Currently we spend about 12% of health care dollars treating diabetes, about $11,000 per year for every diagnosed person, and almost $5,000 a year for those without a formal diagnosis. Compare these costs with the mere $510 annual costs of treating someone with pre-diabetes.
These numbers should prod every practitioner to treat people before they develop diabetes, and every insurance company to reimburse the costs of treatment, but that’s not what happens. Today the Centers for Medicare and Medicaid Services (CMS) dithers whether or not to cover Medical Nutrition Therapy (MNT) for patients with pre-diabetes. So far, no coverage.
FOR PROFIT INSURANCE COMPANIES PROTECTING THEIR PROFITS
The same standoff exists with for-profit insurance companies. My desk is littered with denials telling me that patients who want to address the metabolic mess early in the curve will receive no reimbursement for care.
These patients are referred by their physician, but denied reimbursement by for-profit entities desperate to save their profit margins. What gives? The insurance underwriters know the numbers are scary.
THE LOOMING CRISES OF NOT TREATING PRE-DIABETES
In 2014 NPR reported on a Diabetes Care paper estimating 86 million Americans with pre-diabetes. Compare that to a “mere” 22,300,000 with diagnosed disease and another 8,000,000 not yet diagnosed–and we already consider that an epidemic.
Recently I discussed the issue with a family practitioner at Kaiser Permanente, questioning why nutrition recommendations tended to be sent to patients in a letter, often with an invitation to attend a class. Rarely do I hear of a patient receiving the full benefit of nutrition support using classroom education to cover broad topics, and tapping into MNT to address a more personalized approach and specific concerns. She sighed and acknowledged that the number of patients feels overwhelming.
We will be overwhelmed when all these pre-diabetic patients become active diabetics and need care for dialysis, retinopathy, and neuropathy, and more. We already know costs will skyrocket. So what can we do to turn this metabolic mess around?
Instead of lip service regaling the importance of good nutrition, the medical establishment needs to belly up and provide consumers with meaningful support because it works. I just witnessed the impact of effective nutrition counseling again this week.
“Elena” came to me tearfully and asked for help. In her early thirties and just two years married, the diagnosis shook her to her core. How lucky for her that her employer happens to be a cracker jack dietitian specializing in metabolic health.
EATING MORE THAN YOU CAN HANDLE
No one would ever consider Elena overweight, but I noticed she had “filled out” over the past 10+ years working in my home. Yet for Elena, her carefree days of consuming “comida China” and treats at will took its toll. She presented with a fasting blood sugar of 97 and a hemoglobin A1C of 5.7. Clearly her body was not handling her current diet.
I spend about thirty minutes reviewing key issues regarding food and metabolism. I drew pictures, offered her worksheets and mapped out sample menus.
CHANGE CAN BE GOOD
Then I watched as Elena took in the information, recognized a hint of resignation and the more common signs of early mourning. She loves sweets and treats, and clearly felt burdened by the thought of having limits.
That’s when I asked about what she already experiences with her current diet. Immediately she told me of feeling sleepy and lethargic after eating. She spoke of sugar cravings that distract her and make her feel out of control. And yes, she recognized that she could lose a few pounds. However, more significantly she spoke of the times when she felt like she was starving, when her patience ran thin, and her tongue jabbed too sharp. She took a deep breath, and realized that change could be good.
Over the past three months Elena’s fasting blood sugar dropped from 97 to 87 mg/dl, and her hemoglobin A1C shifted to a normal range, dropping from 5.7 to 5.4. Mostly she figured out how to eat a salad and a vegetable at meals, and she willed herself to consume far less starch and practically no sugar. In fact, she is so careful that my counseling this week focused on helping her shift from the “cleanest” diet possible to one that is more sustainable over time.
As a result of this effort Elena lost 22 pounds. She jokingly admits that she is afraid she will fly away, and friends tease her about being too thin.
It is likely that she isn’t eating enough and needs to figure out how much more carbohydrate she can handle, and when she needs to eat more fat. We can work with that. As she tests how much more she can eat, I encourage her to note what works and what doesn’t work and to use this insight to sustain the metabolic benefits over time.
Elena noticed less bloating and that she enjoyed more energy and fewer cravings almost immediately. However, she also had questions. Intermittently we discussed her concerns and problem solved a few situations.
I probably spent less than 3 hours discussing these issues with her over the last three months, a value just a bit over $500. That’s quite a return on investment if she is able to prevent a diabetic diagnosis in the years ahead.
RESULTS THAT INSPIRE CHANGE
What will it take to decrease incidence of diabetes in this country? I have a very concrete proposal. Try giving dietitians a chance to coach every person experiencing signs of metabolic stress. Let us teach patients and their families how to turn the metabolic mess around before it causes more damage and incurs much greater costs.
Then CMS and private insurance companies should belly up and begin to reimburse MNT for pre-diabetes because dietitians can save a lot of money if you give us a chance. Every consumer deserves meaningful nutrition support, not just those who can afford to pay out of pocket.