Part 2 of 2 parts
At first I was happy to read this, but
the more I reread this, the more I had to wonder if this was for
helping the patient, or assessing ways to divert the patient to the
goals of the ADA, AND, USDA, and HHS. It says, “The
first step in implementing a nutrition prescription is to perform a
careful patient assessment. This assessment should cover the
patient's current habits, issues and needs with respect to the
nutritional recommendations. Identifying the patient's readiness to
learn will affect the ultimate treatment plan with respect to time,
course of initiation, degree of changes to be anticipated, and
prospects for ultimate success. The issues and questions included in
the following checklist may be included in a nutritional assessment.”
The checklist is in the excerpt
slightly more than half way down.
Meal planning really starts the route
back to mandates, mantras, and not creating an individualized
approach. Yes, individualizing is used, but only for the purpose of
preparing you for the last part of the article. They lead you down
the path thinking that it is being individualized for you, but in
reality, it is their goals for you, as they carefully do not say what
guidelines they are referring to and how variable the use of
preplanned menus may not be. Then they bring in exchange or food
choice lists, which are a way of saying there are limitations you
will be facing. Lastly they want you to know counting – for
carbohydrates and fat grams. Now we know high carbohydrates/low fat
(HC/LF) is the guideline of choice.
The last part of the excerpt is where
they kick individualization out the door and openly declare they are
in charge. They have adapted USDA's My Plate slightly (in reality
Joslin had it long before USDA) , but this does not change the intent
of (HC/LF). They pushed the low fat milk to one side (though it is
still displayed) and clearly state “leverage fruit, dessert, or
other side dish”, hello carbohydrates and extreme low fat. They
clearly state that, “New patients can be
given guidance in choosing healthy foods using a picture of a plate
divided into suggested servings .... It is not expected that calories
would be calculated at this point in the process; this is just a
starting point. The key changes targeted by healthy eating guidelines
include:” Yes, new patients can more easily be led
down this path, until they realize what this is doing to their
health.
When David Mendosa advised me to read
the Joslin's Diabetes Deskbook before finishing this, I did not
realize how right he would be. I have my hands on the book now and
have read the chapter the excerpt was taken from and it is just that
– an excerpt. There are now several other excerpts from the
chapter, all aimed at convincing patients that they need to follow
the medical nutrition therapy prescription.
The hopes I had at the beginning have
been dashed and this is just another attempt to make people follow a
regimented nutrition plan that has proven not acceptable or workable
for many of us. There are a few people that this will work for, but
more that it will not.
What is it about statistics and bell
curves that people at the ADA and medical institutions cannot
understand. Below are two examples of bell curves and either will
work to illustrate the level of carbohydrates that people may be able
to consume. On either one, the left side is those that cannot eat
many carbohydrates and the right side is those that are able to
consume high quantities of carbohydrates. When you take the number
of people with diabetes and spread them out along either bell curve,
this shows why a one-size-fits-all recommendation just does not work.
There are likely others that are on the curve where you may fit, but
never enough to make this practical to base one recommendation on.
The following image is the USDA My
Plate adopted June 2011. The book is copyrighted in 2010.
Image courtesy of chosemyplate....
No place in the excerpt (or any place
in the chapter) is there any mention of blood glucose testing. This
would put the individual very much back in charge and avoid a
one-size-fits-all mandate. But this is not the aim of the registered
dietitians. Think about this for a while if you would, if they
encouraged us to test, then we would know how different foods affect
us as people with diabetes. We would quickly know that certain parts
of the plate need to be curtailed to prevent our blood glucose from
rising to unacceptable heights. But they can't allow us to know this
as this would negate the force of prescription and this would not get
their high carbohydrate/low fat message across to us.
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