Type 2 Nutrition #447, What’s happening to medicine today?

Lots of things are happening to medical practices today, and at an accelerating pace. I remember 40 years ago when my GP quit medicine, giving up a nice practice in an upscale community because of Medicare’s onerous reporting burdens. He was independently wealthy, and had a nice social life, but he was only in his early 40s!

Today, independent private medical practices are disappearing at an even more alarming rate, being sucked up by hospital conglomerates. In my area Health Quest and CareMount are cutthroat competitors. A search on CareMount redirects to “Medical Outsourcing.” Wikipedia explains: “Some small practices have outsourced business functions to management services organizations” (MSOs). “Business functions” includes all office staff. My urologist told me that the benefit to him was that he can now “just practice medicine.”

Two specialists I have seen in the last year now work for one of these MSOs. So does my wife’s GP. My internist in NYC is the exception. He resists the trend and recently, while maintaining a very busy private practice, joined a boutique medical group where he offers his patients, for a fee, more personalized attention. I declined. I told him I wanted to see him 3 times a year for blood work. He suggested I come just once a year.

On a recent final visit to an orthopedic, his receptionist asked me if I wanted to receive an updated printout of his clinical notes. I told her “no.” After unexpectedly receiving and reading an earlier version, they upset me. I thought that they did not fairly reflect what I had told him or his nurse; instead, they read to me like they were written to be read by the MSO or some clinical practice reviewer at HHS (Medicare).

I had a similarly eerie experience in Florida several years ago. I had to fire one physician, who was peddling statins and claimed to be a lipidologist.  Another, an endocrinologist, had justly fired me when I told him he needed to go back to school. They both worked for a large group that dominated that part of Florida where I spend the winter. Their MSO is part of HCA Healthcare based in Nashville, Tennessee. The network includes “178 hospitals and 119 independent surgical centers in 20 states and the UK.” The UK!

The orthopedic – remember, his specialty is skeletal issues, in my case a torn tendon – asked me if I was eating a “mostly plant-based diet.” Earlier, his nurse, recapitulating notes from the previous visit, asked me if I was still walking for exercise. I told her I had NEVER told her that I walked for exercise. I have NEVER walked for exercise. The only exercise I do is garden work. Where, or more to the point, why was it in their clinical notes that I walked for exercise? And why would an orthopedic counsel me to eat a “mostly plant-based diet”?

I protested the counsel to eat a mostly plant-based diet. I replied that I eat a Very Low Carb diet and would be a carnivore if my wife would not go apoplectic. I said the body had a zero requirement for plant-based foods and can make all the glucose it needs via gluconeogenesis from protein and fat. I also told them that I drink a pint of collagen-filled bone broth from pasture-raised beef every day to help repair my torn Achilles tendon (as my brilliant editor had suggested). Tendons are made of collagen. My ortho appeared to listen attentively and replied simply that he admired a person who held such passionate beliefs.

My conclusion, I’m afraid, is that to practice medicine today your MSO MD needs to follow the MSO’s and the government’s “formulary,” not just with respect to medications, but for lifestyle (“diet and exercise”) as well. And if those recommendations are not in your clinical notes, the MD’s medical practice is penalized by lower reimbursement rates from Medicare and thus with a lower rating by the bean counters at the MSO….because the MD is not pushing the government’s “lifestyle formulary.” To not push it risks lower profits for the MSO and even job security for the MD, based in part on “job performance.” That’s the price a doctor has to pay today to “just practice medicine.” And that’s what happening to medicine today. 

Type 2 Nutrition #446, “Docs’ Beliefs” prevail in 14 of 17 Primary Care practices

Thank goodness for the headline in this Medscape Medical News story by Miriam E. Tucker: “Docs’ Beliefs Guide Prescribing of Glucose Monitoring in Type 2 Diabetes.” It means they still prescribe routine self-monitoring of blood glucose (SMBG) in patients who aren’t treated with insulin (or a sulfonylurea). The danger from insulin or a sulfonylurea (e.g.: micronase, glyburide, glipizide) is hypoglycemia (low blood sugar).

That doctors still do this is enormously encouraging to me, a type 2 for 32 years who takes a fasting reading every day and recently had an A1c of 5.0%. It is troubling to me, however, that several said that they prescribe SMBG less than they did 10 years ago, when their professional societies were encouraging the practice.

The evidence to stop prescribing SMBG, described as “qualitative data,” was presented here in The Annals of Family Medicine by a medical student at the Cleveland Clinic. The student told Medscape that “for patients who do not take insulin, the preponderance of evidence shows it increases cost without improving HbA1c.”

Duh! If you don’t do something with the information. If you don’t use it to make wise choices about what to eat. If you think the only way to treat T2D is with drugs, and that self-management actions have no educational or motivational value. The opponents of SMBG also cited the cost of test strips as barriers. The medical student does say “our study addresses the physician perspective, but there’s also the patient perspective.” Her team’s next step will be to assess patient’s perspectives of SMBG. Brava, I say. There’s hope.

But the abstract, co-authored by half a dozen MD/MPHs at the Cleveland Clinic, make it clear where this study is going. It states, “The majority [of primary care physicians] continue to recommend routine self-monitoring of blood glucose due to a compelling belief in its ability to promote the lifestyle changes needed for glycemic control. Targeting physician beliefs about the effectiveness of self-monitoring of blood glucose, and designing robust interventions accordingly, may help reduce this practice.” This is what medical students are being taught today. That’s been the problem with these damn studies. They’re myopic and, worse, narcissistic. One physician said, “I try to steer non-insulin dependent patients away from testing at home, mainly because it doesn’t change what I do. I monitor their diabetes based on the HbA_1c and occasional sugar checks.” It’s me, me, me, me, me… No thought or consideration to what the patient can do to control their blood sugars.

Okay, if you believe that your patient has “low health literacy or physical or cognitive impairment,” then it goes without saying the patient’s diabetes care should be in the hands of a health care provider. This may include those who have daily home health care, are hospitalized or institutionalized. But for the rest of us? Are we not capable of participating in the management of our own health care, especially with a condition that is entirely dependent on what we eat for optimized management? But therein lies most of the problem…

Most physicians to not accept that type 2 diabetes is a dietary disease. Nor do most patients. Doctors know it, or should know it, given their training in human biology and physiology, but to admit it would require that they repudiate everything they have been telling their patients about nutrition for 40 years. I don’t blame them for following the guidelines of their medical associations and the prescribed Standards of Practice. It would be hard to look the patient in the eye and say, “It's all been a big fat lie.” (apologies to Gary Taubes)

However, under the circumstances, wouldn’t it be best to leave the options open for patient-centered care? After all, the clinician only sees the patient a few times a year to monitor their T2D condition, but the patient has the opportunity multiple times every day to make wise choices that will change their condition. Self-Management of Blood Glucose (SMBG) is thus the best way for patients to educate and motivate themselves. If by prescribing SMBG the doc’s beliefs contribute to the patient’s self-care, that’s a good workaround! Bravo!

Type 2 Nutrition #445: Are doctors in denial?

When a doctor tells me that I am “no longer diabetic,” as a few have informally told me, are they misinformed about what causes type 2 diabetes, or are they just small business men or women in denial and following the government’s definition which dictates a clinical diagnosis? Because they want to get paid and move on…

I mean no offense, honestly. If I seem impudent, well…maybe I am, a little, but as Dr. Michael Eades said, at the end of #406 here, it’s sometimes necessary for “you” (his readers) to “educate your trained professional.”

For example, at a cocktail party recently I was having a tête-à-tête with a friend, a retired MD, when a tray of shrimp was passed around. I took one, but when the doctor declined, I asked him, “Why?” He answered, “Cholesterol.” He apparently hadn’t heard that, back in 2014, the Dietary Guidelines Advisory Committee had declared that “cholesterol [was] no longer a nutrient of concern for overconsumption.” Or that Ancel Keys, the infamous creator of the “diet-heart hypothesis,” was quoted later in his life as saying, “And we've known that all along. Cholesterol in the diet doesn't matter at all unless you happen to be a chicken or a rabbit.”

With respect to the “misinformed” possibility, and the “denial” question, we know that type 2 diabetes is caused by a metabolic dysfunction in which the body is no longer able to handle a diet high in refined carbs and simple sugars due to Insulin Resistance. The hormone insulin, secreted by the pancreas, carries glucose from digested carbs in the blood stream and, in a normal metabolism, “opens the door” by connecting to receptor cells where the glucose is supposed to be taken up for energy. When the connection doesn’t work, the glucose continues to circulate and the pancreas secretes more insulin to help, eventually wearing out.

Most doctors rely on the A1c or a fasting blood glucose to diagnose a type 2 and begin a course of treatment (“diet and exercise”, and 3 months later, when this fails, prescription meds). These simple blood tests show the symptoms of a disregulated glucose metabolism and are cheap and effective as screening methods. Most people who present with an elevated FBG or A1c are pre-diabetic or frank type 2s. And the meds that a doctor prescribes to treat these symptoms will lower your FBG or A1c somewhat, at least temporarily. But your type 2 diabetes will continue to progress, because the clinician is treating a symptom, not the cause, of the disease.

The cause of type 2 diabetes is Insulin Resistance (IR). The best test for IR is an Oral Glucose Tolerance Test (OGTT). In this test, the patient drinks 75g of a glucose solution, and their blood is tested before and at half hour intervals afterwards for 2 hours. It is usually performed by an Endocrinologist and/or in a hospital outpatient setting, so it’s expensive, but the OGTT will reveal if the patient has Insulin Resistance.

But the government, and therefore your doctor, is only interested in treating your symptom, an elevated blood sugar (A1c). If your A1c is ≥6.5%, you are clinically designated a “type 2 diabetic.” If it is <6.5% but ≥5.7%, you are clinically designated “pre-diabetic.” If your A1c is <5.7%, you are, clinically speaking, “non-diabetic.” If your A1c was previously ≥5.7%, but somehow is now lower, your doctor will declare you “non-diabetic” or “cured,” and by the established Standard of Care, the “system” will reward the doctor financially for this favorable outcome. This totally ignores your INSULIN RESISTANCE. You are still Insulin Resistant, and therefore still type 2 diabetic. If you don’t change your diet, YOUR DISEASE WILL PROGRESSIVELY WORSEN.

So, is your doctor misinformed, in denial, or just being callous? He or she is, after all, in business and just following government rules for treatment and payment. As far as keeping your INSULIN RESISTANCE in check, or even putting your type 2 diabetes in remission while losing weight easily and without hunger, that’s up to YOU. YOU decide what foods you eat. Don’t expect your doctor or the government to know how to “eat healthy.” Following their advice is how you gained weight and got sick in the first place. Your doctor can only test your blood and write scripts to “control” your A1c. But you are still INSULIN RESISTANT and therefore CARBOHYDRATE INTOLERANT!

Type 2 Nutrition #444: “Symptoms are too late”

A while back on Maria Bartiromo’s “Mornings with Maria” on Fox Business, a doctor was asked, “What are the symptoms of pre-diabetes?” He answered emphatically, “Symptoms are too late!” Expecting a different reply, the questioner continued, “But can’t [type 2] pre-diabetes be reversed?” The doctor replied indirectly, but correctly, “Once you are diagnosed diabetic, you are diabetic for life, but you can manage your condition.”

Of course, pre-diabetes and even “clinical” type 2 diabetes, diagnosed with the current blood testing methods (A1c and/or Fasting Blood Glucose), can be “reversed”…but only by and with a permanent lifestyle change.

The doctor interviewed on Maria’s show was introduced with a recorded “teaser” from the popular singer Patti LaBelle. She told how her family had suffered terribly from type 2 diabetes and how she, who was now a diagnosed type 2, was determined to avoid those “complications.” She said she had changed her “way of living, eating and thinking.” She’s right, of course, but of the three, Patti just talked about what she eats.

Ways of eating, however, are still open to many interpretations, including ways of eating to lose weight. Arguably, there are countless ways to lose weight, albeit not permanently. As all dieters know, weight loss is usually followed – often quickly – by weight gain. The reason is that the dieter is hungry. The dieter’s body demands more food to return to energy balance. The signals are hormonal and beyond control of the dieter.

There is a way of eating, if adopted permanently, that will manage both pre-diabetes and type 2 diabetes and produce permanent weight loss. That way is Very Low Carb (VLC). Eating VLC both enables the “dieter” to either reverse pre-diabetes or manage type 2 diabetes and lose weight easily and permanently…so long as you continue to eat VLC. That’s the condition. It’s a trade-off. You get to permanently keep the weight off, and reverse your prediabetes, that is to say, put it in “clinical remission.” Based on the medical Standard of Care for diagnosis and treatment, a doctor will declare you clinically “non-diabetic”  Really! Seriously!

Another huge benefit of this “win-win” outcome is that it will cut in half your risk of cardiovascular disease (CVD), and dying from a heart condition or stroke. These macrovascular complications are in addition to the usual microvascular complications long associated with type 2 diabetes: blindness, amputation and end-stage kidney disease (with dialysis). Other “Diseases of Civilization” associated with the high-processed-carb diet are Alzheimer’s (type 3 diabetes) and various cancers, particularly liver, pancreas, endometrial, colon and rectum, breast, and bladder cancers.

The doctor on Bartiromo’s program made another good point: He declared type 2 diabetes to be a scourge of our modern lifestyle that is “self-caused.” He said 1) we overeat, 2) we don’t eat properly, and 3) we don’t exercise. The first two are interrelated, with the 2^nd being the cause of the 1^st. But to his point: “WE” IS THE PATIENT. “Self-caused” means that WE can do something about it, without intercession by our doctors.

The doctor then lost his way on the eating part. He advocated “fruits and vegetables and lean meat” and avoiding “saturated fat and sugary drinks.” It was essentially, the Mediterranean Diet: Eat processed vegetable oils (PUFAs) and avoid fatty red meat (saturated fat). That’s the government’s pitch. Sad, really, and too bad.

For perspective, just remember that too many processed carbs and simple sugars, and wheat, excessive fructose and excessive linoleic acid (Omega 6s in the polyunsaturated vegetable oils), is how we got sick and fat in the first place. Note that the government’s dietary guidelines no longer limit dietary cholesterol or total fats; they just get it wrong about which fats are bad. For more see #445, “Are doctors in denial?” next week.