NAD Supplements Are Everywhere - What NMN, NR, and 1-MNA Actually Do Inside Your Cells?

Everyone wants to know about the dangers of NAD, but nobody really knows everything that goes into all of these different things that are associated with it. We're going to cover that all in episode 20 of Cell to Systems. Welcome to the show.

There's really a lot of talk about 1-MNA, like that is the hot topic right now. NAD's been around for a while. People are using it orally, but there is a lot of debate. There's some NR injection stuff that happens, and then of course we have just regular nicotinamide, vitamin B3, but in high doses that can actually affect our insulin sensitivity. So all of these things are in this pathway that you guys can explain far better than I can. Leonard, do you want to start off by talking about what all of these are? What are they? So the general consumer who's out there looking at should I order this product on Amazon, or—which we all know—order direct from the company. In my opinion, I think it's always better to order direct from the company because then you know for sure you're getting it from the company. Can you take us through each one of these things and kind of break it down for us?

Sure. So I'll start off with your comment on Amazon. There was this one lecture I gave once where they actually did a study of buying NMN on Amazon. They bought I don't know how many companies and they showed the results: some had zero NMN in there, and it was something like 60-some percent didn't have what they said was in there. I always remember that study, but yeah, be wary of cheap prices on Amazon.

I mean, that's a great point, right? Just to say that right there—you get what you pay for ultimately with any product. You know, manufacturers—I mean, you're a manufacturer. So the one thing I would say to you is, doesn't it make sense that you just buy it direct? You always see manufacturers saying, "Hey, buy direct from us and we're going to give you a discount and also a reorder discount." I don't know, fulfillment might be a big issue for a lot of manufacturers and Amazon makes that easy. But there's also been some real kind of scary stuff around supply chain sort of interruption where people are putting fakes into the supply chain. I don't know if that's true or not, but it is scary to think that you're buying something you think is doing something for you, especially when you're working with a provider and you guys are saying, "Hey, you should be using this," and it's not even there.

Well, the frustrating part, and I'm sure Craig runs into this all the time, is that they initially get—because I don't think people realize how much a doctor or any type of medical practitioner puts into what products they recommend. Going to conferences, knowing who's manufacturing, knowing the people behind the company, having those conversations behind closed doors—that is what goes into someone deciding that they're going to be using this in their practice. Then a patient comes in, they use it, and then they see an Instagram reel or something, or they're on Amazon, and they're like, "Oh, wow. I can get this for a third of the price," and unfortunately, it's a waste. You know that happens all the time.

100%. Yep. I stick to a very few, very well-vetted supplement nutraceutical companies in my practice, and unfortunately, you know, they do oftentimes carry a little bit heftier price tag. But patients ultimately see the benefit of higher quality ingredients.

Yeah. And just because I have some experience in this—I've been around the formulation of supplements and I have more experience now than ever before—early on, I can actually tell you the moment I realized, "Oh, this is how it happens." One of the first times I was getting involved in this, I was formulating a cognitive supplement for a company and an owner, and that owner wanted to do the right thing. And I said, "Okay, there are these six ingredients that I think are the best." And it's not just the ingredients, but it's what form of the ingredient or where you're sourcing it from that makes it more bioavailable. And so if you really want the best product—and that owner, he's like, "I want the best product, hands down."

What happens is that they go to a contract manufacturer, and it's usually a lot of money, like a minimum of $50,000 to $100,000 just to get a first batch. So for a business owner, especially a small business owner, it's a lot of money and it takes five or six months before it's even ready. And this is the moment when I was consulting with them, because he'd call me up about different changes in the formulation, where I realized this is how someone with good intentions actually gets talked into having an inferior product. Right when it's about to be ready and you've been waiting the whole time, they'll come and call you up and say, "Hey, by the way, I know you wanted that curcumin that was more bioavailable, but if I give you this curcumin that I can source from over here, your price goes down x amount." And they're already down $100,000. They're already like, "Well, there's a bunch of good products in here. There's a bunch of good things in here."

Then I would tell him, "Hey, the studies say that it's at this dose where they see the benefit," and then the manufacturer comes back and says, "Hey, I know you really wanted to have that dose, but if we drop it down to this dose, it'll be less capsules." All of a sudden, they start looking at their margin. And this is how people with good intentions slowly get whittled down by the time the product actually comes out on the market. Unfortunately, the consumer just sees the buzzword names. It's like, "Oh, this has alpha-ketoglutarate in it. This has curcumin," and they're like, "I've heard tremendous things about it." Meanwhile, it's 1/10th or 1/20th of the dose that you would actually need. So those are some of the things that you want to ask your medical practitioner about. These are the reasons that you want to ask them and trust them as to what products they're actually out there vetting, because they're looking at everything else, not just the name on the supplement.

Yeah. I mean, to your point, I think this is a huge piece. I mean, like Craig, when someone walks into your practice, you have products available that you have vetted and that you know this is the right manufacturer. You said you keep it to a certain line of them. What's your vetting process like? How do you go about making sure that you're putting the right things into your practice, because ultimately you want the result with the patient that's going to show up in the labs?

In the most simple sense, I go to the conferences where people like Leonard and other names in the industry can tell me what stuff is going to be the best, you know. But all of these supplement companies, a lot of times they're doing their own research, and that is available. They come with the white sheets and everything that you can request, and they're doing their own internal studies and research. Having that available, I actually lay it out on my table here for all the supplement companies that I use so that it's there for patients when they come in for their visit. They know that if they're going to get a recommendation for a certain nutraceutical or supplement, they can go right out to the main seating area in the office and access all of the relevant literature and evidence.

I know we talk a lot about I-Cell water. I want to come back to that before we move on to the topic of the day. I mean, gosh, we're talking about a million other things, but Leonard, it's kind of interesting when you think about I-Cell, it comes in this container. It's like AKG+ is just AKG, but when you think about I-Cell and it's in this container, I wanted to always ask you: should you turn that up and down, shake it around every once in a while while it's closed just to make sure that you're getting a good mixture of it, or does it just not matter?

It shouldn't matter. Frank would give you even more explanation on this if he was here, but it goes through a process of making sure that it's mixed thoroughly so that no matter where within that bottle you get, you get the same ingredients. Frank in the pharmacy has got this massive contraption that makes sure that everything is completely formulated the right way, because there's a certain amount of times that that machine has to go when they're compounding their capsules. The manufacturers, if they're doing it correctly, do the same thing.

Got it. Well, that's good to know. It's a product that I use every day. I remember back in the day just doing it manually when we were making capsules manually and just mixing them over and over and over again. What they'd do is they'd put a little bit of a dye into the powder so that you can see if it was uniform. If you saw little speckles within there, you knew it was not uniform and you'd have to keep on going over and over and over again. Now technology is a little bit better, but yeah, that's a big deal, especially in the pharmacy world. You don't want all the active ingredient in one pill versus the other. So they take that stuff seriously.

Yeah, that can be a real problem. All right, back to the original. What's 1-MNA? What's NAD? There's NAD+—is that a brand or is that something else? And then what's NMN, and then NR? I guess we can leave nicotinamide off the table because that's not really something that's top of mind for people. Vitamin B3, right?

Well, it is NAM. So, it's basically nicotinamide, which is sort of the start of it all in a way.

That's true. It's the base, right?

Yeah, that's the one NAD precursor that people forget about, or even like nicotinic acid or niacin. People go straight to the fancy stuff like NMN and NR, but there are a couple of things that are NAD precursors. The reason that all these even exist is that we know, if you're more into biochemistry or in academia early on in the study of aging, how important NAD is for just about any enzymatic reaction that happens within the body. It's necessary. If you pull up all the biochemistry stuff, you'll see NAD being reduced in every single pathway. So, they found out very early on that this is very necessary, and this is something that gets depleted.

Well, there are some studies recently that say it doesn't get depleted as you age, but it definitely gets depleted when you have DNA damage, when you have poor sleep, no exercise, or as you age, it seems to be depleted—or at least the enzymes that deplete NAD rise. The more damage you have, you think about NAD for every enzymatic reaction. If you have a lot of DNA damage, that means it's going over there to take care of that stuff. If you think just logically as you age, you have more disruption going on. And so the logical thing is, well, hey, if we just give the body what it's missing, everything will be great. And so this is kind of the rise of NAD and NAD precursors.

Why NAD precursors came into the mix is that they found out that the molecule NAD, especially orally, is hard to get into the cell and actually do what it's supposed to. So they started coming up with these NAD precursors that can turn into NAD within the cell, and there are just different steps along that pathway. NMN (nicotinamide mononucleotide) is one of those pathways. NR (nicotinamide riboside) probably has the most studies along with it where it has been shown to increase NAD. Of course, you have NAD through IV use, which is just NAD the actual molecule, and then you have the newest form of NAD precursor in 1-methylnicotinamide, or 1-MNA, that is actually working on a different part of that salvage pathway—the body's ability to recreate its own NAD.

The story around NAD never really stops. You can even go beyond these NAD precursors and look at things that inhibit certain parts of that pathway, right? In the NAD salvage pathway, there are certain enzymes that pull these precursors or pull NAD out of the pathway, so inhibiting those enzymes becomes a strategy. Now you start coming up with things like 5-amino that inhibits the enzymes that would pull that NAD out of that pathway. You have certain supplements like apigenin. Apigenin inhibits something called CD38. As we age, there's this really cool study that shows your NAD goes down but your CD38 levels rise at basically the same time. These CD38 enzymes happen more in immune dysfunction or inflammatory issues.

Then all of a sudden the strategy became, "Hey, we have to do more than just replace this; we have to actually think about some of the supplements that inhibit this enzyme." Can you have a full-on approach? I think the full-on approach doesn't even start with any of these supplements, right? NAD is very closely related to your circadian rhythm. So, we know that when we exercise, NAD increases. We know that sleep impacts NAD. We know that there are things that impact NAD in a poor way, like traveling across the country. So a lot of it is lifestyle modifications. But a full plan, like if you go to somebody like Craig who knows this stuff inside and out and you tell him that you want to improve your NAD, he's going to give you more information than you probably want to know because he's going to be thinking about the NAD precursor, the lifestyle modifications, what are the enzymes that are inhibiting it, and what are the other things that can put you in the right place to make sure that your NAD production is going the right way. So yeah, that's this entire world that can get complicated, but I'll kind of pause there and let Craig take it from there because there are clinical instances where you'd want to use one more specifically for a reason than one of the other ones.

That was awesome. I mean, that encapsulated basically everything. That's a great starting point, Leonard, and you really hit on everything that is relevant, I feel. I was telling Jock a little bit before the show, this is not an area that clinics like mine focus on heavily. There's a lot of patients that come asking for these things because they're hearing that NAD levels are declining with age, and they're looking to help them recover their energy and their vitality after a recent infection or some setback that they've experienced. That is an area that I really do shy away from in the clinic.

As you mentioned excellently, it's the lifestyle stuff. What is going to help NAD want to be around? The main way that we want to have it around is that NAD salvage pathway, right? So we want to be able to recycle all of the components that are going to be necessary to keep those intracellular NAD levels up. Exactly as you mentioned, so much of this is lifestyle-based. It's activation through fasting, through exercise, through lifting heavier, and through contracting our muscles a little bit stronger. It's making sure that we're locking in those circadian rhythms and not ending up sleep-deprived. As far as things that can really degrade cellular NAD, I tell patients alcohol. That's one of the major things. I think that's the only study that they actually have on IV NAD, right? It was for alcoholics.

Yeah. I mean, I'd have to go back and read that.

I think the only IV NAD study out there was in alcoholism or something related to that.

Yeah. And sure, it's going to raise serum levels, but it always comes back to: what is inside the cell? What is intracellular? Right. And that's I think where the precursors do come in. I do have those talks. I have a lot of patients that come in and they've just been pounding NAD precursors for years, which is something that I recommend against. Strategic cycling of precursors is something that I'm a proponent of. Yeah, it is NR, which is a little bit more upstream than NMN. NMN is the immediate precursor to NAD. As you mentioned also, there is more research for oral NR versus NMN, which has some interesting data to support it as well, but there is more research out there these days that shows that NR can significantly improve NAD levels.

It's interesting, these other molecules like apigenin—something that I'm regularly recommending for patients for that CD38 enzyme inhibition, especially if they're dealing with maybe some component of insomnia, sleep disruption, or circadian rhythm issues. So that's an area where I like to target for those patients.

What's funny, Craig—and I might get in trouble for saying this—is that some of the best physicians that I know don't use a lot of NAD precursors. They don't because they're already working on NAD in so many other ways: by reducing inflammation, by working on things that help with sleep, and by making sure nutrition is in play. So it's like that's not necessarily an issue for them. Typically what I find with some of these amazing physicians is that if they do do it, it's sporadically for a specific instance. Maybe there's accelerated weight loss on certain ones, but it's identifying the patient that might need it short term, right? Somebody just went through like an infection and you know that there was a lot of damage, so you know there's a lot of things that are going to be depleted. Or people that travel and they have to fly across the country and they get that jet lag—just to kind of restore that circadian rhythm, a big dose of NAD in the morning kind of helps restore those things. That's the way I use it. I don't take any of those things consistently unless it's something where I feel, "Hey, I can identify—I don't have to take a blood test—that my NAD recycling right now is probably not very good, and I'm going to hit it hard right now for a short period of time." But yeah, hopefully I don't get into too much trouble because I know people love their NAD and they make a lot of money off of it, but some of the best physicians I know that have incredible outcomes really aren't using a lot of NAD precursors.

Yeah, exactly. As I was mentioning to you, Jock, it's just everywhere, right? Leonard mentioned it in the beginning. It's a co-enzyme that's necessary for basically every single enzymatic reaction that you could possibly want to explore in the human body. Without it, we're not going to exist. So, it only follows naturally that the things that we do just on a regular day-in, day-out basis that support overall wellness and health can really go a long way and do most of the heavy lifting to optimizing NAD levels. Patients get into trouble with the other stuff: the chronic inflammation, cancers, poor diet, insulin resistance, all of that where maybe they need a little bit of support.

But yeah, so if you're a patient, potential patient, consumer, or whatever you want to call it—healthcare consumer—and you're listening to this, you're saying to yourself, "Okay, well, I've heard a lot of hype about all of this stuff. Maybe I purchased some of these products online without consulting a longevity provider, a cellular medicine healthspan provider." At the end of the day, the things that you guys are talking about—which again is always fascinating to me, Leonard, because you're the pharmacist that's like, "Don't do it. Most of the stuff is overrated."

Yup.

Which I think is really cool. So hey, let's get down to what are the things that we can do. We can exercise, right? Get great sleep, exercise, recover, eat right—so that's making sure that you've got your macros and micros handled. Then is there anything else? What else is there? I mean mindfulness, breathing, those types of things, or what are the things that can help us make sure that this enzyme is functioning at the highest capacity and that our body is producing and using it on its own in the best way possible?

I think coming back to one of the things that does degrade—and this is getting into a little bit of the science here with this big word that's coming up—there is an enzyme that does degrade over time, and that's NAMPT, which is nicotinamide phosphoribosyltransferase. Okay, that was good.

That's right. Can you say that again?

Is he really going to know what NAMPT stands for?

Yeah, that's impressive.

Nicotinamide phosphoribosyltransferase. This is the enzyme that is responsible for taking nicotinamide and basically converting and metabolizing that into NMN, okay, which is one of the precursors that's then enzymatically going to be converted into NAD through a whole other initialism enzyme. But that does degrade over time, and one of the things that we can absolutely do—and you hear about this all the time in cellular and longevity medicine—one of the things that we can absolutely do to improve those levels is things that activate AMPK. So as you mentioned, it's the exercise. Fasting—appropriate fasting—is absolutely necessary for that.

Of course, we know that there are molecules, peptides, and other things that are going to be AMPK activators too, but so much of what we're really trying to push in this discipline, in this field, is: what can you do without spending money? What can you do that's really going to sustain your health and wellness if the grid went down and you had no access to a cell phone, to the internet, to your pharmacist, or your medical provider down the street? What can you do to support health? And that's always going to come down to the lifestyle stuff. You know, eating a clean diet, lowering things that are going to lower your inflammation, getting optimal sleep, having your sleep consistency dialed in, training those circadian rhythms, and exercising, right?

NAD is something we don't know that much about. Think about this. Everybody talks about NAD so much. There have been so many studies about it. They're still trying to figure out specific pathways and how NAD gets into the cell versus intracellular versus extracellular NAD. They're still trying to figure out if you can even measure it in the blood, right? There's a bunch of tests out now that claim they can measure NAD, but the thing about it is that it's in constant flux. It's constantly in flux. So if you tell me that you measured your NAD in the morning and something happened later on in the afternoon, we don't have any normal reference ranges for that. So as much as we know about NAD, there's still a lot that we really don't.

The way that I think about NAD is very closely related to what Craig's talking about when it comes to exercise. Was that David Sinclair, right? So David Sinclair was the big proponent of NMN, and Charles Brenner was the big proponent of nicotinamide riboside. It was fun watching them go back and forth, having nerd fights online about which one was better. But Dr. Sinclair actually had a great book where it was one of the first ones where they started talking about sirtuins, right? So in the aging world, sirtuins were this big longevity thing. If we can just activate sirtuins, then we've figured it all out. But I think what's more important is understanding the chemistry behind why you would even want to activate sirtuins. The big thing about sirtuins, and why all that research was done in longevity, is that they're dependent on NAD. Sirtuins can't do anything if enough NAD is not in the system.

Why that's important is that if you just erase all that, and if we look at the biochemistry of what's happening when someone exercises and starts moving their body, what we would see is this activation of sirtuins. Then they have all these downstream effects of all the benefits that you're looking for, Jock, which is the reason why you exercise so much, right? It is improving your inflammation. It is improving cognitive function. It's improving fat oxidation. It's bringing glucose into the cell. It's impacting insulin resistance. Your cells are identifying this deficit in energy. And it's like, "Wait a second, there's a deficit in energy. What do we do?" Well, we increase AMPK, and then AMPK does all this amazing stuff. And so, that's really where all the magic happens is within exercise. It's no wonder that NAD is increased when we exercise. No matter how much research I do, it's like at the end of the day, this thing is just mimicking what happens when we exercise.

So I think of it a lot around exercise. At the end of the day, I keep coming to the same conclusion: if we can help people move their body better, it's like the most powerful drug on the planet. Sometimes you could use peptides and specific supplements to aid them in exercising better and recovering from exercise. We put a lot of stake into these amazing peptide molecules, but at the end of the day, I think it's the ability to move better that's causing a lot of the benefit. It's crazy to think how many people are sort of on the peptide train but aren't actually exercising. It's kind of like, what's that about? I don't get it.

Yeah, to your point, Jock—and I'm going to say this in the lecture that's tomorrow to a bunch of physicians—is it really the peptide, or is it the exercise that's secreting these things that have all the benefit? They happen to be peptides that are signaling all these things to happen. But yeah, to your point, Jock, what you're saying is actually reflected in the literature when we study these peptides.

Yeah, it's fascinating. It's amazing. So guys, I think we've pretty much covered this topic today in great detail. I think it's really encouraging for people to realize that at the end of the day, it's the same thing we keep coming back to over and over and over on this show, which is your lifestyle: diet, exercise, sleep, and hydration. I just can't say enough about hydration and how important that is. Craig, in your clinic, when patients come to see you—and then Leonard, I want to talk to you about NuHX a little bit—but Craig, when people come to see you at Remedy in Maryland, when you're first doing a workup, obviously you're going to do some labs. I know you do those there, and then you get the lab results back and you start taking a look. People have come in and they've got their whole list of supplements and they're kind of attached to them. I imagine you have to do a lot of education with them to help them understand, like, you got to let go of this one that you're clutching onto so hard; it's not really working for you. Do you find a lot of resistance, or do people just sort of go, "Okay, you got it, whatever you say"?

It's on a spectrum, you know, because some people are coming in and they've got 25 or 30 supplements, right? And their wife is telling me, "Oh, you know, we're spending so much money on all these supplements. Please help him find a way to cut this down." And so they're oftentimes happy to get rid of some. Maybe they're taking so many pills when they don't even like to take supplements. It makes them feel nauseous and they're just slamming these things regularly. On the other side of the spectrum are the people that really aren't utilizing any supplements or nutraceuticals, and you can see from specific lab work that they really would benefit from certain compounds. Trying to get them to understand the chemistry of it, the utility, and the efficacy of the products that we recommend here in the clinic, and sort of twist their arm a little bit to say, "Hey, this actually can be a needle mover for you."

So it's really a broad spectrum of patients that we see and help along the way with their supplement journey. It's a fun area, and it's interesting because you'd think that people would come in when they're on these 20 or 25 supplements and there's going to be a lot of useless stuff in there. A lot of times there is, but it's really fascinating when you come across that patient who's got it so dialed in. Like every single one—it might be 25 individual supplements that they're taking—but every single one has a purpose and they've figured it out. A lot of times, these are the people that are actually, from what I've seen in my practice, in their late 60s and their early 70s, and their health is dialed in and they've just figured it out over the years. So I'm always marveling at these people. I'm sure they're really spending a bundle of money to get access to these supplements, but I enjoy seeing that, and then also trying to help them maybe combine some of these things to cut down cost and whatnot. But yeah, it's cool.

It's super interesting. I mean, I love what you guys always talk about. Leonard, you always talk about periodization and sort of like, "Hey, if you're staying on this one thing for so long at the same dose, you might want to be thinking about changing that up along the way." NuHX—we've had lots of conversations about this. I think this is like the wave of the future where people are coming in for this evaluation. As we talk about DEXA scans—like I'm going to have a DEXA on Friday, but it's not going to be the scan, Leonard, that basically shows you the intramuscular fat, not just the—that one is from some company, I forgot the name.

Yeah, super cool though.

Yeah, you have to get it. It's expensive, super freaking expensive right now, and then you have to go get a full MRI for like an hour. So it's not—is it Precision Analytical, or is that a lab?

No, that's something else. It was something analytic, but it's expensive. It's an MRI. It takes like 45 minutes at least for them to scan the whole body, but it's really cool because they show you the intramuscular fat. I wish we had that data on every patient, because I would love to have seen some patients that we've seen lose 50 or 60 pounds to see what the makeup of the quality of their muscle is after losing all that weight.

Yeah, really interesting. I always come back to one of the things you said when I'm meeting with patients—one of the things you said on an earlier podcast, it might have been like one of the first podcasts, Leonard—where you were talking about how some of the muscle loss may be a wonderful thing when that muscle quality is degraded, ribboned with fat, and there's a lot of inflammatory signaling happening as a result of that. Losing that muscle is okay; it's permissible. It's one of the things that we can expect and say, "Hey, we need to get rid of this to support ultimately what's going to be a stronger foundation of new and better, higher quality muscle."

Yeah, for sure, which I feel like it's almost against the rules of longevity to say, but it's what we see, and I think more and more data is coming out about that. I think at the beginning people were just like, "Fat bad, muscle good, move on to the next thing." But another thing to mention about the whole NAD thing, because we kind of discounted it, is thinking back to patient selection or situations where it kind of makes a little bit of sense, and I've seen it be very beneficial. Craig mentioned that enzyme, NAMPT—it's like the rate-limiting step in the NAD salvage pathway. So it's like your body's ability to recycle and make NAD itself. Well, if you look at patients with obesity, they have a decline in that enzyme, right? They also have a decline in things like AMPK, and so their signaling is already downregulated in these things that we know are important. For short-term poor metabolism or obesity, we would use that early on—some type of NAD precursor—just because we could make an educated guess that this person's NAD balance was probably off. It doesn't have to be like a long-term treatment, but we know what it looks like in obesity. Using that at the beginning was always beneficial for a couple of months, but usually, they change. Because they change, because they don't have that obesity anymore, and because they're moving their body now, they're signaling differently and they don't need the extra NAD. So there are instances to use it.

At NuHX, what are the precise things that you guys are measuring?

I think there are just like three fundamental things around the ability for the physician to make the best decision possible. That is their body composition—but more than fat and muscle, knowing where the fat is, knowing their appendicular lean mass index or their skeletal muscle index, like where the muscle is. So there's body composition. Then there's metabolic breath analysis. Just what does their metabolism look like at rest? Do they have a slow metabolism or a fast metabolism? Of course, we want to know their VO2 max because that is the marker that we know for mortality risk and biological age, and it means so much.

But then there are all these other markers that you get as to their metabolic flexibility. So, at what heart rate or at what speed they're oxidizing the most amount of fat, or when does their mitochondria break down and switch over to carbohydrates? Is it happening too soon? From those data points, we could actually prescribe exercise. When they come back in, it's really easy to say "insulin resistance" or "metabolic inflexibility," but now we can actually show them like, "Hey, look, your biochemistry is completely different. You were walking on this treadmill at 4 miles an hour and your mitochondria was shutting down. Now you're doing it all the way up to 5 or 6 miles an hour. Look how much more efficient your body is. Look how many more calories you can burn. Your biology, your biochemistry is different—it's of a younger age." So that one's the one I get kind of super excited about.

Then the one that I haven't quite figured out the best way to do this yet: I do a lot of different ways of measuring strength because, to Craig's point, you lose weight, you lose muscle. Is it bad muscle? Is it quality muscle? Did you stay strong? Did you get stronger? That's the one thing that we want to know. And then from there, without even blood work—which the doctor probably already got—we can tell so much about a patient's risk. We can tell so much about compounds that are going to work for them, supplements that are going to work for them. We can tell them so much about what's going to be the most beneficial exercise for them.

I think that this will be the standard of care in the future of medicine. I think anybody prescribing GLP-1s, anybody working on somebody's metabolic health, will want to know those data points just to make better decisions, more personalized decisions. So that's where I don't want to get too fancy with it and start adding a bunch of stuff, because you know how we are—we're going to want to do all types of cool stuff. But I think that is the foundation of it, and that's what we focus on right now.

Right now, if you live in South Florida or you live anywhere—say you have somebody in San Francisco, I mean, I don't think there's anybody else that's doing it the way that you're doing it, I haven't heard of anything like it. So you live in San Francisco, you're a Silicon Valley guy, and you want to figure all this stuff out. You want to go where the people really know. Can you just call up and say, "I want to come," or do you have to be referred by a doctor?

Right now, you can call up and come. We have doctors that send patients from other states. For instance, we have a physician that specializes in long COVID, and these people have really poor exercise capacity. So they want to come in and measure that and see if the protocols they're using are actually moving the needle. So we've had patients fly into town to get this testing done. But I think there's a lot of places that do some version of this, you know. We use a company called PNOE. You could probably go on their website and see anybody that's doing metabolic breath analysis testing. There are DEXA scans almost in every town. So you can kind of put these pieces together. It's just tough right now finding a physician that knows kind of what they all mean.

Well, I think what's interesting about this—let's talk about that because Craig, you've got a PNOE. You're doing it. Love it.

Yeah, and you get great results with that. It's fantastic, it's so personalized, and it's a wonderful experience for the patient unless they're claustrophobic, which, you know, I've had a couple of patients come in and they're like, "Ah, I can't do this. Take the mask off of me right now." But those data points and that biometric information that you get really is so key, and people have no idea that this information is available to them. I mean, being able to dial in somebody's FatMax and say, "Hey, once your heart rate is consistently beating above this number of beats per minute, you've switched over from oxidizing fats and burning through fat stores, and now you're burning glucose, you're burning carbohydrates. So it feels like you're doing hard work, yeah, great, but you're not targeting the tissue that you probably thought you were when you're doing this exercise."

So being able to really sit down with the patient and say, "This is where you're going to burn the most amount of fat tissue. This is the type of exercise that you need to do to accomplish that. This is how many times you should do that throughout the week and for how long each interval is." That is excellent. Then you're getting all of this additional information based on their oxygen consumption and their CO2 elimination of how many calories, kilocalories, they're burning at rest and with activity, so you can really just dial in somebody's macros—especially if you're using something like a DEXA or an InBody or any of those other BIA devices to look at somebody's composition and then determine what their macros are going to be. You can just really, really help people get to that next level using something like PNOE. I think it's an indispensable resource for my clinic and several others, and I'm very glad that I got one.

Yeah, super cool. So hey Leonard, what's really interesting is, so people out there have PNOEs and that's great. As you said, people are kind of piecing these things together, and people can get a DEXA scan or they can have an InBody like Craig has in his practice. At the end of the day, people are still calling you guys all the time because I hear about it. I hear from people that they're calling—"I call Leonard, I call Frank, I have a question for them"—and they're getting information from you about what are the things that they should be doing with this particular patient. You guys are pretty generous with that time and that information. Maybe you could talk more about that and how that relationship works.

So, there are two sides. We spend a lot of time talking to physicians; that is the majority. We do a lot of education through New Bio Age for medical practitioners, where we have a lot of education on peptide supplements, these diagnostics that we're talking about, a lot of lectures, and then those members that are medical practitioners can actually call and do one-on-one consultations with our pharmacists to go over either case studies or better understand any of these things that we're teaching. That's through New Bio Age. Then at NuHX, we have pharmacists there that are actually running these tests every day. Anybody really at this moment—they might not like it if this podcast blows up—but you could call and talk to our pharmacists. They love this. This isn't just like a job for them. They're like Craig. You can tell when someone nerds out on this, they just want to talk about it all the time. And so, that's possible, too.

All right, guys. Well, as usual, this was a phenomenal episode. It's so funny when summertime rolls around, all these people can't join us for every episode, but we had a really productive time today. I really enjoyed this episode and I think the people listening to it will find it fascinating, full of great information. Thanks for watching. We really appreciate you and we hope that you'll like, share, and subscribe to our channel. That really helps us with the algorithm as we bring more and more guests and more and more awareness around the topics that we're talking about on the show. Also, please leave us a comment. We'd love to hear from you. Thanks again. We'll see you on the next episode.