilla, and the next day it'll be a skinless chicken breast instead of just like pork belly. And then after that it's the refried beans with no added fat. And then we're going to go for the low-fat cheese and we're just going to progressively overload until you're eating this bodybuilding burrito instead of the taco bell, you know what I mean?
[00:26:23] But some people really like the-- but I'm just going to dive into the deep end and shock my system. And for some of those people, doing a hedonic reset where you just give yourself a very limited menu of a very bland, hard to overconsume, hedonically low foods and honestly fish or any kind of seafood, and then any kind of salad or green leafy vegetables is the way to go there because it is just so-- you just cannot overeat it. I defy [Cynthia laughs] anyone to have unlimited access to fish and salad with zero-calorie dressing and try to get fat. Like, you just cannot do it. You are going to eat way less. You are just going to eat the amount you need and that's it. But that's a lot more painful.
Cynthia Thurlow: [00:27:09] Yeah, I love both the approaches. Number one, because you're meeting people where they are by deconstructing their burrito to make it a healthier one or for those people who fully like to rip the band-aid off and jump into the deep end of the ocean and are ready to kind of buckle down and have that very bland but nutrient dense food to get those dopamine receptors reset. I think those are two great approaches and obviously probably up to you and your patient to decide who it's most appropriate for. Where does calorie-counting fall into your discussions with patients? I know that I always say calories do matter and macros do matter, but I think the days of this fixation on counting every calorie and measuring every single bit of food is not per se a sustainable long-term strategy. I think for some people, just the awareness around how much food they're eating can be helpful. But do you think that calories are all that important in the work that we're doing?
Dr. Ted Naiman: Calories are super not important in terms of like, “Oh, calories, of course, are very important,” but tracking them is not that helpful. And the first reason that's not that helpful is because nobody has any idea how many calories anyone's burning. You could be 10 times more active than I am. And you might need way more calories per day than I ever will. I might be so sedentary, I barely move. I won't even reach for the remote control because I'll just watch the same channel all day to save calories versus you're just training for an ultramarathon. And so, because you have no idea how many calories someone's going to burn, you just can't even remotely try to prescribe calories. And let's say I did. Let's say, okay, you can only have 1600 calories a day. That's not going to happen. You're going to eat 1600 for breakfast, and then you're still going to be starving because you're training for an ultramarathon and you're just going to eat triple that.
[00:29:00] And so, trying to artificially figure out how many calories someone needs, picking a calorie target, pretending you know how many calories anyone burns to begin with, or pretending you know how many calories are in any food exactly, and then pretending to try to artificially limit that and say, “Okay, well, you just stop eating when you hit this number. Good luck.” All of that is complete garbage. So, it's just absolutely not helpful. Now, it is helpful to know what the heck's in your food. Like, “Oh, hey, did you know that hot dog only has 4 g of protein and 23 g of fat? Because it's the cheapest hot dog in the universe. [Cynthia laughs] And this is like incredibly bad macros. So, I like protein awareness. I like macro awareness. I like looking at grams of macros. I don't find the calories to be terribly helpful unless you're looking at caloric density of two different things and comparing it in terms of how many calories per gram. But calories is just not a helpful, it's a useful construct, it's good to know about them. But trying to artificially prescribe a calorie goal and then meet that goal and limit yourself to that goal is a total joke. It's completely worthless.
Cynthia Thurlow: [00:30:11] Yeah, it's interesting. I see a lot of women that have been over fasting for a long period of time and they're trying to gain awareness because they'll say, “I don't get hungry for a second meal.” And I'm like, “Okay, that's problem number one.” And we'll have them initially tracked just to get a sense of what they're eating and then some instances they've whittled themselves down to 900 or 1000 or maybe 1100 calories a day. And they're wondering why the scale is stuck, their pants are tight, they're not hungry for the other meal. And sometimes it becomes this challenge of creating a reverse dieting situation where we start to slowly adding back in some protein to round things out. Now, you mentioned the piece around quality of protein, and I'm in 100% agreement with you.
[00:30:59] Do you recommend or use any essential amino acids? This is a question that came up multiple times. I know Dr. Don Layman recently was asked this, and he basically said if you're getting at least 100 g of animal-based protein in a day, you don't have any need for EAAS. Do you use this with your patients? Is it a discussion that you have if people are struggling to get enough protein into their diets?
Dr. Ted Naiman: [00:31:22] Essential amino acids, in my opinion, are only helpful if you have someone who's eating a plant-based diet and who's a barely getting enough protein to begin with. So, I do have vegans who come in and I have them just count how many grams of protein they eat in a day and they're getting 48 g of protein. [Cynthia laughs] And at that point, there might be a role for essential amino acids, but even then, I'd rather have someone just eat more of a whole food, whole protein source, to be honest. So, there are exactly zero times I've ever recommended essential amino acid supplements for anyone ever at all. So personally, I'm like, “Okay, just take that money and buy actual protein and just worry about your total and get that higher.” And then you really don't have to sweat the, essentials as much. So, I'm not a huge fan of essential amino acids. I can see how it might be valuable if someone was like a plant-based aesthetic athlete. If you're a plant-based bikini model or something and you're just flying your calorie plane six inches off the ground and you just have to get enough losing and you're-- okay, there might be a place for them there, but just most people know.
Cynthia Thurlow: [00:32:34] Yeah, that's helpful. And it's interesting that question comes up with some frequency, not just on social media, but within groups that we run as well. And in terms of whether someone is intermittent fasting or not, especially in your andropausal, menopausal, perimenopausal patients, do you find that the macro changes become a greater area of focus with your patients? Because this whole issue of sarcopenia, it's a real issue. Maybe not for you and I right now, but I feel like there's really so many misconceptions around the role of muscle and aging and so whether it's sarcopenic obesity, whether it's changes in testosterone, and certainly we're still mitigating and working our way through this whole concept of fear of fat, fear of cholesterol, the net impact on sex hormones, which can be quite profound. I'm just curious, when you're working with your patients and clients depending on where they are at life stage, are these some of the discussions that you're having?
Dr. Ted Naiman: [00:33:40] So, I know internally that if you're a 21-year-old male natural vegan bodybuilder and you just wash with testosterone, your natural testosterone levels like 1600, and you could just eat 90 g of plant protein and just lift all day long, and you'd be absolutely jacked and just completely crushing it. But if you're some elderly, sarcopenic, osteopenic postmenopausal female with undetectable estrogen and testosterone levels, and you have just extreme anabolic resistance and you're already under muscled and behind the eight ball on that one. Okay, now I'm like, you actually need to chase protein with every meal, like, it's your job. And so, I am a little more obsessed with protein quantity and quality and frequency and distribution in someone who has anabolic resistance because they're basically old.
[00:34:36] And so, although to be totally honest, the basic recommendations are pretty much the same for everybody who walks in the door. There's not like, oh, because you're this race and this gender and this age, we're going to do custom, precision personalized nutrition just for you. It's pretty much, it's 90% the same thing for everyone who walks the door. I just know the protein is a bigger deal for someone with this anabolic resistance of aging. And so, I'm still going to have the same basic advice for everyone though.
Cynthia Thurlow: [00:35:09] I love that. I love the transparency. I think that for a lot of women in my stage of life, it's helping them understand, like before you go to bed at night, make sure you have hit at least this threshold of protein intake because we need more for the stimulus, more for muscle protein synthesis, you don't want to get into the dwindles. I see a lot of women and I don't want to pick all my Pilates aficionados, but I do Pilates for posterior chain work in addition to strength training. And there are a lot of very, very skinny women in that group and I think it has a lot to do with, they assume that because they're doing Pilates, which yes, can be strenuous, they think it takes the place of strength training and helping them understand, like it's not just the protein intake, you actually have to work the muscles differently to be able to maintain and build muscle.
[00:35:56] And in some instances women do need some degree of testosterone therapy in menopause or even in perimenopause, depending on where they are. Some women continue to make plenty of testosterone in menopause, many of them do not. And I think that if you're someone that's lean ectomorph, you may need some testosterone to help bolster the reserves as you're navigating middle age and beyond. I'm curious when you are working with any patient, because it sounds like you treat everyone similarly in terms of your foundational approaches, when you're talking to them about foods to avoid, things to avoid in your diet. And this is where a lot of the Twitter or X-related questions came through. What are your thoughts on seed oils and salad dressings? Is this something people need to avoid? Is it problematic? Do you get concerned about it? What are your thoughts on seed oils and dressings?
Dr. Ted Naiman: [00:36:51] Got you. So, of course there are just a zillion people in our low carb, paleo, keto, carnivore sphere that are deathly afraid of seed oils. They're the source of all evil. They break your mitochondria. They just fundamentally destroy your body. I am zero afraid of seed oils on some mechanistic HNE, like theoretical. This is going to oxidize and break all your electron transport chain. [Cynthia laughs] All this mechanistic, theoretical scaremongering about seed oils. I have none of that. All I know is that over the past 60 or 70 years of the obesity epidemic, the amount of calories from refined fats, from seed oils has just been gargantuan and a huge chunk of all the calories in the obesity epidemic stored in people’s bodies right now came from seed oils.
[00:37:48] I do not think that makes them uniquely damaging, I don’t think they’re any worse than saturated fat just from an overall health perspective, and possibly slightly better than saturated fat. If you really just look at all of the research and actual human controlled trials and compare that to, seed oils are not worse than saturated fat for health in my opinion. I am however very freaked out about refined carbs and refined fats in general, especially the two combined together, because that's what's giving you pretty much all those extra calories, is added fat, added sugar, combination of the two is extraordinarily hedonic and people just overeat the heck out of that. And so yeah seed oils are a massive problem, but only because of the quantity and the magnitude and the dose makes the poison and they're not uniquely damaging.
[00:38:42] So, when I go to a restaurant I'm not like “Ooh, did this touch a seed oil? Was this fried in a seed oil? Does this salad dressing have seed oil on it?” I don't even care. I know I'm going to minimize the dressing and the oil and the grease and all that in whatever I’m ordering or eating anyway. And I don’t care if it came from a lard, seed oil or what, like I’m really not that worried about it. And honestly if you’re keeping the refined carbs and the refined fats low, you’re just going to automatically not eat too much seed oils to begin with. So that’s where I’m out with the seed oil thing. Not uniquely, especially damaging all by themselves in some magical theoretical mechanistic way.
Cynthia Thurlow: [00:39:25] No, and that's refreshingly honest and thank you for that. I too, when I go to restaurants now, I was telling my husband it was getting to a point where I would go to a restaurant that the thought about what-- I just said, I'm going to enjoy the process, I'm going to enjoy the meal. We eat out very irregularly, but I'm just going to enjoy the meal and not stress too much. I'll focus on my protein and my vegetables and all will be good. Thoughts on high fructose corn syrup and artificial sugars. I know two separate things, but what are your thoughts about these and what's to be avoided? I think in the low-carb space there's always a hot new artificial sugar of some kind, whether it's stevia or monk fruit or erythritol along with the aspartame, sucralose variety as well.
Dr. Ted Naiman: [00:40:08] Right, right. So, basically, I'm zero afraid of artificial sweeteners. So, I just consume a ton of aspartame and sucralose and erythritol and monk fruit and I like all of that stuff. This seems to be fairly harmless. We have some studies showing that in obese person is trying to lose weight, that diet soda might perform better than water for fat loss and body composition just because it satisfies a sweet taste that humans naturally have for no calories. So, I do think artificial sweeteners are perfectly fine. I like the whole risk reduction model. So, if you're replacing your sugar with an artificial sweetener and you're trying to lose weight, I think that's great. I don't have a problem with them. I'm not telling people to avoid any of those in particular.
[00:40:57] I mean, other than just like don't eat too much sorbitol or you'll get the worst diarrhea of your life. [Cynthia laughs] But otherwise not really afraid of them. Same thing with high fructose corn syrup. So, to me this is just the cheapest sugar. So, it's going to be more plentiful in the food supply because it saves companies money. So, it's really only a problem because it's so cheap that it's easy to throw in everything. And I don't see it as uniquely worse than sugar, particularly. Fructose is another thing that as long as you're not hypercaloric, if you're eating the right amount of calories, fructose is quite harmless. Saturated fat is quite harmless. These two things are opposite sides of the same empty calorie coin. One is carb, one is fat, one is plant, one is animal.
[00:41:45] But they’re basically things that are purely empty calories. And if you’re not overeating calories and you have a high enough protein percent and enough micronutrients, you can have some of these empty calories in there. But because they’re empty calories, if you’re consuming too many of them, they’re basically not helping you from a satiety per calorie standpoint. They’re just adding calories and not satiety. And so that's, I think, why some of these things are bad. The seed oils, the saturated fat, the fructose, they're basically empty calories. They're placeholders for refined empty calorie source.
Cynthia Thurlow: [00:42:22] Yeah, that makes so much sense. And thoughts on plant-based defenses the lectins, the oxalates. Do you think in someone that has an otherwise healthy gut microbiome they can tolerate these things? Or the people that become intolerant to some of these plant defenses, it's really a side effect of work that they need to be doing on the gut microbiome. Whether it's they've got an overgrowth of bacteria, or maybe they've got leaky gut, or they've gotten to a point where they just really need to be more conscientious about their overall health.
Dr. Ted Naiman: [00:42:57] I mean, some people are sensitive to these things. So, as a practitioner, you only have to see a couple people with just severe celiac disease and how it just destroys their health before they realize what they have. And while they're still eating gluten, you see a few of those, and then you're like, “Oh, there might actually be something to this,” but the vast majority of people don't have to worry about it. Like, if you're cooking your legumes very well, you don't have to worry about the lectins. You don't have to worry about the phytates, you don't have to worry about the oxalates. All these things are on a u-shaped curve, where okay, if all I'm having is raw spinach and kale smoothies all day, every day, day after day, I will get a kidney stone from the oxalate load quite possibly, but within a reasonable amount, almost nobody has to worry about that or micromanage it.
[00:43:47] It's the same thing with the lectin. Yeah, it's like, okay, if I grind up and eat raw kidney beans, that is not going to be a good thing. But if cook all these legumes, well, you probably don't have to worry about it. I mean, you don't have to be religiously paleo. I think most people can eat these things if they're cooked well. And most of that antinutrient is basically denatured by cooking. So, if you're cooking this stuff, you're pretty much okay.
Cynthia Thurlow: [00:44:18] I got another question about protein. Is protein a free food? This is hilarious. Can you get fat on excess protein?
Dr. Ted Naiman: [00:44:26] So, you could, theoretically, if someone just gavaged the protein calories into your GI tract every minute of [Cynthia laughs] every day. I think the satiety is so high that you’re pretty much unable to eat enough of it to really get there. Also, the thermic effect is so high and it’s so much work making fat out of protein that it basically doesn’t happen to any significant degree. And we don’t have any studies where we forcibly overfed animals 100% protein diet, that probably wouldn't pass an IRB. But I am a little curious to know what would happen. I guess theoretically, you could just gavage enough calories into animal's stomach directly, forcing them to like a foie gras type scenario, [Cynthia laughs] you could theoretically add some fat from protein, but it would be, herculean effort and I would say almost no one can eat enough additional protein to really significantly gain body fat.
Cynthia Thurlow: [00:45:34] No. Last question that I received is about guidance for obese middle-aged females who don't want to go to the gym. How do you clear them for more intense exercise, like HIIT and I know the answer to this, but they were very specific that they wanted me to ask you this question. So, this is someone who doesn't really want to go to the gym. It sounds like they intend, they want to get healthier. How do they go about determining whether or not it's safe for them to do more and more exercise and more intense exercise.
Dr. Ted Naiman: [00:46:04] Right. So, I encourage everyone to always just gradually, progressively overload. So, with cardio, just like we wouldn't have you bench press 500 pounds the first time, we might start out with the bar and then just add some plates a little bit here and there, you want to do the same thing with cardio. You want to start out at a lower intensity and then just gradually ramp up the intensity. And of course, with all my patients, the second anyone has any exertional chest pain, lightheadedness, if you walk halfway up a hill and you feel like an elephant sitting on your chest and you can't breathe, this is combination of chest pressure, shortness of breath, maybe some lightheadedness. Okay, you need to go see your practitioner. You need a stress, like a cardiogram.
[00:46:45] We throw people on the treadmill, we're like maxing out their heart rate and then doing echo on them and like just actually looking to see what's going on. That is the gold standard. But most people if you don't have a lot of risk factors, you can kind of just do it on your own. But pay attention to how you feel. If you're just winded because you're out of shape, that's fine. You can push into that discomfort, but if you're getting chest pain, you feel like you're going to pass out, you need to just stop and go see your doctor. Anytime you do super, super, super high-end exercise, there's a 0.000001% chance you could just instantly drop dead.
[00:47:23] But there's like a 99.9999% that you will actually benefit from that, you will make some positive adaptations, and the next time you do it, you'll have a better cardiac output and more capillarization in your muscles and better oxygen delivery and transport, and you'll actually be-- When you do that kind of high-end cardio every day in, day out, day out for like a year, it's a fricking superpower. You can just run up 10 flights of stairs, you're not even short of breath. Everybody else is stopping to rest, and you're like, “What? I'm fine. Let's go.” Doing cardio and a lot of cardio, and high-end cardio is basically like a superpower, and everyone can get there if they're healthy enough. And the way you find out if you can handle it is you just progressively overload it and see how you feel. And if you know you're having heart symptoms, which is mostly exertional chest pain, you want to stop and go see your provider.
Cynthia Thurlow: [00:48:19] Sounds like great ideas. And lastly, I just wanted to get your thoughts on GLP-1 agonists. So, obviously they're super popular right now. There's a lot of government funding, and the pharmaceutical industry is going crazy because they're the now being given out and prescribed with such frequency. What are your thoughts on GLP-1s and in terms of their metabolic effects, but also balancing that with muscle loss, which I think is one of the greatest concerns that I'm seeing, other than some of the side effects, most of which are unpleasant, a few of them are a little bit more concerning. But are you using them in practice and where are you choosing to use them judiciously with patients?
Dr. Ted Naiman: [00:49:02] Right, right. So, of course, on the diet and exercise guys. I'm always trying to sell people on diet and exercise. However, I'm also living in the real world, and I'm all about arm reduction, risk reduction. I'm using any tool in the toolbox. So, I am prescribing all of these daily. I'm just daily prescribing semaglutide and Ozempic and Wegovy and tirzepatide and Mounjaro and Zepbound and Liraglutide and Saxenda and you name it, I've prescribed it. I have tons of experience with all of these. I have been prescribing Victoza or liraglutide for what a decade or something for type 2 diabetes. And this is the most powerful type 2 diabetes drug on the face of the earth. It really purely works through satiety per calorie. You’re basically just getting more satiety for no calories.
[00:49:51] Can you pull the same thing off by just eating? If I had a diet where 1 hour before each meal, you have to eat a pound of skinless chicken breast and a pound of asparagus. Thats your new diet. You eat this and then you eat whatever you want, it would have the exact same effect. It would probably not be quite as effective because the magnitude of GLP-1 you get from the injections is way higher than anything you could do with your diet even if you ate a bale of hay. But it’s a similar effect. You can pull it off without an exercise. The big problem with GLP-1s is it’s the same issue we run into with extended fasting. So if you’re like, I’m just not going to eat because I’m not hungry and you do that for a really long time, you’re going to have a horrible ratio of lean mass loss to fat loss. So, anytime you lose weight, there’s ratio of lean mass loss to fat mass loss, and the goal is to lose all fat and no lean, you will always lose some lean mass. You can’t do 100% and 0%.
[00:50:51] But if you’re an elite natural bodybuilder with tons of testosterone, eating a crap ton of protein and just lifting like it’s your job, you could lose 95% fat and only 5% muscle and hang on to all of that lean mass, which is what you really want because then once you are thinner and weigh less, you still have the same basal metabolic rate because you still have the same lean mass and the fat is not very metabolically active. So, you’re not going to regain, you can lose weight and stay fairly low if you retain all of that lean mass. The yo-yo dieting happens when you just are “Okay, I injected this stuff, now I’m not hungry and I’m just not going to eat.”
[00:51:33] And then it might be as ugly as 60% fat loss and 40% lean mass loss. And then when you become weight reduced, you’ve lost so much lean mass, that your basal metabolic rate is low, and you’re just going to immediately regain, you’re unfortunately just going to go right back to where you were. You can combat that by prioritizing protein, lifting weights, optimal resistance training, and then also doing, as you lose weight, doing more cardio. So, your overall energy expenditure is just as high as it was before you started the drug. And I’m always nagging everyone who I put on these drugs. I’m like, okay, you're using this to jump start things, but you also want to do all the right stuff, protein, lifting, cardio, and the people could get there without the drug by doing all these things.
[00:52:25] But I recognize the fact that if both your parents are morbidly obese, and you were morbidly obese as a toddler and as a child and as an adolescent, there was no time in your life where you had a normal weight. And you've had so much adipocyte hyperplasia, that some of these people just getting them down to 30% body fat, they're just as hungry as if I was dieting down to 5% body fat and I was just stage lean, you know what I mean? They've shrunk their adipocytes, the same amount that I would for a bodybuilding show, but they're still 30% body fat because they have so many extra fat cells. And for these people, I'm like, “Man, we've got to help them out any way they can.”
[00:53:08] So, I do have patients who nail the diet and the exercise, and they go on the drug, and I have crazy stories, like, people lose 150 pounds completely, just wipe their diabetes out. Their A1c is like 4.5% and they could actually stop the drug. They'll probably rebound some, but most of the benefits that I know they're going to maintain and some of them have off the drug because they nailed the diet and the exercise, and it’s basically protein, satiety per calorie, resistance training, muscles, and cardio, and overall caloric burn. And if you can nail all that stuff, I think that drugs are great. If somebody's doing all this stuff, and if they do have programmed obesity from their parents and it's just like, why not help these people out. So, I really see the whole spectrum of good and bad from the injectables, and as long as you have all this knowledge going in, it's another tool in the toolbox.
Cynthia Thurlow: [00:54:15] Yeah, I think it's important for people to understand that it is a little bit of a shortcut. But those big macro viewed of strength training, protein prioritization, those are still important. They're not negated by the use of the drugs. Well, I always love our conversations. Please let listeners know how to connect with you on social media, how to work with you if they live in the Seattle area.
Dr. Ted Naiman: [00:54:39] Got you. Okay, so I'm on all the socials @tednaiman. I'm most active on X and, maybe Instagram and you can, connect with me there. I'm working very closely with, Dr Andreas Eenfeldt of Diet Doctor fame, with this new Spinoff brand, Hava. You can check it out at hava.co. We've built an app, the Hava Eat app, and it's pretty spectacular. You can just take a photo of all your food and it will give you the satiety per calorie of what you ate. And it's an amazing way to have your eyes open to protein percent and fiber and energy density and basically things that are going to get you closer or farther away to your goal. So, you can check me out on socials @tednaiman and you can check out Hava at hava.co.
[00:55:29] I wrote a book called the PE Diet, which is pretty much anywhere books are sold. Unfortunately, my practice is closed to new patients, so I work for a major medical center in Seattle, but I'm basically not taking new patients. And I don't do any remote consultations or anything. So, nobody can really work with me one-on-one at the moment. But I probably put most of the good information I have in that book anyway.
Cynthia Thurlow: [00:55:55] It is a great book. Thank you again.
Dr. Ted Naiman: [00:56:00] Thank you.
Cynthia Thurlow: [00:56:03] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
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