Interview with Dr. Ted Naiman – The P: E Diet Book – “Leverage Your Body to Achieve Optimal Health”
In this post, Mike Berta interviews Dr. Ted Naiman on his release of The P: E Diet” Book and his thoughts on various topics regarding protein, metabolic health, and fat loss.
Mike is a dad, husband, engineer, low carber & often N=1 tester in the Seattle, WA area. He’s been a low carber since 2014, has been a patient of Dr Naiman since 2015 and joined the Ketogains moderator team in 2017 shortly after completing his first bootcamp. He can be found in the Ketogains FB group & on Instagram @Ketomyburrito
Dr. Ted is a Family Medicine Doctor who practices in the Seattle, WA area.
“Dr.Ted Naiman and his co-author William Shewfelt make the case for prioritizing the amount of Protein in your diet relative to the amount of Carbs and Fats in the diet. The authors argue that we are in a “global epidemic of energy toxicity” which puts us a risk for obesity and chronic disease. This energy toxicity comes from the overconsumption of Carbs and Fats together which has also displaced Protein from the diet.
In order to navigate this mess, we need to go out of our way to target Protein and minerals which will allow us to feel full with less energy intake. The authors also note for optimal health we should also go out of our way to increase our lean mass (muscle and bone) by placing high amounts of tension on our muscles via resistance training.”
Editor’s Note: The P: E Diet will soon be translated in Spanish by Ketogains! – check it out HERE.
Congratulations on the book. I read it and loved it. Thanks for sitting down to answer some questions today and thanks for being my awesome doctor. I’ve done very well under your care, so I wanted to give a quick shout out to that.
First of all, did I get that brief summary of the book right?
Thank you! Yes, you completely nailed it! The entire concept of the book is really just prioritizing Protein over non-Protein energy, and then placing maximum tension in all of your muscles on a regular basis. We fit the entire book on one page pretty easily, but I think you just fit the entire book on a business card or maybe even a postage stamp. I like it!
The book is co-authored with William Shewfelt. He’s an actor, speaker & health/fitness advocate. According to IMDB he is a Power Ranger!!!! That’s so amazing. Anyway, how did you sync up with him?
Yeah Shewfelt is a cool guy! It was Jimmy Moore who first introduced us. William approached me about the book. He just came right out and said, “We need to write a book together”, and I was like, “I think you are right!”. And it took off from there.
So, I’ve been following your work for the last 4 or 5 years and you, like me, seem to kind of moved away from Low Carb-High Fat and ultimately ended up with the P: E diet. Am I correct that your views have evolved over time and if so, can you describe your thought process on why your views evolved over time?
Oh, definitely my views have evolved over time, and continue to constantly evolve. I know that at least half of everything I currently believe is wrong, and now it is just a race to do enough research to find out which half. Initially the only thing I really knew was that some amount of Carbohydrate restriction was very helpful to my patients with metabolic syndrome.
Then I think that I ended up on the same ‘Paleo → Keto → Carnivore’ slippery slope as everyone else, because it is pretty easy to just assume that if excessive Carbs are bad, the optimum quantity of Carbs must be zero. But now I think that I have taken a slight left turn with the P: E approach and I feel that where I am at currently is a bit more nuanced and a little less dogmatic than my previous mindset. I am trying to avoid an all or nothing approach at this point, and I am trying to stay as open- minded as possible.
Also, along those same lines in the book you talk about decreasing Carbohydrate frequency as opposed to Carbohydrate quantity. Just speaking for myself, I’ve noticed that Carbohydrate tolerance seems to go up the higher my activity level (climbing mountains, playing soccer, resistance training, etc) and I seem to maintain my body composition at 100G of Carbs per day pretty easily. Is this typical with your more active, leaner patients?
Yes, this is typical. I see a lot of low Carbers who have shaved the Carbs all the way to zero but are still not reaching their goals because they aren’t leveraging exercise. It is really tough to get all the way to your body composition and metabolic flexibility goals without utilizing exercise. I think the sweet spot is a non-zero amount of Carbohydrate and then a small but adequate amount of effective training.
On the flip side I’m assuming you have lots of patients who are in very poor health. Are you OK with your T2D patients eating up to 100G of Carbs per day if it’s in one meal or is your preference that they stay in that very low Carb keto range?
I am 100% ok with this, but the idea is to reduce added Fat by an isocaloric amount and/ or increase activity/exercise by an isocaloric amount. I don’t expect anyone to actually try to calculate these, but I do recommend eating lower dietary Fat when eating these Carbs, and also trying to get in some form of exercise daily!
I’d feel pretty dumb if I asked you about Carbs but failed to mention the Ketogains TKD protocol. I’m going to assume that every Ketogains member has read the FAQ but incase one or two didn’t the idea is that it’s all about muscle Protein breakdown vs muscle Protein synthesis. Some Carbs around training will increase insulin a bit which inhibits muscle Protein breakdown without inhibiting muscle Protein synthesis. I am curious if you have experimented with pre-work out Carbs and if you have gotten any benefits from them?
I have definitely experimented with pre-workout Carbs, typically in the form of fruit. I think that for many this is an effective ergogenic aid, similar to caffeine. However most of the time I am eating Carbs later in the evening as more of a backloading strategy, because I really like to work out fasted. Not because I think that fasted workouts are necessarily magical, I just personally feel better that way.
Also depending on what kind of activity one is doing they might get a performance benefit with TKD or some Carbs in general. I’ll do lots of running and HIIT while fasted and/or on keto. It’s horrible and it sucks but it really builds up that endurance base of making myself perform solely on my bodies own energy stores (Fat and glucose if we are being honest) Then on race day or say an important soccer match on the line I’ll consume some Carbs before hand and it’s like adding rocket fuel to the tank. Curious what you think about this train low; compete high technique?
I am all in on the ‘train low, compete high’ strategy, and this is exactly what I do myself. For general training, I push myself to workout fasted and I go ahead and deplete a ton of muscle glycogen. But for an event or anything competitive, I will eat some Carbohydrate strategically. This seems to work for me as well.
OK-enough about Carbs; this is KETOgains after all. If someone is stalled on a keto diet you’d want them to increase their P: E which means they need to eat less Fat because they’ve already kicked out the Carbs. How much should they decrease their Fat consumption by? Is there a specific P:E ratio you try to get people to aim for if they are stuck and not making much progress?
100% correct — if you have pulled the low Carb lever as hard as you can and you are still stalled out, the next step with your diet would be reducing dietary Fat. Which is not going to work if you are hungry—thus increasing Protein at the same time and targeting a higher P:E ratio. I personally feel that equal grams of Protein and Fat (a P:E ratio of 1:1) is a really good maintenance zone for most people, so for Fat loss I would definitely recommend keeping Protein grams higher than Fat grams on a daily basis. The higher you get your P:E ratio the more dramatic your short-term results will be, but this will also be less sustainable. For this reason, I recommend a P:E ratio roughly in the 2:1 ballpark —of course, this does not at all have to be exact and it will be a moving target and different for everyone. The general concept is simply increasing this ratio slightly until you are making gradual and sustainable progress.
Protein Sparing Modified Fast (PSMF) is the highest P:E ratio one can get. I’ve seen some people tweet some pretty crazy graphs at you where they are eating 250G of Protein with 20G of Fat and 20G of Carbs. What are some situations where you would recommend or absolutely would not recommend someone giving PSMF a try?
PSMF is 100% not sustainable for more than a few days so I really don’t like it for the average person. Fat loss is a marathon, not a sprint. For most people, getting all the way down to their goal body Fat percentage will take at least three years. And then you have to maintain that for the rest of your life. So, you really want to make slow and gradual changes that you can realistically build into your routine indefinitely. However, there are a few settings in which a short PSMF might be helpful.
First of all, if you have a dangerous amount of energy toxicity (think an uncontrolled type 2 diabetic with high blood sugar and/or high triglycerides), PSMF could actually be a life-saving intervention and I have seen triglycerides go from over 1,000 to under 100 in just a week or two of this sort of diet. It is pretty much just as powerful as fasting, but with less risks of lean mass loss, electrolyte imbalances, reduction of metabolic rate, and refeeding syndrome.
PSMF also might be a good motivator for some people, sort of a way of jump-starting a Fat loss diet. It is also useful to see how effective a low Carb AND Low-Fat diet can be for Fat loss, which might confirm for some that this is a good direction to take.
In your website and book, you are directed to a calculator to enter in macros to get a protein to energy ratio per gram. At the risk of asking kind of a silly question why do Carbs and Fats count the same on the chart even though Fat has more energy per gram than Carbs?
This is a great question, and there are a number of reasons for this. First of all, it is SO much easier to calculate the P:E ratio using grams, which are readily available on all food labels. If you are trying to use calories you pretty much have to pull out a calculator immediately, which just adds unnecessary complexity.
Secondly, Fat is essential, and Carbs are not. If you eat a zero-Fat diet you will literally die. And even a Low-Fat diet, with Fat less than around 30% of calories, will very likely lead to problems (low testosterone, gallstones, etc.).
The requirement for Carbs in the human diet, on the other hand, is exactly zero. So, I am sick and tired of Fat being punished by the entire calorie concept. Calories are broken anyway, because PROTEIN calories don’t seem to count, and we should only be worrying about NON-PROTEIN ENERGY calories in any case. So, using calories feels like a big step backwards. Another reason is that Carbs are massively overeaten in our modern society. Sure, Fat has twice as many calories per gram, but the average American is eating THREE times as many Carb grams as they are Fat grams.
Oh, and don’t forget that Carbs are extremely disruptive to ‘Fat adaptation’, and most Americans live in a state of relative ‘glucose dependence’ because they eat Carbs with such a high frequency. Finally, eating large quantities of Carbohydrates all the time doesn’t make a lot of sense when you look at diet in general through an evolutionary lens.
Since you are a family medicine Doctor, I assume you work with kids. I am curious if you see obesity and metabolic issues with children that come into your office and what your recommendations are in those cases?
Half of all adults in America are prediabetic or diabetic, and now one quarter of all adolescents are in the same boat. My general advice to kids is identical to my advice for adults. Target Protein first and foremost.
Protein should be the focus of every meal and every snack. Have plenty of healthy nutrient-dense high P: E foods available at all times, and eat these first. This approach crowds out a lot of the ubiquitous food-like garbage that surrounds us everywhere and really increases your chances of success.
Once you go out of your way to eat the Protein and minerals that you need, it is a lot easier to walk past all of the processed low Protein high energy crap.
What are you thoughts on the school lunch program? I ran some meals from my daughter’s school lunch menu on the P: E calculator and the results were at at the Standard American Diet level. The Carbohydrates and Fats tend to be plant based and ultra processed variety (sugar, flour & oil). Animal Fats sadly is low by design. Protein quality and quantity seems low. Seems like a total disaster. Can you talk me off the ledge a little bit or is it really as bad as I think it is?
No, I can’t talk you off the ledge. I have done the same thing with the meals at my daughter’s school. School lunches are an unmitigated disaster. I fight back by providing tons of great and tasty high P: E high nutrient-density foods at home and my daughter also packs a lunch to school.
In regard to economics Protein seems to be the most expensive macronutrient. What have you been able to unearth on the economics of Protein and how do your patients with very limited means find a way to make this work?
Protein is definitely the most expensive macro by a wide margin. Protein is far more expensive to produce and to transport. Protein requires a lot of more refrigeration and cooking, and it has a shorter lower shelf life and therefore a much lower profit margin. If you are selling food and you want to maximize profit, you want to avoid Protein completely and honestly Carbs are where you are going to make the most money.
Breakfast cereal is one of the highest margin foods you can sell. The economics of all of this are honestly a huge driver of the global obesity and diabetes epidemics. However, there are some Proteins that are relatively inexpensive. In fact, two of the very best Proteins on earth are also two of the very cheapest: ground beef, and eggs.
The average price for a pound of ground beef in America is $3.80 and the average price for a dozen eggs is $1.20. So, you can definitely follow the P: E diet for $5.00 a day.
The very first time I saw you in 2015 my HDL cholesterol was in the 20s which was really bad. Dave Feldman tested me recently and now it’s up almost to 70 which is much better. My LDL and triglycerides have always been normal/boring (except that one time). I’m wondering if it’s common to see HDL improvement in your patients who follow the principles of the P: E diet? Do you have any tips to optimize HDL and the lipid panel in general?
The best way to raise HDL is to get leaner. There is an inverse linear relationship between body Fat and HDL. Therefore, anything that makes you leaner will raise HDL. There are associations between higher Protein diets and higher HDL, lower Carb diets and higher HDL, and increased high-intensity exercise and higher HDL. Very likely however that these things are all just lowering body Fat, and this naturally lowers triglycerides and raises HDL.
Among Ketogains you are sort of known as that guy who has gotten awesome results with only bodyweight training. What attracted you to bodyweight training vs using equipment such as barbells, dumbbells, etc.?
I am really just trying to demonstrate the fact that you don’t need a lot of stuff in order to get strong and build muscle. And by ‘stuff’ I mean equipment, gyms, trainers, supplements, money, time, or really anything at all. At first this minimalist approach was just a sort of ‘proof of concept’, but now I love this approach because it gives me the freedom to train ANYWHERE and ANYTIME. This is super liberating.
In the book you talk about “Demand Training”. What is that and is it specific to bodyweight movements?
‘Demand Training’ is really just a name for the stimulus that your body requires in order to make the positive adaptation of building muscular strength and size. Adding muscle tissue, or even maintaining muscle, is a very expensive process for your body in terms of the investment of raw materials and energy, and you will only do these things if your body is convinced that this is crucial to your very survival. So, the point of ‘Demand Training’ is generating muscle time under tension to the highest level of failure discomfort that you can tolerate, in order to send a loud and clear message to your body that it is inadequate in its current form. If you successfully communicate this to your body, and you have the necessary Protein and minerals, your body will respond by increasing the size and strength of the muscles involved.
This is not at all specific to bodyweight movements and you could accomplish this with weights, machines, bodyweight training, or even isometric training. The type of exercise you are doing is just a way to create maximum tension in your muscle and could really be almost anything at all.
I’ve found that going to failure is very difficult. The closer I get to failure the more form breaks down and I’m not sure it’s really much of an effective rep. There also might be a bit of a mental barrier. Do you have any tips to really bust out those last couple of reps to truly hit failure?
I like to only perform the concentric, or difficult, or against gravity, part of an exercise until I can no longer maintain good form…then I just hold isometrically at the hardest point until I can no longer hold that, and then I lower myself against gravity (eccentric) as slowly as possible with good control. This is the ‘Triple Failure’ technique that we describe in the book!
What are some health span benefits to strength training and how do you convince the average person walking into your office that they should start performing resistance training?
Literally the stronger you are the longer you are going to live. Strength also improves your health span and the quality of your life. Increased lean mass gives you huge metabolic benefits as well. Everyone’s goal should be achieving the highest lean mass naturally possible, and this is going to require PROTEIN and RESISTANCE TRAINING. In order to convince the average person, I try to get them to start with the tiniest intervention possible, to really lower the bar to entry and to just get them in the door. A good example might be inquiring about the maximum number of push-ups they can do, and then asking them to try to beat that number once a day and see what number they can build up to over time. This takes less than one minute for most people but is an excellent form of resistance training of the pushing muscles.
In regards to cardio in the book you mention that you are a big fan of HIIT and even recommend the dreaded burpee for those “really feeling masochistic”. I hate burpees so bad that I actually feel bad for the cartoon woman in the book doing them. All kidding aside for those who are up for it, why should they consider burpees in their HIIT routine?
Nobody HAS to do burpees. But we are all about time efficiency and getting the maximum benefit in the minimum amount of time. No other single bodyweight exercise is going to get you to maximum cardiovascular Fatigue faster than these! This is probably why they are so heinous for most people.
Thanks again for taking the time to answer all of these questions. To wrap things up: Any updates on perhaps a printed copy of the book? And lastly where online can folks connect with you?
Thanks for the interview! Right now, I am sad to say that the book does not exist on paper and we don’t have plans for this currently.
The book can be downloaded online as a PDF for $20 at thePEdiet.com,or in AMAZON KINDLE, but at 328 pages and around 500 full color graphics and photos and illustrations it costs more than this just to print it on paper.
We hope we can find a way to print this in a more cost-effective way in the future! You can contact me on Twitter, Facebook, or the web by searching Ted Naiman.
The P: E Diet will also be available in Spanish by Ketogains in mid 2020.