Spencer Nadolsky: The Doc Who Lifts With His Patients
What if there was a doctor who told you that you could replace your medicines with diet or exercise? A doctor who practices what he preaches, and would even take the time out of his day to work out with you, and sit down with you afterward to talk about your life over lunch? A doctor who actually wants to get to know you so they can best manage your patient care? They would be a dream come true, right? You may think such a physician doesn’t exist. But Spencer Nadolsky is no normal physician. Spencer Nadolsky is all of the above, and he’s famously known as “The Doc Who Lifts.”
Author of The Fat Loss Prescription, and family practice physician specializing in obesity, Dr. Spencer Nadolsky approaches his practice a bit… differently. As he puts it, “ Most doctors don’t have as much interest helping those with obesity since they feel it is a matter of just putting your fork down and pushing yourself away from the table. But the complexities of obesity show it is much more than that, and it is fun working through those complexities with my patients.”
So how does he work through these complexities? Well, he recently took a day off to work out with a patient, and then went to Chipotle afterward to talk more intimately with his patient about his life, his family, and his daily struggles. This approach to health care is almost unheard of, and now Dr. Spencer Nadolsky wants to expand this concept not only within his practice but to other physicians as well.
Here Dr. Nadolsky shares with us some insight into how he became the physician he is today and his ideas for the future of healthcare.
Dr. Spencery Nadolsky: what led you to this line of work as a family and bariatric physician?
I grew up in a science and athletic driven family. My mom and dad were teachers. Father was a biology and chemistry teacher along with a football and wrestling coach. My brother set the precedent by being very good at athletics and school. I followed suit and did extremely well in high school academically and eventually athletically.
It was my initial lack of success in high school athletics compared to my brother that led to my love for exercise and nutrition science. I assumed my genetics would have propelled me in sports but I was wrong. With my early failures in sports, I began studying exercise and nutrition science to help me accel.
I applied what I learned and eventually became a state champion wrestler and all-state in football. In college, I applied the same principles and did well wrestling at UNC-Chapel Hill.
I loved using nutrition and exercise science for performance purposes, but my passion grew for using the principles in the general public. My thought was that if I could be an elite athlete with this obsession with nutrition and exercise, I could help people use just a fraction of it to prevent and even cure chronic disease.
With this in mind, I went to medical school to pursue this dream. I decided on family medicine first since I thought that I could reach people at a young enough age to prevent disease or at least catch pre-clinical/subclinical diseases and divert the patients towards health.
My love for bariatric medicine and lipidology stems from the aforementioned exercise and nutrition science. The crux of lipidology is preventing cardiovascular disease. If we can prevent our number 1 killer, we can help people live longer and happier lives.
As “The Doc Who Lifts”, how does this fold into your philosophy and approach to healthcare?
I am obsessed with the idea of exercise (and lifestyle in general) as medicine. While I love promoting weight lifting, I encourage everyone to get as much of any form of physical activity as possible on a daily basis. If I could get all of my patients to exercise as I do, I could reverse many of their diseases.
There are many other doctors out there who lift. Studies show that those who exercise and practice what they preach are more often to promote the same to their patients. This is very important of course.
My patients follow me on Facebook and Instagram and see how I practice what I preach. It is motivating for them. They also learn about other patients who were successful in using lifestyle, so it is a big advantage.
You recently took half a day off to work out with a patient and then went to Chipotle. Why Chipotle, and what did you discover from that experience with your patient?
Chipotle is just tasty and CAN be a place to choose more healthful options. It is also more informal and relatively inexpensive. One could argue about the bacterial outbreaks, but I think the risk is small LOL.
We are able to have a good conversation about not only nutrition and exercise but also life. Being a family medicine physician, we care about the entire person instead of one organ system. We care about their emotional and mental health too since that is EXTREMELY important.
Working out with patients is an amazing experience especially if they haven’t stepped foot into a gym or have never really lifted weights. Patients are intimidated by the gym and rightfully so.
Not knowing what to do in front of other gym goers is daunting. I am able to show them that weights aren’t as difficult or painful as they thought. It is also more time to get to know the patients.
Currently, there is a nationwide program called “walk with a doc.” It is pretty cool and a good way to get some activity while hanging out with patients, but I think stepping it up a notch is a good idea if possible using the more formal exercise.
What advantage would a “doc who lifts with his patients” program have over a traditional plan of working out with a trainer and seeing a nutritionist?
The advantage is getting the patient in the door first. Patients trust their doctor a lot. We are also a health professional the patient will see before making that leap to joining a gym or hiring a trainer. If we can bridge that gap to make it happen, we can be the needed catalyst for exercise. I think starting with a doc who lifts and then going to a trainer is the ideal model.
Based on my own experiences, we would find that many more patients would start exercising more across the country if this approach were to be implemented on a larger scale. It would be the spark for patients who otherwise wouldn’t exercise.
There are other obesity doctors who have gyms connected to their clinics and I think it would allow for the spread of this idea as long as it was fiscally sound.
Logistically speaking, how would that idea work?
Pretty much all lifestyle-related chronic disease guidelines list exercise and nutrition as first-line treatment. So I want to know why fitness facilities are not more connected to medical clinics?
The idea would be to have more partnerships with gyms and clinics. Connect the two. Have more patient-friendly gyms I think. I know a lot of other doctors who are interested in this. I have seen some who have done this, but it is rare.
Out of curiosity, how does the current healthcare system hamper a program like the one you have suggested? And what about this is making it difficult to give better care to your patients?
1) Insurance picking and choosing what they believe is the correct treatment path for my patients. This comes down to crony capitalism and corruption in my opinion.
2) The government creating more and more checkboxes we have to “click/check” because they believe it will improve care. May sound good on paper, but in practice, it just decreases the amount of time we have with a patient to get to the root of their issues.
3) Decreasing time for each patient with the reimbursement model we have now based on the above.
How would a Dr. Spencer Nadolsky or ‘Doc Who Lifts with his Patients’ type of program mitigate the biggest issues we face today with health care?
This program would effectuate decreases in medicines and expensive health care down the road. For example my classic 50-year-old male with class 1 obesity (BMI 30-34.9) who has pre-diabetes, mild hypertension, obstructive sleep apnea, hyperlipidemia, and mild osteoarthritis.
I have helped patients like this become entrenched with exercise and nutrition where they didn’t need any more medicines and got off their CPAP machine. This approach has also decreased the pain in their knees. Helping patients feel better and decreasing overall costs is the goal in my opinion.
But for a program like the one I am proposing, there are a few barriers:
To implement quickly, it couldn’t be done with a hospital group due to the hoops you would have to jump through. On a very lean level, I could see this starting with a physician doing a day of clinic at an actual gym that would allow it. There are some liability/legal barriers to this I am not sure about, but if you are in private practice, you could tell your scheduled patients to meet you at the gym of choice.
This is kind of what I do right now but on a smaller level. I have had a couple of patients come to my house where I have a very well furnished garage gym. This is probably not ideal but gets the job done. I have listed some other models below.
For me personally, I would want to start it in the right area. I am not sure where that is right now. Also, my wife is a Navy physician so I don’t know if I will be where I am right now in 1.5 years. But I don’t see this as a huge barrier though because:
A) I have multiple state licenses and I could start it by having one clinic day per week at a participating gym as described above.
B) I would love to be part of expanding this model quickly by teaching other doctors how to implement it, which would scale the idea. I wouldn’t need to be present at any one location for this of course.
Then, of course, funding is always a barrier. I have discussed with many physicians about this idea and they are worried about having to run a gym as a business along with their practice. Space in a medical facility is likely more expensive than a gym so to make sure it is profitable or at least doesn’t lose money is key.
There are ways around that as described above with partnering with gyms. Insurance doesn’t usually pay for gym memberships so this would likely be a cash endeavor, which I describe below more in detail.
What are some models for this program that you’ve come up with so far?
An ideal would be creating a small gym that had a couple of patient rooms connected for evaluations, but there are some pros and cons to that approach.
PROS: I think it would be best to bring your patients who are unsure about exercise straight over to the weights etc. after you saw them in the patient room and then show them lifting weights and exercise is not as bad as they think. They then start their membership in the gym and you are around to help them and then they schedule appointments with you for formal visits as needed.
This would be a combination of an insurance-based model for the visits and then monthly cash-based retainer for the gym. You could do the clinic all cash-based too as direct primary care is gaining traction e.g. 50 bucks for a formal visit with the usual recurring membership fee.
CONS: There may be a selection bias with the patients who go to a “gym clinic”. Those who are healthier would seek out this type of place and would negate the changes in someone who wasn’t sure who goes to a normal clinic. This is why marketing would be important. Would you have to make the monthly fee so high to where the people who need it the most wouldn’t be able to afford it?
Another model would be closer partnerships with clinics and gyms. Start partnering physicians with those who gym owners. Or, discuss with major hospital systems with fitness facilities already built that they should have physician offices connected to the building.
PART 2: Since this program doesn’t exist yet, maybe you can speak to us about some obesity-related topics that may be of interest. How about the involvement of genetics and lifestyle factors in obesity?
Genetics is extremely involved in the process of weight gain. A lot of it stems from differences in appetite and hunger, which is why our recently changed environment impacts us more.
“Genetics load the gun and environment pulls the trigger.” Of course where we store/burn fat and metabolic rate make a difference too, which can be determined by genetics.
There are monogenetic forms of obesity along with genetic syndromes, which are rare but should be looked for when applicable. Epigenetics of obesity is fascinating as well because it turns out we have consequences of what our mothers did while we were in utero. These play similar roles.
Our weight gain stems mostly from our lifestyle choices, which can be dictated by environment AND genetics/epigenetics. It is very individual and quite complex.
Why do you think it is important for people who struggle with obesity to seek the care of a physician?
Many people think that obesity is just a result of laziness. When you seek a physician trained in obesity medicine, they can help you instead of shame you. Helping with lifestyle changes if of course the number one treatment, but many will fail with this approach. An obesity physician can give medicines to help with hunger/appetite and if need be refer to a surgeon when applicable.
For instance, Metformin is a medicine approved for type 2 diabetes, but it actually has some weight loss properties. It helps with both appetite and insulin sensitization. The mechanism of action is thought to be through its effects on AMPK. Its effects are mild though compared with other medicines approved for weight loss.
Are there any reasons why someone who isn’t obese would seek out care from an obesity physician?
It’s possible the patient may not fit the standard definition of “obesity” from an anthropometric standpoint (BMI), but may fit from a metabolic standpoint, which is mostly a new train of thought. Some ethnicities have a lower cutoff of BMI too which may not be known.
One thing we like to push through is using waist circumference to better define obesity since where we store the weight is very important (waist being the worst place).
Have you received new patients who were poorly managed in the past?
I do see it. A lot of it is a system-wide healthcare issue due to lack of time and resources along with likely not staying up to date. Most of it is unnecessary medicines or wrong dosages or even just lack of a good history taking. Most patients don’t know the difference because they were just following the doctor’s orders.
What are some of your eating habits? What can we glean from the system you have in place for yourself?
I like the “protein and plants” approach. A lean protein and some sort of plant (or two or three) in the meal. This could be something like eggs and fruit or chicken and vegetables. I eat more carbohydrate-rich (rice) foods on days I work out. While I focus on fruits and vegetables, I also try to get a serving or two of legumes/oats per day as well. I eat about 4 meals per day.
For my one (and possibly only lol) bodybuilding competition, I wanted to be precise so to not lose much muscle during the process. It was a bit tedious and socially painful at times I will admit. If you track your calories and macronutrients with more precision, you can modify the variables and have more control. I don’t do it now because I find I do a good enough job without it and I am not trying to compete in bodybuilding.
Weightlifting vs. Crossfit. What kind of exercises do you recommend for beginner weight loss trainees?
I tend to not recommend Crossfit to my patients right away unless they ask about it. I find it can be too much too fast for them, but some have had amazing success with it.
I start with an easy full body machine or dumbbell workout a few times a week along with a daily 30-minute walk after dinner if possible. I do recommend Fitbbits to my patients if we think it will help them go for an extra walk if they don’t hit the target. For some patients, it is a waste of time because they won’t use the information as intended.
Do you test for autoimmunity in your practice and include it in your differential diagnosis? If so, how does this affect your treatment protocol?
Since I have Hashimoto’s Thyroiditis I am very cognizant of it and test it often when indicated. Many autoimmune diseases go undiagnosed for a long time though and the symptoms overlap. I try to hone in on symptoms of a patient and test for specific autoimmune disorders when indicated but there isn’t a good reliable battery test that is cost effective.
Have you ever recommended a Paleo Diet for patients with autoimmunity? Have you ever recommended it for obesity? Why or why not? (I have to ask, of course)
Yes for autoimmune diseases I discuss the case studies out there and give them resources for the protocols. I think the preliminary data is fascinating although I remain skeptical at this point. Either way, I offer it to patients as a possible adjunct to the standard of care.
Many of my patients with obesity are drawn towards a Paleo Diet. What ends up happening often times though is the restrictive nature (e.g. no dairy/legumes/grains) can be a hindrance for long-term adherence. We work through it and find a diet that works for the long-term though.
Why do some people find it so difficult to lose weight? What sort of underlying and perhaps lesser-known conditions would make it challenging to control hunger?
Our bodies and our environment work very strong against us. Regardless of metabolic adaptations (a lower than expected metabolic rate after weight loss), we also have decreases in non-exercise activity (less fidgeting, walking, and movement in general), along with increases in our hunger/appetite.
All of this while having an extremely obesogenic environment. We have extremely tasty foods surrounding us at all times with day-to-day stresses like work and family/friends. We are fighting an uphill battle.
Many medicines can increase hunger that many may not be aware of including anticonvulsants and even antihistamines.
With the emerging science exploring the gut microbiome, how does the gut microbiome help us shape our understanding of the etiology of metabolic dysfunction?
I think we are just getting started with this. We are finding correlations of the microbiome in lean vs. obese individuals, but how to make clinic changes based on this is lacking right now. There is a lot of chicken or the egg in this field, but at every obesity conference I go to it is discussed.
What are lipopolysaccharides? How can this affect hormones involved in obesity?
Lipopolysaccharides (LPS) are part of the gram-negative bacteria structure. We learn about these early in medical school from our microbiology classes. In obesity/insulin resistance they have gained a lot of notoriety due to the plausible underlying pathogenesis. Our guts contain a bunch of bacteria. Many of which are gram-negative. This means they have LPS in their structure.
In medical school, we learn about how devastating it can be to get a load of bacteria in our bloodstream, which can cause sepsis, with subsequent organ failure and death. However, we are now finding that those bacteria (including gram negative) in our gut are getting into our system in small amounts.
The LPS component triggers an immune response and we can get a low-grade inflammation from this (not the same overwhelming response as seen in sepsis of course).
There are hypotheses of the role of LPS and gut dysfunction in obesity/insulin resistance most of which is biologically plausible now with all of the studies going on. The increase in inflammation could have a role in appetite regulation along with metabolic rate and also tissue insulin sensitivity and adipose regulation.
It may not be a panacea for obesity but it is likely a contributor. I think we will see a lot more in the coming years regarding fecal transplants etc. as treatment options.
It’s often suggested in the Paleo Community that leptin resistance is caused primarily by the consumption of sugar. Can it also be caused by consuming fat?
Actually, excessive calories, in general, is causing excess adiposity (especially abdominal). A combination of high fat and sugar is likely the worst.
Well, how can we mitigate those concerns?
A properly structured Mediterranean-style high fat very low carb diet that is hypocaloric in nature would mitigate those concerns. High saturated fat intake, as opposed to mono/polyunsaturated fat, is related to increases in LPS. Not to mention just being hypocaloric can clear a lot of these issues regardless of the macronutrient content.
Solid. Do you have any concerns regarding the glorification of all fat in recent years? Or concerns regarding the vilification or carbohydrates in recent years?
I think it is great that we have gotten over the vilification of dietary fat but I don’t think we should be glorifying butter specifically. High saturated fat (specifically palmitic acid from butter) diets can still result in unfavorable lipoprotein profiles.
Having said that, I think the promotion of olive oil, nuts, avocado, and fatty fish has been awesome. However, I think the vilification of carbohydrates is the same as the vilification of fat. It’s quite ridiculous. There needs to be more context.
What are your thoughts on low-carb, low-fat, low-calorie, and intermittent fasting, or Keto dietary interventions? Do they each have merit?
I think it is hard to say the clinical implications of each in every individual. I think we will have more precision when we pin down the testing. Many of these diets will work in many conditions. For example, I have patients reverse their diabetes with low-fat diets that are higher in carbohydrates. I, of course, have people do the same (more often in my clinical experience) with low-carbohydrate diets.
The principles are similar though. Get people to eat more plants and in a hypocaloric state and good things happen.
Fat Shaming. Tell us how you really feel.
All of my patients with obesity have had some sort of fat-shaming in their lives. Determining how much it affects them is hard because there are likely subconscious issues we will never be able to quantify.
Whether we like it or not, our words matter to those around us regardless if we are health practitioners or just friends and family. Having some more sensitivity to those with obesity goes a long way.
This doesn’t mean that some respond favorably to tough love though. Some of my patients with obesity want me to be tougher on them. This doesn’t mean I should degrade them though and call them names.
Last question: Are there any other questions I failed to ask you, that you think merits answering?
One thing I see a lot especially on the internet are groups of people who fall under a nutritional/health line of thinking e.g. paleo, low-carb, fasting, vegan, evidence-based, etc. Many of these camps get in fights with each other and argue over the most minute details. A lot of these details don’t even matter when it comes to practicality though when in the clinic.
For example, most of my patients could have vast improvements by just swapping their morning muffin and Starbucks calorie loaded latte to an apple and a couple of eggs or instead of having a can of regular coke and pizza for dinner they had some water with some homemade meal.
If we could harness the energy of the anger towards each other on the internet and spread it to help those who haven’t a clue, I think we could make some real progress.
Solid. Spread the Love. Thanks for talking to us, doc. Very excited to see what the future holds for this program you have envisioned.
So stay up to date with the progress of his vision to expand the Doc Who Lifts with his Patients Program by following him on Facebook HERE, and if you’d like to lose fat, build muscle, lower your blood sugar and feel amazing, you can get his FREE 5 Days to a Better Body and Healthier life email course NOW at www.drspencer.com