March 30, 2013

Medical Nutrition Therapy by Prescription – Part 1

Part 1 of 2 parts

From the book Joslin's Diabetes Deskbook, second edition, this excerpt is interesting and definitely more definitive than most information that I read about nutrition for people with diabetes. To be honest, this is the first time I have read diabetes nutrition being referred to as “medical nutrition therapy.” Yes, and I must apologize for this error as the American Diabetes Association has been using this term for several years – in their annual guidelines. My dislike for the ADA has colored my reading habits and I had hoped that it would not. Now I have a greater understanding of the purpose behind the use of the term “medical nutrition therapy.” This is the procedure they use to convince people to consume greater quantities of carbohydrates.

Then to include this in the diabetes treatment strategy makes this a topic of interest. I will admit that in rereading the excerpt, I have developed some serious questions about it and have some real concerns about what is not being said. Why? Because the opening is there for mandates and the one-size-fits-all mantra. I would feel a lot more at ease if some points had been made that would have precluded these from happening. I have mixed feelings about the way this topic is presented. This will cover the conflicts that are built in and some that may not be apparent on the surface.

The one statement that has me worried about what may not have been included in this excerpt is this, “The American Diabetes Association, the American Dietetic Association (now the Academy of Nutrition and Dietetics) and Joslin Diabetes Center have developed guidelines and curricula for nutrition education.” I could accept Joslin Diabetes Center, but to include the ADA and AND raises all types of red flags for me. Anytime I have read something when these two organizations are either involved or mentioned, they use the “for individuals” platitude and later opt for the one-size-fits-all mantra and preach high carbohydrate/low fat (HC/LF) which does not work for many individuals with diabetes.

Registered dietitians working for the Joslin Diabetes Center may be able to do things for the individual, but I have met the worst of the RDs in my area and they all tailor nutrition around HC/LF and insist that I eat a set number of carbohydrates per meal. This does not work for me and I have the over weight problem to prove it. Then, when you find out that the Academy of Nutrition and Dietetics is introducing legislation in most states to make them the only organization legally allowed to give out nutritional advice. I say that this monopoly position takes away my rights to get nutritional information from others that are not governed by mandates or that do not take their guidance from the USDA and HHS. Fortunately, more people are beginning to understand how wrong their guidance is and how unscientific the background is for their nutrition guidelines.

Using the nutrition prescription involves calculating caloric levels and determining appropriate levels of nutrients. It factors in the weight, clinical goals, activity levels, and health status of the patient. Yes, the excerpt said this and three of the factors are correct to be assessed, but clinical goals? Come-on people, lets be real. How can clinical goals be a valid part of patient assessment? Oh, right, this is where they throw individual treatment out and issue the mandates, mantras, and one-size-fits-all. This is where they say you are not trying hard enough to follow their directions and thus you are noncompliant, so out the door you go. This is so like the ADA and AND, but I had hopes that Joslin was bigger than they were. This does point out the use of the “by prescription” and why they are using it. Patients are wising up to the purposes behind the use of certain terms. By using prescription in combination with medical nutrition therapy, they are hoping patients will be more likely to follow their advice.

Because of my conflicts with RDs, you know this statement has to upset me, “The registered dietitian (RD) is an important part of the diabetes healthcare delivery team.”  Yes, it does, but not as badly as it has. This has been a point of contention for me. Lately, both on some diabetes forums and in some of my emails, fellow people with diabetes are saying they have figured out when the RDs are no longer working for them as individuals and are in the one-size-fits-all mode. They know that they need to cut them out of their team.

The next section cuts to the core of the problems for many people. What is “healthy” eating? I admit I have been a misuser of this term big time and I will try to break myself of this habit. The term “healthy” is a misnomer in so many of its uses that it is becoming an accepted term. This still does not mean that it is used properly. For this clarification, I must thank Adele Hite, who says, “A word about “healthy” food. I have no idea what that means. To be honest, I’d love for that term to disappear altogether. The World Health Organization describes health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” If “being healthy” is the equivalent of “being well,” then it is easy to see that the phrase “healthy food” makes little sense. It’s hard to be “well” and be “food” at the same time!”  Maybe I am stretching a little, but I think this applies equally to “healthy” eating, “healthy” lifestyles, and several other uses. Read her blog here for further explanations.

Back to the excerpt, the goals laid out are realistic, but often misused. The goals listed are - individualized calorie levels for growth/maintenance or weight loss, blood glucose control, normalization of blood lipid levels, and blood pressure control. No mention is given to blood glucose testing and a way of achieving the first two goals. What is lacking is any discussion of the standards that are reasonable ranges to be achieved. Without these, the patient has no knowledge of what to work towards. Here again I have to suppose they are omitting this because they adhere to the USDA and HHS guidelines and do not want us as patients to discover how bad these guidelines are for us.

Continued in Part 2.

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