Teach Doctors Nutrition, Then Let Them Practice Medicine

The major caus­es of death and dis­abil­i­ty in the Unit­ed States today are diet-relat­ed dis­eases. As I explain in my book Where Do Goril­las Get Their Pro­tein?, you can pre­vent heart attacks and many can­cers by eat­ing a low-fat, pure­ly plant-based (veg­an) diet. That same diet can also pre­vent and even cure some seri­ous autoim­mune dis­eases, such as rheuma­toid arthri­tis. Yet doc­tors are not being taught about diet. Instead, they learn how to use med­ica­tions and surgery to treat diet-relat­ed dis­eases. To avoid pay­ing for those expen­sive treat­ments, insur­ance com­pa­nies are putting restric­tions on what kind of care they will cov­er.

Often, insur­ance com­pa­nies refuse to pay for an expen­sive treat­ment until the doc­tor has proved that all of the cheap­er treat­ments have failed to help that patient. This pol­i­cy is called “fail first” or step ther­a­py. Unfor­tu­nate­ly, a patient with a seri­ous con­di­tion could die or end up per­ma­nent­ly dis­abled unless the right treat­ment is used right away. As a result, doc­tors have been spend­ing more and more of their time in nego­ti­a­tions with insur­ance com­pa­ny clerks. Trag­i­cal­ly, those clerks often end up mak­ing the treat­ment deci­sions, even though they are not qual­i­fied to prac­tice med­i­cine and have nev­er even met the patient. To solve this prob­lem, we must give doc­tors bet­ter train­ing in nutri­tion, and then let the doc­tors, rather than insur­ance com­pa­ny clerks, prac­tice med­i­cine.

Step ther­a­py is a per­ver­sion of a good med­ical idea called stepped care. Stepped care is the idea that patients with a less urgent or less seri­ous case should get treat­ment of a low­er inten­si­ty, at least at first. For many ill­ness­es, it makes sense to start with a less-inten­sive treat­ment (such as a change in diet) rather than using a more-inten­sive treat­ment (such as med­ica­tion). Even if med­ica­tion is need­ed, it may make sense to start with a cheap gener­ic med­ica­tion with a well-estab­lished safe­ty pro­file, rather than using an expen­sive new drug whose long-term safe­ty is unknown. Yet even if doc­tors are using the stepped care mod­el, they do not need to start with the bot­tom step. They can jump to a mid­dle step or even the top step in seri­ous cas­es.

In stepped care, the doc­tor and the patient make the med­ical deci­sions. But in “fail first” or step ther­a­py, the bean-coun­ters at the insur­ance com­pa­ny make the med­ical deci­sions. By requir­ing “fail first,” insur­ance com­pa­nies ensure that a lot of patients will have treat­ment that fails. In con­trast, doc­tors want to pick the ther­a­py that is most like­ly to suc­ceed.

Since so many dead­ly and dis­abling dis­eases are caused by an over­ly rich diet, dietary man­age­ment should be the first step in man­ag­ing them. Dietary ther­a­py itself can fol­low a stepped care approach. For arthri­tis patients, the first step in dietary man­age­ment is a low-fat veg­an (pure­ly plant-based) diet. Ani­mal pro­teins and fat­ty foods pro­mote arthri­tis. If the ani­mal pro­teins enter the blood­stream before they are bro­ken down into indi­vid­ual amino acids, they can pro­voke the immune sys­tem to make anti­bod­ies. Since the ani­mal pro­teins resem­ble human pro­teins, those anti­bod­ies can then attack the person’s own tis­sue. Diets that are high in fat and cho­les­terol make this prob­lem worse by dam­ag­ing the lin­ing of the intes­tine, mak­ing it leak. (Some of the med­ica­tions used to treat arthri­tis pain also dam­age the intes­tine.)

If a low-fat veg­an diet does not pro­vide ade­quate relief with­in a few weeks, the patient can also elim­i­nate the gluten-con­tain­ing grains (wheat, rye, and bar­ley). If prob­lems per­sist, the patient can be taught how to fol­low a for­mal elim­i­na­tion diet, which excludes the oth­er plant-source foods that are known to cause prob­lems in some patients (e.g., corn, soy, straw­ber­ries, cit­rus fruits). After the patient feels bet­ter, plant-source foods can be care­ful­ly rein­tro­duced, one at a time, to iden­ti­fy the foods that were caus­ing prob­lems.

In severe cas­es, such as a flare of rheuma­toid arthri­tis, the doc­tor may want to start with a ther­a­peu­tic fast, which is the top step in dietary man­age­ment. A ther­a­peu­tic fast involves tak­ing noth­ing but water by mouth for days to weeks, in a set­ting of com­plete rest. This is the ulti­mate elim­i­na­tion diet. By eat­ing noth­ing at all, the patient avoids all pos­si­ble dietary trig­gers of dis­ease. A ther­a­peu­tic fast also caus­es hor­mon­al changes that stop run­away inflam­ma­tion. After the fast, foods should be rein­tro­duced care­ful­ly, one at a time. Ther­a­peu­tic fast­ing should be done only under med­ical super­vi­sion. It is pow­er­ful med­i­cine against the dis­eases of over­nu­tri­tion, such as type 2 dia­betes and hyper­ten­sion (see chap­ter 9 of my book Thin Dia­betes, Fat Dia­betes: Pre­vent Type 1, Cure Type 2). It has long been known to be a safe and effec­tive treat­ment for a flare of rheuma­toid arthri­tis.

Insur­ance com­pa­nies devel­op poli­cies to boost their own prof­its, not to pro­tect their sub­scribers from get­ting the wrong treat­ment. There is a bet­ter way to con­trol health­care spend­ing, while improv­ing pub­lic health. Give doc­tors basic train­ing in nutri­tion. Teach them how to use diet rather than drugs to solve diet-relat­ed prob­lems. Then, let the doc­tor decide what oth­er kinds of treat­ment his or her patient needs, even if that treat­ment is expen­sive. Let the doc­tors, not the accoun­tants, prac­tice med­i­cine.