DiabetesinControl.com
is a website with “news and information for medical professionals.” Last
November it trumpeted, “Medicare to Pay for Obesity Prevention in the Name of
Prevention.” What a boon (boondoggle?) for physicians! And what an
incomplete and mixed blessing for their patients! Medicare has finally recognized
that obesity prevention in the form of counseling, as public health policy,
might be as efficacious as costly gastric bypass surgery. Reducing obesity
through “intensive medical nutrition therapy…could produce similar results,” it
concluded. But only if your primary care physician “supervised” its
administration. It sounds to me like it’s all about billing.
One of the
reasons offered is that “It’s almost impossible for physicians to take care of
everything. They don’t have the expertise [how true!] or the time,” according
to the piece. “Seventy-two percent of primary care physicians surveyed…said
nobody in their practices had been trained to deal with weight-loss issues.”
Yet they say (and to me, the irony here is very heavy), “unfortunately, those
best prepared to provide obesity counseling will not be able to bill directly
to do so.” Under the rules, “those with expertise in the field, such as
registered dietitians, are not eligible to bill directly.” Medicare, with
perhaps just a little lobbying from the American Medical Association, “has
limited who is able to bill for those services to primary care physicians,
including nurse practitioners, clinical nurse specialists and physician
assistants. Medicare will cover services from ‘auxiliary’ providers only if the
service is provided in a physician’s office suite and the physician is
immediately available to provide assistance and direction,” it added. Yep, it
is all about the billing.
The decision
about registered dietitians is, of course, for
me, good news. Registered dietitians and CDE’s, if they follow the training required for certification, are the
least qualified persons to provide obesity training, at least to the
pre-diabetic and Type 2 community. This has been my personal experience from
attending group counseling for diabetics provided by a CDE/RN at a local health
care facility, and years ago with a registered dietitian and much more recently
with a CDE.
Years ago, my
doctor employed a registered dietitian in his “office suite” (her “office” was
in a closet!). This carbohydrate intolerant Type 2 diabetic remembers her
advice “Eat a ‘balanced’ diet,” she said, “and exercise.” The truth is that she
was as ignorant as my doc about the effect on a Type 2 diabetic of
eating from 40% to 60% of calories in the form of carbohydrates. My meter
provided plenty of feedback, all of it negative.
Forty-five to
sixty-five percent carbohydrates is the amount recommended by the Institute of
Medicine for everyone in the latest Dietary Guidelines for Americans, 2010 (Table
2-4, pg. 15). The USDA’s Nutrition Facts panel on processed food packaging
is likewise a one-size-fits-all formula. Carbohydrates are 1,200 (60%) of the
2,000 calories in the Standard American Diet (SAD,) for a woman. It’s 1,320 of
2,200 kcal for a man! And that’s why Type 2 diabetes is a “progressive”
disease, folks! To be clear, I know that both my doctor and his dietitian
had in mind a good health outcome for me. They both wanted me to lose weight. But
their dietary advice for me, a Type 2 diabetic, was bad advice as it ignored the implacable fact of carbohydrate
intolerance. The outcome could only result in my disease continuing
to be progressive. Progressive disease and complications are, however, not
inexorable. And if you need to lose weight, you do have a better alternative.
My experience
with a CDE (employed by a doctor) was the result of a silent auction for a
non-profit a few years ago. The bidding started at $20, so I placed the first
bid, and it was the only bid. At this point I had been eating Very Low Carb for
about 10 years. I had lost 170 pounds and had eliminated virtually all my oral
diabetes meds. My blood glucose was normal, my blood pressure (on the same meds)
had dropped dramatically, and my blood lipids (both HDL and triglycerides) had
totally turned around. I no longer had Metabolic Syndrome or detectible
hypertension (with meds) or Type 2 diabetes as
long as I refrained from eating carbohydrates. Okay, those conditional
statements are caveats, but that is a price I was and am willing to pay for the
complete abatement of my symptoms. In doing so I am now at much lower
risk of all the Diseases of Civilization to which I was exposed before I
began this Way of Eating. It was a rough session for the CDE, but she
toughed it out. In retrospect, the whole episode wasn’t a very nice thing for
me to do, but she needed to hear my story. That’s why I write this blog, to get
the word out.
So “save your
money,” so to speak, if counseling is voluntary as with Medicare, or just
ignore the advice if obesity counseling, also at government expense, is
required by the NHS. Your health will be better served if you listen to your
meter and avoid “one size fits all” diets (and clothes!). My next column will
address another recent milestone discovery. More “old” news: Obesity is a
Disease (for billing purposes).
Postscript:
“The
Power of Sugar,” published two days ago in The Atlantic, is an interesting read for two reasons: 1) the
charts, and 2) it is from an economist’s perspective. Unfortunately, it contains an
egregious editing error: The headline on the first shaded box
reads, “Fructose and Glucose are Essentially Same.” That is
wrong, as the text of the shaded box (and science) makes clear. What the
headline meant to say was, “HFCS and Sucrose are Essentially Same,” which is
basically true. It is ironic that the editor unknowingly demonstrates the point
the writer makes, that the “recent focus -- medical, media and regulatory – has
converged…” All three (the editor, if not the writer, in the case of the media)
perpetuate the ignorance in this headline.
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