To become a medical doctor in the United States, you need to get a bachelor’s degree, with many courses in biology and other sciences. Then, you need four years of medical school. Then, you need to do an internship and residency. Yet after all those years of training, you might still know practically nothing about nutrition and dietetics. Also, you often won’t get to decide what care your patient can get. Those decisions will be made by accountants at your patient’s insurance company. The accountants may insist on a “fail first” approach to treating many serious diseases. As a result, many patients have to get bad care before they can get good care. To improve healthcare while controlling healthcare costs, we must teach doctors about nutrition and then let doctors, not accountants, make the medical decisions.
“Fail First” Is Bad
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 haggling with clerks at the insurance company. Most of those clerks are not doctors, and none of them have a doctor-patient relationship with the patient. To solve this problem, we must make some improvements in medical education and then give doctors more power.
Stepped Care Is Good
Step therapy is a bad version of stepped care. In stepped care, patients with a less urgent or less serious case get treatment of a lower intensity, at least at first. For example, many patients should try a change to a healthy diet before they take possibly dangerous medication. If the patient needs medication, they might start with a cheap, old drug with a known safety profile, rather than starting with a an expensive new drug whose long-term safety is unknown. Yet even in stepped care, doctors do not need to start with the bottom step. In serious cases, they can start with a middle step or even the top step.
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 are supposed to pick the therapy that is most likely to succeed.
Most of our main causes of death and disability in the United States are the result of eating an overly rich diet. Thus, dietary management should be the first step in managing those diseases. Yet even dietary therapy can follow a stepped care approach. A low-fat vegan diet solves most diet-related problems. Some patients need an even more restrictive diet.
For arthritis patients, the first step is to remove all animal foods and all fats and oils from the diet. Animal proteins and fatty foods promote arthritis. Animal proteins look a lot like human proteins. If a bit of undigested animal protein gets into your bloodstream, your immune system may make antibodies against it. Those antibodies can then attack your own tissue. Diets that are high in fat and cholesterol make this problem worse by damaging the lining of the intestine. (Some of the medications used to treat arthritis pain also damage the intestine.) If your intestine leaks, then more bits of undigested protein will get into your bloodstream.
An Elimination Diet
A low-fat vegan diet can restore many patients’ health. Patients who remain sick can try a gluten-free vegan diet. Gluten is a protein found only in wheat, rye, and barley. In a small percentage of the population, it causes a disease of the intestine, called celiac disease. If the gluten-free vegan diet does not provide enough relief, the patient can try a formal elimination diet. Dr. McDougall’s Diet for the Desperate is an example. It excludes the other plant-source foods that sometimes cause problems in some patients (e.g., corn, soy, strawberries, citrus fruits). After the patient feels better, these plant-source foods can be carefully reintroduced, one at a time. The goal is to identify which foods were causing problems.
In severe cases, the doctor may want to start at the top step. For a patient with a flare of rheumatoid arthritis, that means a therapeutic fast. During a therapeutic fast, the patient takes nothing but water by mouth for days to weeks, in a setting of complete rest.
A water-only fast is the ultimate elimination diet. By eating nothing at all, you avoid all possible dietary triggers of disease. A therapeutic fast also suppresses inflammation. Of course, if you continued fasting, you would starve to death. So you have to break your fast eventually. After the fast, foods should be reintroduced carefully, one at a time.
Therapeutic fasting should be done only under medical supervision. Fasting is powerful medicine against the diseases of overnutrition. It can cure type 2 diabetes and high blood pressure. (See chapter 9 of my book Thin Diabetes, Fat Diabetes: Prevent Type 1, Cure Type 2).
Accountants Should Not Practice Medicine
Insurance companies are for-profit businesses. They are not public health agencies. As a result, they develop policies to boost their own profits, not to protect your health.
To improve public health while controlling healthcare spending, teach doctors about nutrition. Teach doctors how to use diet rather than drugs to solve diet-related problems. Then, let the doctors decide what other kinds of treatment their patients need, even if that treatment is expensive. Let the doctors, not the accountants, practice medicine.