On Monday, June 27, the LA Times reported that the U.S. Preventive Services Task Force is currently urging doctors to identify patients with a body mass index of 30 or more–currently about 1 of 3 adults in this country. The idea is to let patients know that obesity increases risk of disease, offer them counseling and get insurance companies to pay for the service.
I understand the desire to do something. The costs associated with metabolic disease are staggering. We can’t afford this much health care. At the same time, this proposal is riddled with problems. Maybe public health types need to take up the mantra physicians are supposed to heed: first, do no harm.
WEIGHT CANNOT MEASURE HEALTH
My first issue is with the methodology. Doctors are instructed to identify people with a BMI of 30 or above and kick into gear. The focus is on weight, as if weight is an adequate surrogate measure of health. It is not. It is a lazy and biased measure that doesn’t really have as much in common with health as we are led to believe. There is no context. For extensive debate on this point you can reference Glenn Gaesser’s Big Fat Lies or Paul Campos’ The Diet Myth.
The real focus should be metabolic health. True markers of health include measures of fitness and freedom from disease. It is far more significant to not need blood pressure medication or be able to reduce meds for diabetes than to reach an arbitrary number on the scale. I have had countless patients improve in every other parameter, yet see only modest weight loss. There is more to this discussion than a simple number. What will it take for us to realize we can’t measure health on a scale?
BMI IS A LIMITED AND FLAWED TOOL
My second concern is that BMI is nothing more than a calculation of weight and height. It maintains all the flaws of using weight as a surrogate for health. BMI does not assess body composition or distribution of fat weight (two factors that research repeatedly tells us are more effective at assessing risk of disease than weight alone.)
BMI assumes risk when there is none, and ignores risk as long as your body weight is low enough. Thin people are diagnosed with heart disease, diabetes, and cancer, too. There is too much collateral damage for labels like “obese” and “over-weight” to bandied about so carelessly.
WAITING FOR DISEASE
The third issue is that insurance reimbursement for nutrition counseling is limited to individuals with a BMI greater than 30. Such a policy underscores the goofiness of arbitrary cut points. I remember one patient gaining 25 pounds in order for her desired bariatric surgery to be eligible for insurance reimbursement.
In the twisted logic of western medicine we wait to treat people when they are diagnosed with disease because insurance payment is link to diagnostic codes. The current recommendations for weight loss counseling share the same twisted logic. The metabolic issues linked to weight gain and obesity can be detected decades before someone attains a BMI of 30. Why not provide support and counseling to minimize the problem in the first place?
DOCTORS WILL PROVIDE THE COUNSELING
My last and most personal concern is that the current recommendations leave the docs in charge of everything. Current regulations charge the physician with screening patients, addressing the risks associated with obesity and counseling them or referring them to an appropriate resource.
I understand that cost containment is probably a primary motive for this provision. Yet, in the real world I know most physicians have neither the time nor expertise to truly counsel. Most doctors have never taken an academic course in nutrition. Telling someone they need to lose weight is not effective counseling. The real work is helping clients bridge the gap between knowledge and behavior. Adequate time and the clinician’s skill are critical.
KNOWLEDGE IS NOT BEHAVIOR
I had one physician recently confess to me, “Physicians are the worst eaters.” Time constraints and pressures to do more in less time mean that many physicians stumble. In their fast paced worlds, they are often no better prepared to navigate our abundant and adulterated food supply than their patients.
So where will the clients be referred? Not to someone like me.
WHO WILL COUNSEL PATIENTS?
Under the proposed provisions, insurance will not cover services provided by an independent dietitian. I am not under a physician’s supervision.
I have been in practice over 25 years. How ironic that today I spend a good deal of my time presenting information and strategy regarding weight management to physicians, physician assistants, nurses, nurse practitioners and other health providers.
I help clients begin to understand metabolism and work with their bodies. I help clients cultivate an approach to food that works for them. That means I am more focused on working with my patient than following an “evidence based” food plan pretending that there is one specific diet that is appropriate for all persons with a specific disease.
I spend far more time than the average 6-8 minutes most physicians allot per patient visit. Who would you rather ask to provide nutrition counseling services for you?