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.