Reducing the Costs of Our Healthcare System

Lifestyle interventions are required to adequately address the rise in obesity 

Medicare has recently decided to cover Intensive Behavioral Therapy for Obesity (IBTO). This landmark decision is very important because obesity will now be recognized independently from co-morbidities such as diabetes and heart disease. Medicare recipients who are obese without other health problems will be allowed to receive IBTO without co-pay in the hope of preventing the development of chronic diseases associated with obesity. The potential for saving healthcare dollars is great, but there is one caveat of this new coverage: The most qualified professionals to provide IBTO are excluded from directly billing Medicare for this service.



Intensive Behavioral Therapy for Obesity will include:

1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2);

2. Dietary (nutritional) assessment; and

3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.



Patients who meet screening eligibility are entitled to:



• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months 2-6;

• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg weight loss requirement.



Medicare names primary care physicians, clinical nurse specialists, nurse practitioners, and physician assistants as being the only professionals who can bill Medicare for IBTO and the primary care clinic as the only site where IBTO can be provided. This leaves out registered dietitians and clinical psychologists, whose training qualifies them over primary care practitioners to most effectively provide this service. Patients who desire to work intensively with dietitians or psychologists will have to pay for these services on their own.



After reviewing the ruling posted on Medicare’s website and looking over the references that were provided in support of IBTO coverage, I’m stumped by this decision. Many of the references cited had dietary interventions provided by registered dietitians. A 2004 article published in the Annals of Internal Medicine by the Centers for Disease Control and the Primary Prevention Working Group names dietitians among the most qualified providers to administer lifestyle interventions. This same article states, “even the most highly motivated physicians typically have minimal education or training in lifestyle intervention, and they usually have inadequate access in their practice to the resources needed to support lifestyle intervention. Well-intentioned attempts by physicians to practice “lifestyle medicine” with scarce resources can lead to embittered rejection of health promotion.” The article then goes on to state, “No efficacy study had physicians directly involved in delivering interventions.”



Dietitians bill insurance at 85% of the physician rate. It doesn’t make fiscal sense to allow primary care providers to bill at a higher rate for IBTO when they are not trained in this technique and they do not have the time to provide such involved therapy. I hope in the future that Medicare sees the value that registered dietitians and clinical psychologists bring to the treatment of obesity and allows them to bill for this service independently from primary care providers.


Please support the effort to urge Medicare to allow registered dietitians to directly bill for obesity services by signing this White House petition by January 7, 2012.


Reference:
Centers for Disease Control and Prevention Primary Prevention Working Group.
Primary Prevention of Type 2 Diabetes Mellitus by Lifestyle Intervention: Implications for Health Policy. Ann Intern Med. 2004; 140:951-957

Medicare Chooses Inferior Care for Obesity

Preventing dietitians from becoming providers for obesity care is not in the best interest of patients 

I received some good news the other day. Medicare has agreed to cover Intensive Behavioral Counseling for Obesity for eligible Medicare beneficiaries. And then I read the statement released by the Centers for Medicare & Medicaid Services (CMS). Registered dietitians and psychologists will be excluded as obesity care providers. According to CMS obesity counseling must be provided by a “qualified primary care physician or other primary care practitioner and in a primary care setting.” What does this mean? A "qualified primary care physician", according to the Social Security Act is a physician who is a general practitioner, family practice practitioner, general internist or obstetrician or gynecologist. A “primary care practitioner” is defined as a physician with a primary specialty of family medicine, internal medicine, geriatric medicine or pediatric medicine or a nurse practitioner, clinical nurse specialist, or physician assistant." Obesity services must be provided in a primary care setting which CMS defines “as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings under this definition.”


The bottom-line is that registered dietitians who are highly trained to intensively counsel obese individuals will not be allowed to bill Medicare for obesity intervention and private nutrition practices that are established and operated by dietitians are not considered an appropriate setting by CMS for nutrition education of these individuals.

I cannot say for certain what was really behind the decision to exclude dietitians from becoming Medicare providers for obesity counseling because Medicare's explanations seem lame to me. The American Dietetic Association described CMS's action with regards to the exclusion of dietitians as follows:

  it appears that CMS excluded RDs for two reasons:

1. CMS believes it lacks the statutory authority to include RDs as providers outside of diabetes and end stage renal disease; and

2. CMS believes it is important that preventive services be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient’s total health care. As such, they believe primary care practitioners are best qualified to offer care in this context.

Apparently Congress has not charged dietitians in the fight against obesity but dietitians are allowed to help people with diabetes and end stage renal disease. Many people with diabetes are obese and when I am counseling them for diabetes management, weight management is always a part of the intervention.

As for "preventive services being furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient's total health care," what Medicare fails to see is that it doesn't matter how well care is coordinated if it is inadequate. To date primary care intensive obesity intervention consists of MDs and NPs telling patients that they need to lose weight and referring them to a dietitian. Now that MDs and NPs will be able to bill for counseling for obesity they can remove the dietitian from the equation and bill their services at a much higher rate than the RD would bill and provide less than adequate nutrition counseling possibly after attending a weekend course on obesity management to supplement their one medical scool course in nutrition. I don't mean to disparage doctors, but they are not trained to provide comprehensive nutritional intervention. My husband is a physician and he is the first to admit that most doctor's knowledge about nutrition is lacking. Think about it this way, does Medicare require that physical therapy be provided under the primary care physician's watchful gaze in a primary care setting?

I am always dismayed when I read press releases about new scientific discoveries related to obesity in which the final sentence in the release states that this information can be used to develop a drug to combat obesity. Obesity fighting drugs that have already been released are often recalled because they pose a serious risk to health and can cause death. Humans have existed for thousands of years with minimal obesity until now. We know how to combat obesity and it is not a pill. It is inexpensive but labor intensive and it does not make research and drug companies incredibly wealthy.

A cynical interpretation of this whole debacle is that lobbying from Big Pharma helped to ensure that the practitioners who can prescribe medications would be the only ones whose obesity related services could be covered by Medicare.

It is sad to me that some highly qualified nutrition and behavioral therapists (dietitians and psychologists) will be excluded from treating Medicare recipients. Patients who want to see dietitians and psychologists for nutrition and behavioral counseling will have to pay for these services out of their own pockets (again).

What do you think? Will Medicare provide the most comprehensive treatment for obesity by the most qualified providers?

“Gout” You by the Toe? Kick It with Good Nutrition

Lifestyle contributes to gout 

Gout has long been viewed as a malady suffered by the wealthy, those with means to afford rich foods and wine. Today, gout is the most common form of inflammatory arthritis suffered in men, effecting 3.4 million adult men and an increasing number of postmenopausal women. The incidence of gout is on the rise and lifestyle factors play a significant role in its occurrence.




Gout is characterized by on overproduction of uric acid or a decreased excretion of urate in the kidney. Uric acid is the end product of purine metabolism. Most purines are contained in the human body as DNA. Cells of the body are constantly turning over with the release of genetic material and their consequent breakdown to uric acid. Foods and beverages that we consume can also contribute to the overall uric acid load in the body. When the uric acid level of the body is elevated, crystals can form in the joints. These crystals activate an inflammatory response, which brings on the pain and swelling of gout. The big toe and ankles are common joints affected.



Gout has been shown to be related to the metabolic syndrome, which includes features that increase the risk of heart disease and diabetes such as obesity, elevated cholesterol, high blood pressure, and insulin resistance. Overweight and obesity seem to play a role in both gout and metabolic syndrome. Maintaining a healthy body weight is import in the control of gouty inflammation, however, sensible eating is important. Following a low carbohydrate, high protein diet for weight loss can exacerbate gout.



High protein foods tend to contain more purines with the potential to raise uric acid level, though not all high purine foods have the same ability to cause an attack of gout. Beef, lamb, pork and fish are primary offenders and should be eaten less often and in smaller amounts. A small portion is considered three ounces and is the size of a deck of cards. Most restaurants serve meat in portions of six ounces or greater. Plant foods higher in purines do not seem to bring on gout and do not need to be limited. These include whole grain breads and cereals, oatmeal, wheat germ, wheat bran, mushrooms, green peas, spinach, asparagus and cauliflower. These foods have other health properties that may protect against gout. Low fat dairy products seem to protect against gout and it is recommended to eat at least two servings a day. Dairy products are low in purines and increase the excretion of urate. Vitamin D may also play a role in gout. Many people who have gout are deficient in vitamin D. Urate may prevent the activation of vitamin D, which is believed to have anti-inflammatory properties.



Alcohol has long been known to be a risk factor for gout. Beer is high in purines but alcohol in general may also be implicated. Alcohol is dehydrating and poor hydration increases the risk of gout. Alcohol intake should be controlled; especially beer and special attention should be paid to drinking enough water. This is particularly true when traveling. Many people experience gouty attacks while on vacation. They are dehydrated from their travels and imbibe more than they would at home.



Other diet and lifestyle factors important in the management of gout are:

• Reduced fructose consumption. Fructose is the only sugar that increases urate. Fructose is found most in soft drinks, sweetened juices, apples and oranges.

• Increased fruit and vegetable consumption (except apples and oranges). These foods are known to decrease inflammation with the potential to lower urate.

• Increased vitamin C intake. Vitamin C found in many fruits and vegetables decreases urate. Supplementation of 1500 mg vitamin C daily may be helpful. Vitamin C supplementation should be split throughout the day (500 mg with meals three times a day is suggested).

• Cherries are known for their anti-inflammatory ability. Consumption of cherries and cherry juice decrease gouty attacks.

• Increased physical activity is associated with decreased risk of gout.



As with all diet and lifestyle recommendations, do not undertake dramatic changes in your habits without supervision and advisement from your physician.

How Are We Teaching Our Children to Eat? Some Comments on McDonald's

Unfortunately, eating fast food regularly is a reality for many families 

I'm not quite sure what to think about McDonald's pledge to improve the nutritional offerings of their trademark Happy Meal. By the end of 2012 all Happy Meals will automatically include apple slices and the calorie content will be decreased by 20%. This is good, but will it really make a difference in battling childhood obesity? The bottom line for me is that allowing your kids to grow up eating McDonald's food (or any fast food) is like throwing them in a swimming pool without lessons and expecting them to know what to do. Let me explain.

When my kids were young, I would meet other mothers at a Maryland McDonald's so our kids could play. Our local McD's had a Playplace for the kids to climb and run. After an hour of play, we would buy the children Happy Meals. I noticed that my kids and my friend's kids would eat only a very little bit. We ended up throwing at least half of the meal away. The kids were little (under 5 years) so of course they couldn't eat the whole meal. We did this a few times and there were times that I did this with my kids alone. Despite being in the metropolitan Washington DC area, I was lonely and isolated from my friends because it took at least an hour to get anywhere. Letting my children play at McDonald's got us out of the house.

When I moved to Rochester, NY my two older children were 4 and 2 years old. I began stopping in at the corner McDonald's at lunch time on occasion. As I sat watching my kids barely eat their meals I finally got some sense. By continuing to take my kids to McDonald's I was teaching them to like fast food. In the world of nutrition and health, I was teaching them how to drown.

McDonald's will most likely benefit from all the hoopla surrounding their recent press release. Consumers will view the company as caring and wanting to improve the health of children. I don't believe it! Large companies care about their finances. If they truly cared about childhood obesity, they wouldn't market their foods to children with toys. The toys in Happy Meals will still be offered. McDonald's wants your children to learn how to like their food so that they will continue to eat it as they grow up.

I read through several comments at the end of one of the online articles about this topic. One reader suggested that McDonald's trash should be evaluated for all the wasted Happy Meal produce. I'm sure that there are a lot of wasted hamburgers, chicken nuggets and French fries in that trash too. We give up so easily when teaching our children how to eat better. We stop offering vegetables because they won't eat them not knowing that the simple act of consistently offering healthy foods is important.

My question to those who give up trying to feed their kids healthy foods; would you stop teaching them math just because they are having difficulty with subtraction? The way to work towards combating childhood obesity is to feed your children lots of vegetables, not buying them the "healthier" Happy Meal.

I'm giving away the family cookbook No Whine with Dinner by fellow RD's Janice Newell Bissex and Liz Weiss. Comment on this blog post by August 31st, 2011 and you will be entered to win this cookbook to help your kids eat healthier (just in time for the new school year)!

Nutritionists Blog About MyPlate

A more simple model for healthy eating 

MyPlate is barely a week old and the nutrition world is buzzing about it. If you are curious about what this new icon is and what it might might mean to you, read on.

I'm happy to share a link with you that is a collection of blog posts written by dietitians (myself included) on the new MyPlate. Much thanks goes the Janet Helm of Nutrition Unplugged for organizing this list. Enjoy reading the various comments on MyPlate from nutrition professionals and add to the discussion with your own comments if you feel so moved. We'd love to hear your voice!

MyPlate Blog Link

Keeping Your Food Focus in an Attention-Grabbing World

Isn't all yogurt probiotic? 

It seems that almost every month there is some new concept in nutrition that seeks to grab our attention. Many eating styles and food products are developed to help people adopt these "new" eating principles. Some examples of these are the Paleo Diet, Atkin's Diet, glycemic index, raw foods diet, gluten-free diet, juicing and super foods (this list goes on and on). There is a lot to grab our attention and the end result for many people is not better health and vitality, but a short stint following an unmanageable eating pattern, a little weight loss, and more weight gain down the road. All of this is for the privilege of spending a small fortune.

I'm not saying that diet and nutrition principles don't have merit. A gluten-free diet is vital for people with celiac disease and the rest of us could probably stand to consume less refined wheat products. Rather, I think we lose our focus on eating a healthy diet by being drawn into food fetishes that may not make any sense for us. As an example, I've heard many people claim that they won't eat carrots, grapes or watermelon because they contain sugar. To equal the amount of sugar in a 12-oz can of Coca Cola Classic you would need to eat 4 cups of watermelon, 10 large carrots, and 45 grapes. Some people might be able to eat this much, but I'm sure that they would be quite full and not able to eat much for a period thereafter which is not the case when you drink a can of Coke. Also, consider that natural foods such as carrots, grapes and watermelon contain nutrients that promote health.

I was recently asked my opinion about Joe the Juicer who has a website called Fat Sick and Nearly Dead. Joe found "religion" (health) through juicing and now is on a crusade to transform the world. There is some sensible nutrition advise promoted on Joe's website and it is this advise that is responsible for transforming lives. Juicing is the vehicle that is used to promote a more plant-based diet. If you can live on juice, then this is the diet regimen for you. If not, then you better pay attention to adopting healthy lifestyle habits that you can maintain, and forget the juice.

When adopting a healthy lifestyle, ask your self this question: Can I maintain this change over my lifetime? If the answer is no, figure out what you can do to be healthier and establish SMART goals for yourself. A SMART goal is specific, measurable, attainable, realistic and time-lined. A SMART goal will lead you to the healthy lifestyle you are seeking, one goal at a time.

My kids often joke about being distracted by shiny objects. There is a lot of "nutritional glitter" out there vying to take your attention away from more sensible practices. Trust in your common sense and your ability to stay the course. It may not be as dramatic as juicing, buying amped up yogurt or getting your stomach stapled. But it is what works. Slow and steady wins the race, as long as you stay on the course.

MyPlate Introduced. Now What?

The endless junk food aisle 

Yesterday was a big day in the world of nutrition. The 20 year old Food Pyramid was retired by the USDA and the new MyPlate was unveiled. The new food guide shows a plate with four sections for the basic food groups: grains, fruits, vegetables and protein. To the side is a cup of dairy. The new food icon was introduced by USDA Secretary Tom Vilsack, US Surgeon General Regina Benjamin and First Lady Michelle Obama at a press conference yesterday morning. Vilsack commented that the personal health of the nation is as important to the wellbeing of the country as its fiscal and economic health. It is an issue of national security when many youth are too overweight and unfit to protect the country. Dr. Benjamin concurred that childhood obesity is one of the greatest challenges facing our nation. She stated that the goal of the new food icon is to provide clear and simple information based on science to guide the American people to make healthier food choices. First Lady Michelle Obama commented, "What is more simple than a plate?"

Michelle Obama goes on to say that there is still work to be done in leading our nation toward health. I can't agree more! I like the simplicity of the icon and the message to the American people to eat less that is a central tenet of the Dietary Guidelines. But I wonder if this new food guide will have any impact upon the way that Americans eat?

At the Future of Food Conference in Washington, DC last month, Secretary Vilsack commented that the way farm subsidies are appropriated will change with the new Farm Bill. He hopes to empower more small family operated farms which means decreasing (or ending) the subsidies paid to larger agribusinesses. To me, this is a more important step in changing the US food and health environments than the combined efforts of the new MyPlate, Dietary Guidelines and universal health insurance. The endless aisles of junk foods, cereals and beverages are directly related to subsidies paid to grow corn, wheat and soy which allowed the creation of cheap processed foods. Cheap processed foods are bad for health for many reasons, one of which is that they displace healthier foods such as vegetables, fruits and whole grains. When soft drinks and junk foods are more expensive and vegetables and fruits are less expensive, Americans will buy less junk. When we see smaller displays of junk foods at the grocery store, then we'll know that we are moving in the right direction.

Vilsack goes on to say at the MyPlate press conference yesterday that you have to walk the talk. He tells a story of how the new icon influenced him recently at a dinner where he was served a piece of steak that covered more than half his plate. He purposefully didn't eat it all. I hope Congress has the same good sense when it comes to passing a Farm Bill that will change the US food and health environments. Congress will have to turn a deaf ear to the wealthy and powerful food lobbies and do the right thing for the American people by voting to reduce subsidies to large agribusiness. Our national security depends upon it.