Patients suffering a severe type of heart attack are younger, more obese, and more likely to smoke according to a study presented at the 65th American College of Cardiology conference last month. With Americans suffering more from preventable “lifestyle” diseases like diabetes and high blood pressure, the lead author, a cardiologist at Cleveland Clinic, uses his platform to admonish others. “The primary care physicians and the patient need to take ownership of this problem.”
Well, yes and no. Primary care physicians and patients probably do need to more effectively address and engage in prevention, however barriers to change stem from a wide range challenges, including what we consider prevention.
WHAT PASSES AS PREVENTION?
The Affordable Care Act attempts to shift the medicine towards more prevention with the notion of decreasing more expensive care down the line. The current systems favors medications and procedures, with the toxic impact of burdening our economy while delivering worse health outcomes than other industrialized nations.
Prevention embraces the notion that we can live our lives in a way that decreases risk of disease. Preventative efforts target lifestyle factors including what we eat, how we move, and what we do to manage our lives. Ideally efforts to prevent illness promote services and programs that meaningfully impact these key lifestyle behaviors. However, a closer look at what passes as prevention hints at the challenges ahead.
I witness the efforts at Kaiser Permanente with both professional and personal curiosity, and appreciate that the Kaiser model works well, often trumping other health care plans. Still, I find myself scratching my head every time a press release crows about Kaiser’s #1 status.
I understand the public health implications, but honestly all the talking doesn’t feel like prevention to me. It feels like someone checking off a list, with others collecting the data. Mostly I started wondering how prevention is being measured in the first place.
WHAT GETS MEASURED AS PREVENTION
I spent a little time perusing the website for the Office of Disease Prevention and Health Promotion and found an outline of prevention efforts targeting adults, women, and children. As I tallied the initiatives, it became obvious that prevention may as well be code for screening. Here’s what I found.
ADULTS – 14/15 resources for adults involved screening while the other resource allows for no-cost vaccines. Screening measures include counseling to address alcohol addiction, support smoking cessation and treating obesity. NOTE: the recommendations included on the website outline what patients should do but doesn’t provide any guidance to obtain services or get them reimbursed. The dismal statistics regarding obesity counseling covered under Medicare services reveals just how a good idea gets sidetracked.
WOMEN – 20/22 services involve screening, while two preventative measures involve free access (birth control resources and folic acid supplements for women intending to get pregnant). Preventative measures include counseling for five conditions, including domestic violence, smoking cessation for pregnant women, sexually transmitted diseases, chemo-prevention, and breastfeeding support.
CHILDREN – 22/26 services for children involve screening. Children are screened for elevated BMI levels and obesity, as well as lipid disorders (think elevated cholesterol, triglycerides or low HDL-cholesterol levels). Free counseling supposedly includes counseling to address obesity, but that seems more treatment than prevention. Why are we waiting for a child to be diagnosed as obese to offer support?
WHY IS PREVENTION MORE SCREENING THAN SUPPORT?
Health screenings allows doctors to learn more about their patients, which is a good thing. However, what good does it do to identify risks linked with poor metabolic health if patients enjoy little access to effective nutrition education and medical nutrition therapy?
When I looked closer at the NIH directives for prevention, programs that offer counseling and support tend to focus on domestic violence, substance abuse, sexually transmitted diseases and other concerns that sit at the crossroads of public health and medicine. What’s missing is meaningful support to help consumers improve their metabolic health with concerted in-the-trenches education and counseling that works with consumers as they learn to eat better and navigate the complex and often overwhelming world we live in.
In the meantime, Kaiser continues to send out letters to patients to address nutrition concerns, such as this one directing a member to “follow a low cholesterol diet”, maybe attend a cholesterol class, and check back with the doctor in 6 months. In essence the medical world continues to believe one dietary approach will work for all patients with the same diagnosis, and no one has figured out that knowledge is not the same thing as behavior.
LITTLE ACCESS TO MEANINGFUL SUPPORT
Those of us in the trenches already know that real change requires more than information. Patients and consumers alike benefit when meaningful support targets core behaviors and beliefs including one’s ability, willingness, and readiness to change.
Meaningful intervention involves face time, but most patients enjoy little access to sophisticated nutrition counseling by a registered dietitian even to treat disease. Too often a soundbite to lose weight or eat better from a doctor or nurse with too much to do and not enough time suffices as “diet counseling”. Why do we tolerate not-so-benign neglect of nutrition in health care?
Even if the medical world did a better job referring patient to dietitians, most dietitians in private practice I’ve spoken to don’t accept insurance reimbursement for two primary reasons. First, an obscene amount of time taken to navigate the reimbursement process. Second, abysmal reimbursement rates when limits services are covered. The billions we spend on medical care for ever more sophisticated treatment can’t make up for basically ignoring prevention.
At the end of the day sophisticated nutrition support remains most available for consumers with an ability to pay for service. Everyone else is treated to a one-size-fits-all approach to food that increasingly is linked to the very diseases the guidelines are supposed to address. That’s not good enough to stem the rising tide of metabolic disease and obesity in the US population. The answer lies in prevention, not more aggressive treatment.