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Dean's avatar

Every study shows the importance of keeping blood glucose low - that even those with high-normal levels have increased risk of dementia, heart issues, eye issues, and the thousand metabolic problems that high blood sugar can cause. Of course, the purpose of all the screening is to sell drugs but instead of running an article by someone trying to justify doing nothing about her high-ish blood sugar, Dr. Prasad would have done well to highlight how desirable and easy it is to lower blood sugar with time-restricted eating (intermittent fasting), lowering carbs, and a little more exercise.

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Vandan Panchal's avatar

As an internist and having a public health background, I think the author has missed a point while using her own example, as she is actually likely to be an outlier in the population who actually have optimal metabolic health. What I see in my daily practice, is a completely different reality, where I would say 70-80 % of my patients have overall poor metabolic health, which is the underlying root cause etiology for all their conditions.

As doctors, and in current "in and out" model of medicine, metrics and numbers are unfortunately what are used to assess performance which has so many downstream second order effects. Rather than focusing on labs like A1c, as the only measure and lipid panel, we forget the big picture of what is causing them to have these numbers in the first place. On one side, there is over treatment of elderly patients in terms of A1c, which can lead to risk of having risks of hypoglycemia, but on the other spectrum, there are too many patients who have completely normal A1c < 5.6, on whom I cannot put them on medications that can help improve their metabolic health, (eg, GLP-1 analogues), that have had a profound effect of helping patients lose weight, and have subsequently helped with their overall mental and physical wellbeing.

A recent NHANES study, found only 6.3 % of adults in optimal cardiometabolic health, which is just appalling. Considering that we are reaching 20 % of GDP, as health expenditure, and most states, the biggest employers are either retail giants like Walmart, and Amazon, and hospital systems, the market incentives are complete opposite to what we perceive as a good health.

"Less is more" model of healthcare doesnt work, as hospitals rely on sick patients being seen consistently, without poor biopsychosocial care provided outside. No wonder, we spend the highest $$ in the last year of patient's life, trying to fix something that was broken a long time ago. What I strive for in my patients, is how to convince them to change their daily behaviors, which I thing arguably is the most difficult thing to do, and unfortunately as part of training, we spend the least amount of time on it. We just assume that patients arent going to change, and its all their bad decisions that have led them to be like this, which is a very naive way to look at the systemic issues present. I occcasionally joke, the primary care DR stands for "Downstream Revenue", as it is just a referral based system to incentivize specialist interventions, so that they have to justify their existence. Obviously, this is an overgeneralization, but we spend less on primary care, and its in a dire state because of how it is perceived as low status in the healthcare world. In one year of my practice, my assumptions of thinking that primary care is boring are completely proven wrong, and I have never felt so grateful and proud of my patients, that have actually gotten better, and improved their behaviors if provided with the correct tools, and actually "LISTENING" to them.

Vandan Panchal, MD MPH

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