A Telemedicine Physician on U.S. Health Care, Nutrition, and Metformin Biohacking
An Interview with Dr. Spencer Nadolsky
Editor’s note: This interview took place in November 2019.
It’s no secret that the American health care system is deeply troubled. We spend $11,000 per year on health care—18% of our GDP. That’s 60% more per person than Norway, more than twice as much as Canada, and nearly three times as much as Spain spends.
Yet at the same time, the United States is not a very healthy country. Not only do we have one of the world’s highest obesity rates, but we also rank 37th in life expectancy — tied with Albania, and well below every other highly developed economy.
Yes, our health care system sucks — but most Americans also don’t do a great job of taking care of themselves. And unfortunately, our health care system right now doesn’t do a good job of encouraging patients to help themselves.
Dr. Spencer Nadolsky is a board-certified family and obesity physician who has helped thousands of patients over the past eight years lose weight and keep it off. Dr. Spencer saw the inefficiency of working only in the clinic, so his dream was to help people lose weight via the internet using a combination of personal, in-depth coaching and telemedicine.
Dr. Spencer has an undergraduate degree in exercise sports science from UNC-Chapel Hill where he also wrestled heavyweight and, at one point, was ranked in the top three in the nation. He speaks all around the world about weight loss and health and is also the author of “The Fat Loss Prescription.” He is the chief physician for renaissanceperiodization.com
In this interview, Spencer shares his thoughts on what’s wrong with the American health care system, how it can be improved, and what the average American can do to avoid obesity and live a healthy life.
Can you explain exactly what it is that you do and what kinds of people you usually work with?
I am a family physician with specialty boards in obesity and lipidology. I also joke that I am a memeologist since I make funny health and fitness memes for Instagram.
Using technology, I see patients primarily through the internet using video conferencing. I treat mostly obesity and lifestyle-related disease. Most of the people who come to me are sick of the current medical system and want a doctor who understands fitness and preventive health. In general, they are the more motivated folks who want to rid their weight-related issues using lifestyle (and sometimes medicines if truly needed).
What do you think are the fundamental problems with the U.S. health care system? What would you change about it if you could?
There have been long books written on the topic, but essentially we, as a country, need to figure out how to prevent chronic disease and spend fewer health care dollars, while also ensuring everyone living here is able to afford to get the care they need in an efficient manner without burning out physicians. That is a run-on sentence!
The joke is that we have a sick care system, not a health care system. We spend huge amounts of money when end-stage disease is present when we could have spent less money just preventing it in the first place.
Physicians don’t get enough lifestyle medicine training in medical school and residency (training after medical school). On top of that, the system isn’t even built to allow for doctors to practice lifestyle medicine due to time constraints and reimbursement. So even if they were trained, it wouldn’t work very well.
Our system is archaic and expensive. It’s hard to get medical records for patients, and when you do, the records are jumbled and disjointed. Insurances control what you can and cannot do/prescribe. Physicians have lost most of their autonomy after selling out to big hospital systems who control everything. Administrators with no medical knowledge are running things and trying to make more money while doctors and patients are suffering.
It’s quite a horrible system. Everyone should have care. Everyone should be able to afford it. Physicians shouldn’t be getting burned out. It should be more efficient.
What are the main advantages to seeing patients remotely the way you do?
The big advantages are remote monitoring and efficiency/flexibility for both the patient and the doctor. Patients shouldn’t have to make a visit and take a half-day off work just to go over one simple lab or even to get a lab order. A quick text back and forth can take care of many things.
Which medications do you think are most over-prescribed and which ailments most over-diagnosed?
Antibiotics for sure, for viral infections. It is ridiculous.
Many chronic disease meds that could be alleviated with lifestyle. For example, proton pump inhibitors used long-term (stomach acid suppressors). Sometimes they are needed, but often times it is due to lack of time and knowing the patient!
You recently had a blood glucose monitor implanted into yourself. Can you explain how that works, how much it costs, why you did it, and what the results were? Is it something you’d recommend to a lot of patients?
A continuous glucose monitor is something you can attach to your skin, and it penetrates just slightly enough to monitor your sugars in your interstitial fluid (not your blood like regular glucose monitors where you prick your finger). The one I used checked sugars every five minutes, but there are others out there that check at different time periods.
I paid cash for mine at about $300, but if you have diabetes (type 1 or 2) you can usually get it paid for by insurance. I like to try things out that I prescribe for patients to experience what they go through.
It was interesting to see which foods increased my glucose more than others and what activities influenced them as well. For example, we know white rice has a larger response than brown rice based on studies, but I actually saw it in my own levels, which was neat to see. Walking also dampens the spikes in sugars after meals too, which of course we already knew.
I generally recommend them only for patients with insulin resistance and glycemia issues to give them motivation to stick to the foods we know will be beneficial for them. If someone without insulin or sugar issues wants one, I have no problem writing the script to get one for cash if needed.
Almost everyone who tries those seems to focus on testing individual foods. But I’ve read that the glycemic index of mixed meals is lower than the glycemic index of individual foods — have you found that to be true?
Yes — what you eat with the food will change the response. So fibrous foods and fat and protein can change it for sure!
Tell us about metformin — why is it so popular these days, and how safe and well-researched do you think it is? Also, it clearly aids weight loss, but for people who are not overweight, do you think this will be pure fat loss, or is it likely to cause muscle loss as well?
Metformin is a very old type 2 diabetes medicine, but still one of the best. It has become more popular with the biohacker community in order to hypothetically improve longevity (extend life). The weight-loss effects are very mild but may be useful for those with overweight/obesity. For those without overweight, I am not as excited about it. There are potential interferences with muscle gain and even fitness.
On a related note, what do you think of metformin’s purported anti-aging and anti-cancer benefits?
Not proven but hypothetical. Not a very harmful drug other than B12 deficiencies over long-term use.
Which nutrient deficiencies do you see most commonly in patients who exercise and are mostly in good shape? How would you have them fix those deficiencies?
Very little with those who eat a nutrient-dense diet and get sunlight. Without sunlight, I do see vitamin D insufficiency and deficiencies. Supplementing with vitamin D 1000 IU or more daily can be useful. Beyond that, maybe fish oil if not eating fish, and vitamin K2.
Which dietary supplements do you find worthwhile for the general population? Do you recommend multivitamins, vitamin D, fish oil, creatine, etc.?
Rarely do I tell everyone to use a blanket supplement regimen. I am more targeted. No sun? Maybe vitamin D is a good idea. Can test for it too. No fish? Fish oil may be necessary.
What about B vitamin malabsorption? Do you see that a lot? And I’ve seen research showing that even if your B vitamins are within the normal range, you’ll still have better mental performance if it’s near the top versus the bottom of the range. Do you see a lot of people with vitamin levels just barely in the normal range, and if so, do you see it as an issue?
Rarely do I see B vitamin malabsorption unless someone has an inflammatory bowel syndrome or an autoimmune disease (pernicious anemia). Most people I see are supplementing and have very high levels of vitamin B. Some vegans who don’t supplement are low just due to intake.
What sort of exercise regimen do you typically prescribe for patients who want to lose some weight and develop a healthy lifestyle? What balance do you strike between weights and cardio?
I always prescribe a mix of weights and aerobic if time permits. If not, then picking one over the other based on their preferences. Ideally though, they would get three days a week of lifting and then mix in aerobic and a lot of non-exercise activity thrown in, like walking.
In terms of ailments, what about postural issues? Do you see a lot of those caused by sitting at desks all day? And do you think anterior pelvic tilt is really as common as trainers make it out to be, or is it massively over-diagnosed?
Pain from bad posture is not really founded on great science. I think immobility can cause many issues, though, in general. It would be nice for everyone to be active and mobile. I think it was an easy way to diagnose most people with anterior pelvic tilt and prescribe stretching and exercises for it, but it won’t automatically cause one pain.
How common are sleep issues in your opinion?
I think MOST people have inadequate proper sleep. I have a high amount of sleep apnea in my practice since many patients have obesity. A lot of other patients just have primary insomnia.
What’s your opinion on ketogenic dieting, intermittent fasting, paleo, vegan diets, Whole30, etc.?
Keto can be a tool, along with IF, for finding a way to improve health via less energy intake. I think paleo is unnecessary for the most part unless it helps with certain intolerances. Same with Whole30.
Aside from diet and exercise, are there any other health practices you recommend for overall health and longevity?
Sleep, of course. Ensuring other fun hobbies. Community, etc. It’s hard in our super digital world, though.
Everything described above regarding diet and activity and sleep also reduces risk of cancer.