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Nutrition was not exactly a prominent component of Dr. Mark Sabo’s medical school curriculum.

“I had one afternoon of nutrition training in med school,” said Sabo, an OptumCare® pediatrician in Connecticut.

He’s not alone. Only about one-fifth of American medical schools require students to take a nutrition course.1 And yet, “now almost everything we see can be traced back to proper nutrition and proper exercise,” Sabo said.

Physicians, health systems and insurers alike can help improve Americans’ health by infusing nutrition education into their clinic visits and covering it as a part of preventive care.

About half of American adults have one or more chronic conditions, many of which are related to poor eating habits and too little physical activity. Heart disease, type 2 diabetes, high blood pressure, bone conditions and some cancers are among them.2

Children have not escaped the effects of a poor diet. About one-third of American youth are overweight, increasing their risk of type 2 diabetes. Type 2 diabetes used to be rare in kids, which is why it was called adult-onset diabetes — but no longer.3

“Before I got into med school in 1999, type 2 diabetes in children was not a thing,” Sabo said. “If you saw a child with type 2 diabetes, you would write an article about it and it would be published, because it happened so few times.”

To better respond to the needs of his young patients, Sabo — along with his wife, Jennifer Sabo, a registered dietitian — founded the Healthy Me Childhood Obesity Program. The goal is to encourage positive lifestyle change through small steps over time.

“It really depends on what the family is motivated to work on,” Jennifer Sabo said. “It can be, for instance, decreasing juice intake, reducing screen time, or increasing physical activity.”

An alternative to medication

The Sabos’ approach can have lifelong effects. Treating adult patients with drugs like Lipitor for high cholesterol and metformin for diabetes is “just putting a Band-Aid on a problem,” said Mark Sabo.

“If we were schooled in proper nutrition and had the ability to do more for prevention, it would go a long way to decreasing the need for these medications and decreasing the prevalence of these conditions,” he said.

Dr. Stuart Seigel, an endocrinologist with OptumCare in Orange County, California, agreed. “What I always tell the patients is that food or nutrition is more powerful than any medication that we could prescribe.”

Seigel has created an approach that works well for his patients with diabetes — many of whom would rather avoid drugs if they can, he said.

“I try to simplify the process. I give them menus that enable them to hit a certain amount of carbohydrates per meal. Since diabetes is a disease of carbohydrate metabolism, the fewer carbohydrates they eat, the fewer medications we need to prescribe,” he said. “It essentially gives people the tools to gain control of their disease through nutrition.”

Accordion Block
  • Sample 40 gram carb plan for diabetes

    Starches:

    • White or wheat bread (1 slice) = 15 grams of carbs
    • 1 flour tortilla = 25 grams of carbs
    • 1 corn tortilla = 15 grams
    • Bagel (whole) = 50 grams
    • Cinnamon raisin bagel (whole) = 80 grams
    • Baguette (6 inches) = 30 grams
    • 1 roll = 20 grams

    Fruit, 10 grams each:

    • 1 cup whole strawberries
    • 1 kiwi
    • 1 cup raspberries
    • 1/2 cup blueberries
    • 1/2 grapefruit
    • 1 plum

    Each meal should add up to 40 grams of carbs. For example, 2 slices of bread (30 grams) + lettuce, meat, cheese and tomato (free) and 1 cup raspberries (10 grams)

    OR
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He had one patient who went on the recommended diet and switched to a newer-generation insulin. The combination worked wonders, resulting in a weight loss of 40 pounds and bringing the man’s A1c, a three-month measure of blood sugar levels, down into the fives. (The normal A1c level is below 5.7%.4)

“He says to me, ‘What did you do? My friends don’t believe it, and frankly, I don’t believe it,’” Seigel said. “He was absolutely shocked by the results.”

Like the Sabos, Seigel said it is vital that patients feel the problem is not insurmountable. “A lot of times, it's much more complicated than it needs to be. But you make it easy, the patients are much less overwhelmed. And boom, you have success.”

Supporting more nutrition therapy

Many insurance plans cover medical nutrition therapy (MNT) for diabetes. Medicare Part B covers it for diabetes and kidney disease. MNT includes therapeutic services and counseling by a registered dietitian referred by a physician to help patients manage the disease.5

In addition, some insurance companies consider nutritional counseling a medically necessary preventive service for certain patients, such as obese children and adults.6

Health care providers have called for broader coverage. In a 2017 Journal of the American Medical Association article, endocrinologist Dr. JoAnn Manson of Brigham and Women’s Hospital said insurers should make such coverage consistent and be sure their policies are comprehensible for patients.7

“It has to be really clear what’s covered and what isn’t, and hopefully clinicians will be able to get reimbursed for these interactions,” she said.8

These services are often underutilized. In one study, fewer than 7% of privately insured people with newly diagnosed diabetes received diabetes self-management training to help them learn more about nutrition, checking their blood sugar regularly and staying active.9

Prevention works best

What if we could prevent poor nutrition and its consequences from happening in the first place? Mark Sabo said that’s the most effective way to keep kids and adults from developing diabetes and other conditions related to obesity, like high cholesterol, heart problems and kidney disease.

In fact, he incorporates nutrition education into his encounters with all patients, not just those who are overweight, Sabo said.

“I bring it up at every visit. I don't care if the kid is a star athlete — we talk about proper nutrition,” he said. “The other providers in our Healthy Me program are encouraged to do that as well.”

Jennifer Sabo said the program has handouts on a variety of nutrition topics, like the importance of whole grains and increasing fruit and vegetable consumption. That way, the provider has a sort of script to guide them.

“We have a lot of handouts that are just basic, good healthy nutrition tips so that they can have something every single time the family comes in,” she said.

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References

  1. Harvard T.H. Chan School of Public Health. Doctors need more nutrition education. 2017. Accessed June 7, 2019.
  2. Health.gov. Dietary Guidelines 2015-2020. Nutrition and Health and Closely Related. Accessed June 8, 2019.
  3. Centers for Disease Control and Prevention. Prevent Type 2 Diabetes in Kids. Last updated June 29, 2017. Accessed June 8, 2019.
  4. National Institute of Diabetes and Digestive and Kidney Diseases. The A1C Test and Diabetes. April 2018. Accessed June 10, 2019.
  5. Academy of Nutrition and Dietetics. How an RDN Can Help with Diabetes. Published Nov. 1, 2018. Accessed June 10, 2019.
  6. Aetna. Nutritional Counseling. Medical Clinical Policy Bulletins. May 22, 2019. Accessed June 7, 2019.
  7. Office of Disease Prevention and Health Promotion. Promoting Nutrition Counseling as a Priority for Clinicians. Published Nov. 29, 2017. Accessed June 10, 2019.
  8. Ibid.
  9. Centers for Disease Control. Morbidity and Mortality Weekly Report. Diabetes Self-Management Education and Training Among Privately Insured Persons with Newly Diagnosed Diabetes – United States, 2011-2012. Published Nov. 21, 2014. Accessed June 10, 2019.