March 31, 2013

Medical Nutrition Therapy by Prescription – Part 2

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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