Tuesday, March 10, 2009

Registered Dietitians and the White House Forum on Health Reform

In honor of National Registered Dietitian Day (March 11) this post is part of an RD Blogfest. Links to a variety of blogs written by Registered Dietitians, the food and nutrition experts, are offered below. I hope you will enjoy the rich information made available by many of my colleagues, and seek the advice of a Registered Dietitian for your food and nutrition questions.

As a Registered Dietitian I was encouraged to hear President Obama’s comments from this week’s White House Forum on Health Reform and to see his determination to proceed with health care reform, though it is a touchy subject indeed. The exploding cost of health care is arguably the greatest threat to the well-being of individuals, families, businesses, and the American economy itself. The escalating cost of insurance premiums and health care, coupled with sinking wages, and combined with increasing numbers of uninsured Americans, is a recipe for disaster. The opportunity for RD’s to explain our services has never been better.

President Obama identified in his speech that we did not get here by accident, and that the problems we face today are a direct consequence of actions we failed to take yesterday:

“Since Teddy Roosevelt first called for reform nearly a century ago, we have talked and tinkered. We have tried and fallen short, stalled time and again by failures of will, or Washington politics, or industry lobbying.”

While he may have rightly focused on our collective failure to reform the health care system I think this is an opportune time to add the failure of individual Americans to responsibly steward their own health with healthy diet and exercise to the national conversation. Our collective failure may be true enough, but it is no excuse for the explosion in lifestyle disease. Lifestyle disease is not a result of too little acute care, but rather a result of one person at a time neglecting to eat a healthy diet and exercise. It should not take government or businesses having to provide programs for people to eat a healthy diet and exercise. Sadly, we may have come to the point that it does. The 77,173 Registered Dietitian’s currently in the United States are well-positioned for the change in focus that may lie ahead.

President Obama acknowledged the inevitable opposition he is already encountering:

“And today, there are those who say we should defer health care reform once again—that at a time of economic crisis, we simply cannot afford to fix our health care system as well.”

Yet very few will say we should defer preventive efforts. An emphasis on prevention in health care reform may help build a much-needed bipartisan bridge. While I was sad to see it was not a priority campaign issue, a focus on prevention in health care was the one issue in the campaign that all candidates agreed on! (President Obama even mentioned “Registered Dietitians” in his campaign—imagine that!). Prevention efforts may also be an attractive way to ease the philosophical divide that separates the Obama administration and Republicans because prevention cannot be misinterpreted as “government controlling health care”.

Furthermore, in what must be a coordinated effort to fix the health care system and simultaneously rebuild crashing businesses in America, assisting employees in becoming healthier will go a long way to reducing the fear of the American business owner over health care costs. The return on investment for wellcare for businesses is significant, even lifesaving (no pun intended). I have said for 10 years that it would become more important once it hit the pocketbook, if the dis-health of the American worker (and exorbitant cost of health care) didn’t take the business down first. That time has come.

President Obama noted:

“Too many small businesses can’t insure their employees.”

But they CAN afford less-expensive preventive efforts, especially if government dollars help.

The economic crisis is multi-factorial, and whether health care can be considered a causative issue in the economic crisis or able to be dealt with as a separate issue will probably be hotly debated. But everyone agrees on prevention, and it is the obvious starting point for the collaborative work that is going to be necessary between all parties. In fact, it may be the only way to get any collaboration on the issue of health care reform.

President Obama confronted the probable skepticism he will meet with regarding whether Washington can bring about this change because of the inability to reform health care in the past. A focus on undeniably cost-effective prevention is change people can (and do) believe in. He won’t even have to convince anyone--it is a basic fact that everybody already believes in. It still boggles my mind why our health care system is so heavily weighted towards acute care given this basic fact that everybody knows (Governor Huckabee just commented this weekend on his television show that 80% of America’s health care dollars are spent on acute care). Perhaps the lopsided emphasis on acute care stems partly from a “tyranny of the urgent”, perhaps the compassionate American mindset preferentially prioritizes the sector of people in acute need, and certainly a profitable industry has been built around acute medical care. The private sector and free-market economy has allowed cream of the crop inventive genius to emerge and produce great medical advances, which in turn can be profitable, but expensive. Perhaps a bit of pride in the mix, since America’s medical genius was highly-regarded in the past, has encouraged a continuing focus on developments in acute care to the negligence of the rather unspectacular preventive care. While we are all thankful for medical advances if and when we need them, the less profitable prevention efforts must now be the focus of our health care system—at the very least we must try to better balance acute care with prevention dollars. Prevention has been under-funded for far too long by the health care industry and by the government. If the current administration is going to strong-arm some of its policies of change, perhaps they should consider requiring insurance companies to cover preventive services. Businesses who watched the bottom line erode with the medical crisis in America have had to fund wellcare with their own precious dollars. Government help in funding prevention/wellness efforts would be appreciated by all parties. With a lopsided under-emphasis on prevention by the health care industry and government, is it any wonder it is often under-emphasized by individual Americans too? The American mindset must change, and that must start with leaders. I do give kudos to President Obama and Michelle for living out their examples of healthy eating and exercise in front of the cameras (as did President Bush), and for raising healthy children, but I believe a larger impact is made when we put our money where our mouth is.

Government-funded public awareness campaigns have not been enough. More than 90 million Americans are affected by chronic diseases (HHS and USDA, Dietary Guidelines for Americans 2005, Message From the Secretaries). While billions of dollars have been allotted to battling the trend, the overall health of America continues to decline. 24 million Americans have diabetes, an estimated 57 million Americans have “pre-diabetes, and “adult-onset diabetes” has made a surprise appearance in children and is now common. Sixty to 75 million Americans suffer from the related disorder metabolic syndrome (Reaven and Strom, 2000). About 12 million people in the United States have coronary heart disease (National Heart, Lung, and Blood Institute, 1998). Co-morbidities are no longer unusual. Sixty-five percent of Americans are now either overweight or obese . . .

We are clearly in trouble. America’s health has continued to decline despite increased efforts and money designated to increasing public awareness. For the most part, people are not just going to “get healthy” because they realize they should, even though they understand that there are benefits of being healthy and dire consequences of staying unhealthy. It would seem there is more needed in the approach. While there have been excellent government initiatives at public education, they have been relatively ineffective as compared to the scope of the problem. Clearly the prevention efforts need to be more intensive. The United States Department of Agriculture and other public health organizations have accomplished the herculean job of disseminating excellent nutrition information so that Americans are largely without excuse. Irregardless, while many Americans are making significant lifestyle changes many more are not. Although access to correct, understandable nutrition information is a necessary component of behavior change, many people need practical help with HOW to apply the information and recommendations and with the formidable process of actually making the changes in lifestyle behaviors that will last. Former Secretary of Health and Human Services Tommy Thompson and Secretary of Agriculture Ann Veneman conceded:

“. . . putting this knowledge into practice is difficult” (HHS and USDA, Dietary Guidelines, Message From the Secretaries).

Healthy People 2010 by the Dept. of Health and Human Services reports on the significant increases and epidemic costs of diabetes as a major public health challenge, concluding:

"Several factors account for this chronic disease epidemic, including behavioral elements (improper nutrition, for example, increased fat consumption; decreased physical activity; obesity). . . and the relative weakness of interventions to change individual, community, or organizational behaviors (Clark, 1998; King, et al., 1997; Center for Disease Control, 1997).

If ever Registered Dietitians were needed, they are now.

The authors of “Prevention Makes Common ‘Cents’” by the U.S. Department of Health and Human Services, September 2003 include a number of meta-analyses which provide in-depth information about specific aspects of worksite wellness programs. While it is clear that many health promotion and disease prevention programs do work and do result in significant cost savings, there are important distinctions worth noting, especially given the need to maximize every dollar in our current economic crisis. For example,

“Many studies have focused specifically on the return on investment (ROI) from worksite health promotion and disease prevention programs. One recent review identified well-conducted, rigorous evaluation studies of ROI, then documented the range of ROI estimates in these studies, and examined the factors that influenced program outcomes and ROI estimates. Findings on the return on investment for health promotion and disease management programs were reported for nine employers: Canada & North America Life; Chevron; City of Mesa, AZ; General Mills; General Motors; Johnson & Johnson; Pacific Bell; Procter & Gamble; and Tenneco. . .

For these employers, disease management programs resulted in the highest returns on investment, and the educational health promotion and disease prevention programs the lowest returns. Moreover, the more expensive programs resulted in lower returns on investment than some of the less expensive ones. The reviewers suggest the possibility that the higher costs may stem from the larger capital investments that go into on-site fitness centers or classroom-based education programs. They also point out that the typical health promotion and disease prevention program provides health education to most or all employees but usually shows savings for only a small portion of the neediest employees, whereas disease management programs are targeted on a smaller selected group of employees. They conclude that, in designing effective programs that will improve employee health and productivity and produce good returns on investment, employers should consider an array of health and productivity programs (rather than focus on the ‘pure’ wellness program) and integrate them with health and demand-management or disease-management activities.
pp. 23-24

Registered Dietitians are uniquely trained to provide the highest quality nutrition education available in these United States of America, and also administer the specific “medical nutrition therapy” (the recent term adopted since Medicare coverage for Registered Dietitians) necessary for disease management. The authors’ conclusion supports the importance of providing wellness programs (typically disease prevention programs) with the dual capability of providing disease management. In this time of economic crisis it is critical that the Registered Dietitian, the only professional uniquely qualified to do both nutrition education for disease prevention and medical nutrition therapy, be utilized to the highest degree possible. The need for RD’s has never been greater.

Prevention is key, and RD’s can be the heroes of the hour. Insurance companies will be more willing and able to expand coverage, especially with government help, if they have some measure of assurance that their insureds will be healthier longer. Businesses will not only better survive financially, their employees will be more productive, better workers. The burden on the health care industry to provide acute care to an increasing number of sick Americans will be somewhat eased. America can be a healthier, more prosperous place, but our help as RD’s has never been needed more than now.

I think President Obama gets it—not only can we afford to invest in preventive methods, we cannot afford not to any longer.
Diane Preves, M.S., R.D

I encourage you to see what some of my fellow dietitians are doing by visiting the following links:

Cheryl Harris - Me, a Gluten Free RD!
Meal Makeover Moms' Kitchen - Family Nutrition ... It's our "Beat"
Wendy Jo Petersen - March 11 is our day to shine!
Rebecca Scritchfield - Big Tips from a "Big Loser"
UNL-Extension, Douglas/Sarpy County - Nutrition Know How - Making Your Life Easier

Another blog I recently became aware of is A Weight Lifted--a healthy weight loss blog for women tired of dietiting at http://aweightlifted.blogs.com/ from the folks at Green Mountain at Fox Run--A Women's Healthy Weight Loss Retreat. These folks are asking for participation in a very short 4-question survey at http://tinyurl.com/c34bum. Go ahead, help them out, and enjoy some of the helpful information at their site.


  1. Happy RD Day to you.
    Fellow blogfest blogger,
    Anthony Sepe

  2. Dear Diane,

    Happy National Registered Dietitian's Day!

    The journey toward a healthier, more balanced lifestyle is not known for its easy terrain. Despite our best intentions, it is common to slide back into old habits and behaviors. With each challenge we get disappointed in ourselves, beat ourselves up for failing, and eventually quit our positive efforts. Our failure reinforces the belief that we can’t have what we most want.

    I appreciate your blog post and your passionate call to action. One person at a time we can make a difference - in our own lives and in the lives of others.

    With joy,
    Annette Colby, PhD, RD

  3. Diane,

    Your post is so timely and thorough! Thanks so much for making it part of Blogfest!


  4. Diane,

    Thank you for your thoughtful post. I believe our healthcare system will be reformed and that prevention will be a centerpiece. I agree with you that more resources need to be put toward public awareness a la social marketing efforts.

    Happy RD Day!


  5. Diane,
    Wasn't it a heart-leaping moment to hear the word dietitian mentioned by President Obama during the campaign? Let's hope we all can help turn the Titanic around so that healthy food for all is the cornerstone for true disease prevention in this country.

    Happy (late) RD Day!

    Diana Dyer, MS, RD

  6. As a student with an unresolved career dilemma (RD vs. MD), this article was much appreciated.

  7. Thank you for this much appreciated article. Getting people to understand healthy food choices and actually incorporating that knowledge into their daily lives is key to good health and prevention of disease.

    Cheers to all you RD's out there! Happy belated RD Day!

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