Wednesday, September 25, 2013

The Nutrition Debate #146: Medicare to Pay for Obesity Counseling 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).

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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