July 11, 2024

Elimination diets, privilege, and the Whole30

A female dietitian sitting in her office, working on her laptop.

One of the most common criticisms I hear about the Whole30 is that an elimination and reintroduction program like ours should only be prescribed and monitored by a Registered Dietitian (RD) or Registered Dietitian Nutritionist (RDN).  Critics of the Whole30 say there are risks to following even a short-term elimination diet on your own. They believe dietitians are best qualified to mitigate those risks and design a program tailored to each person’s unique context and goals. 

Honestly, I agree. Working with a dietitian to design, implement, and apply your elimination diet (or other nutrition protocol) is the best-case scenario. A dietitian would work with you one-on-one to obtain your health and medical history. They’d also review your health concerns and current dietary regimen. Then, they’d craft a dietary protocol customized for your unique body, context, and goals. You’d meet with them regularly to ask questions and share your progress. During follow-up visits, they would answer your questions, troubleshoot, provide you with resources and recipes, and help you turn the experience into a sustainable lifestyle.

What is never acknowledged in these conversations, however, is the amount of privilege this “best-case scenario” requires. There are very real systemic barriers that make working with a dietitian challenging at best, and impossible for many.

  • Do you have health insurance that covers multiple visits to a dietitian or nutritionist (outside of a diagnosed health condition like diabetes or kidney disease)?
  • If not, do you have the $70–$150 (or more) for each visit?
  • Do you have the time to source and interview dietitians to work with?
  • Do you have the time to meet with a dietitian (during their business hours) each week?
  • Do you have transportation to and from visits, if they don’t provide telehealth?
  • Do you have access to childcare during these visits?
  • Can you take the necessary time off to accommodate these visits?

I’ve done significant research into working with a dietitian or nutritionist to craft an elimination diet that addresses general health concerns like fatigue, sleep disruptions, digestive issues, chronic pain or inflammation, or skin conditions. This article is also in collaboration with Clara Nosek, a Registered Dietitian Nutritionist and the creator behind @yourdietitianbff. Clara works through the lens of non-diet, providing fun and educational messages that remain in alignment with her commitment to accessible wellness and nutrition.

Let’s dive in.

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Does insurance cover a dietitian?

Every insurance carrier and plan is different, but I found one commonality across all of the major carriers: They only cover working with a dietitian if you have a specific diagnosed medical condition.

  • Anthem/Blue Cross Blue Shield generally offers nutrition therapy coverage if you have specific health conditions (such as diabetes or an eating disorder), or are classified as obese by a physician. 
  • SelectHealth (my insurance) covers five, 60-minute visits per year only for diet-related health conditions (such as an eating disorder, cancer, Celiac disease, heart disease, Crohn’s, diabetes, or obesity). When I called to ask about preventative nutrition advice or dietary counseling to address general health complaints, they recommended talking to my primary care physician.
  • Aetna considers nutritional counseling medically necessary only for those who are obese or overweight with cardiovascular disease risk factors, and those with other chronic disease states (such as diabetes, eating disorders, gastro-intestinal disorders, hypertension, kidney disease, or seizure). Their site specifically says, “Aetna considers nutritional counseling of unproven value for conditions that have not been shown to be nutritionally related, including but not limited to asthma, attention-deficit hyperactivity disorder and chronic fatigue syndrome.”
  • United Healthcare requires both your physician and the plan coordinator to agree that your weight is causing additional health problems, or you must have diagnosed health conditions (such as diabetes, heart disease, gout, or renal failure) to be eligible for nutritional counseling with a dietitian. Your coverage includes just three meetings per illness. 
  • Medicare (Part B) covers medical nutrition therapy services only if you have diabetes or kidney disease, or you’ve had a kidney transplant in the last 36 months. A doctor must refer you for services.
  • Medicaid often does not cover nutrition counseling with a dietitian, and some states do not recognize dietitian nutritionists as Medicaid providers. If you have diabetes, nutritional therapy might be covered in just seven states under the National Diabetes Prevention Program (National DPP).
  • Your Health Savings Account (HSA) also requires a Letter of Medical Necessity (LMN) in order to be reimbursed for dietitian or nutritionist services.

Even if you do have health insurance that will cover meeting with a dietitian for preventative care or to resolve general health complaints, you may only be eligible to receive compensation for a specific number of visits. You may also have a maximum amount your provider is willing to cover. In addition, you may have to meet your deductible before visits will be covered. In addition, your visits may require a referral from a physician, requiring multiple appointments just to see a dietitian. And as not all insurance providers cover telehealth sessions, you may be limited in who you can see, or have to travel long distances to work with someone in person.

How many visits do you think you’d need to successfully complete an elimination diet? Even if you were allowed five visits per your insurance plan, is that enough for:

  • A thorough intake
  • An explanation of the diet
  • Helping you plan and prepare
  • Troubleshooting and providing guidance through 30+ days of elimination and reintroduction
  • Evaluating your results

Summary: This doesn’t even take into account the kind of guidance and support you’ll need to turn your learnings into a sustainable diet and lifestyle! It’s often not easy to work with a dietitian through your health insurance, and may prove impossible if you’re simply hoping to resolve general health concerns through an elimination diet.

Can you pay out of pocket for a dietitian?

If health insurance doesn’t cover your visits, or if (like so many) you don’t have comprehensive healthcare or insurance, you can pay for a dietitian’s services out of pocket. Hourly rates for consultations with a dietitian do vary, but on average, you can expect to spend:

  • $70 to $150 per session (60 minutes)
  • Up to $225 for a comprehensive intake appointment 

I did some research myself in this area. The University of Utah charges $70 an hour to work with a dietitian (which does not include a meal plan). My co-worker in Tampa called a local dietitian nutritionist and was quoted $90 an hour. A Colorado Springs gastroenterology clinic charges $120 for the intake, $95/hour thereafter. A local Salt Lake City dietitian working in private practice charges $165 per session (flat fee). Note, there may be specific clinics or individuals in your area (or via telehealth) which offer dietitian fees on a sliding scale, if you qualify—which would require far more research and paperwork.

Summary: Just five sessions out of pocket with a dietitian could cost $350 or more. For many, that’s not at all accessible.

What other factors are at play?

Even if you had the money to work with a dietitian, you’d also need the time, energy, resources, and work or childcare coverage to be able to attend the appointments. That involves:

  • Researching dietitians in your area (or virtually, if you want telehealth)
  • Finding those accepting new clients
  • Connecting with them, discovering their rates and availability, seeing if they’re a good fit for your goals and context
  • Making appointments that suit your work and childcare schedule
  • Taking an hour off from work and/or childcare to attend the appointments (and if traveling, including additional time for the commute and money for gas)

Granted, any health effort requires time to research, including the Whole30. However, if you’re looking for a specific person to work with (and don’t have a starting point, like a referral from a doctor or a reference from a friend), that requires far more time and effort. 

In addition, meeting with someone regularly during business hours can prove challenging, especially if that person is a working parent, single parent, lacks transportation, or has a chronic illness or condition. Telehealth certainly makes the process easier, but that still requires time, a private space, and perhaps childcare help.

In addition, not everyone receives the same quality of healthcare. Those who are Black, trans, disabled, or overweight are often unheard or dismissed in the healthcare system. In this context, you may be less trusting of your practitioner to offer nutrition counseling, or may not be able to find a dietitian with the right experience or background.

Summary: For many, just the act of finding a dietitian would prove too intimidating or challenging. There are many systemic barriers to working with a dietitian—which really sucks, to be clear.

The Whole30—an accessible alternative

Working with a dietitian to craft your elimination diet is your best option. But if you don’t have the time, money, or resources to do so, the Whole30 is a damn good (and highly accessible) alternative. 

Over the last 14 years, the Whole30 program has been endorsed by hundreds of dietitians, medical doctors, therapists, and other qualified healthcare providers. Our program cannot provide personalized guidance. However, we do offer an accessible, robustly supported, proven template to identify hidden food sensitivities and radically transform your health, habits, and relationship with food.

Despite not offering customized programs, tailored meal plans, or one-on-one coaching, the Whole30 has garnered thousands of glowing testimonials. People report the improvement or elimination of symptoms ranging from migraines to anxiety, acne to digestive issues. In fact, many of these testimonials come from the healthcare providers who prescribe Whole30 to their patients and clients, like Catherine Moring, PhD, RDN and Dr. Brendan McCarthy. (And sometimes they come from the doctors themselves, like this testimonial from Karen Onyirioha, MD.)

Note, the Whole30 itself (as with any elimination diet) also requires a level of privilege. Buying whole foods, meat, and produce requires access to well-stocked grocery stores, and the budget and time to grocery shop for perishables. The comparison here is simply between doing an elimination diet with a dietitian, versus completing an elimination diet like the Whole30 on your own, utilizing all of the free resources we’ve made available.

Summary

Clara summarized our discussion by saying, “This reminds me of the conversations surrounding convenience foods. Specifically, the healthism-loving, food elitist propensity to demonize processed/ultra-processed foods and shame people for choosing to purchase these foods. There is more than one “right” way for a person to optimize their health. The dietitians disparaging Whole30 and healthism advocates critiquing processed foods operate from a framework that idealizes certain types of diets. Both groups advocate for what they believe to be the ‘purest’ form of eating—and automatically dismiss alternatives as less healthy or (morally) inferior.”

She went on to add, “When evaluating the implementation of elimination diets, you cannot ignore the nuanced realities that exist for so many. The accessibility of food choices, availability of insurance, and limitations of insurance and healthcare all play a role. It takes time, money, and energy to do anything. Designating one way as ‘bad’ can alienate or shame those who chose one over the other—thus mirroring the broader cultural struggle around food, health, and morality.”

Why shouldn’t people try to improve their health on their own? Suggesting elimination diets should only be completed under the guidance of a healthcare professional is like saying, “Exercise is complicated and risky, so don’t try it unless you’re working with a trainer.” If you don’t have the time, financial resources, or access to a personal trainer, exercising using free resources on the internet is a fantastic place to start. I think of the Whole30 in the same way.

Identifying ways to improve your health, quality of life, and vitality should be accessible to all, not just those with the time, money, and resources to afford it. The Whole30 offers an accessible, well-supported, effective alternative to learn more about the way various foods and food groups impact you in your unique context.

References

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