Why We Can’t Blame Physicians for the Metabolic Health Crisis—But We Must Change the System

The United States faces an unprecedented crisis of metabolic disease. Rates of obesity, type 2 diabetes, fatty liver disease, and related conditions continue to climb. And while it’s easy to point fingers at physicians for not offering better solutions, the reality is more complicated. Individual doctors are working within a system that makes meaningful prevention nearly impossible.

A System Designed for Prescriptions, Not Prevention

The structure of modern medicine leaves little room for addressing the root cause of metabolic health. Office visits are often limited to 10 or 15 minutes, barely enough time to review labs, refill prescriptions, and check off administrative boxes. In such a model, there is no bandwidth for deep conversations about diet, exercise, sleep, or stress—all of which are central to metabolic health.

Financial incentives make the problem worse. Physicians are often rewarded for prescribing medications, rather than focusing on prevention. Prescribing medications is quick, billable, and often tied to performance bonuses based on metrics like: how many of your patients with high LDL are on statins? How many with diabetes are on SGLT2 inhibitors? If it’s above a certain percentage, you get a bonus. By contrast, meaningful lifestyle counseling—time-consuming and complex—is rarely reimbursed, if at all.

Continuing medical education doesn’t help either. Much of it is directly or indirectly influenced by the pharmaceutical industry, which shapes far too much of physician training and priorities. And that’s not even mentioning the ubiquitous television commercials, which result in patients asking for or demanding specific prescriptions.

The Missing Infrastructure for Lifestyle Change

This isn’t because doctors don’t want their patients to be healthier. 

Physicians want to help patients improve their diet or activity levels, but they often lack the tools and support systems needed to do so.  Sustainable behavior change requires a new infrastructure: critical thinking dietitians, health coaches, group visits, apps for tracking progress, and ongoing follow-up. Few clinics provide these resources. Without them, physicians are left prescribing quick fixes, knowing full well that lifestyle change may be more effective but definitely harder to deliver within the system’s constraints.

This isn’t negligence—it’s a systemic failure. The design of the healthcare system itself leads doctors toward pharmacologic management and away from the solutions we desperately need.

We Don’t Have to Accept It

But just because physicians aren’t to blame doesn’t mean we have to accept the status quo. Tackling the metabolic health crisis will require innovative policy and systemic reform that realigns incentives and broadens the scope of care.

All we have to do is see the examples from various Direct Primary Care practices, or even app-based care models that have published their impressive results for weight loss, diabetes remission, medication deprescription, and significant overall cost savings. How can we emulate those practices on a larger scale?

Here are a few places to start:

• Support routine testing for metabolic health: Fasting insulin levels, HOMA-IR, triglycerides, HDL, body composition, and visceral fat measurements should be routine, not something special we have to beg for.
• Insurance reform: Pay for what works. Intensive lifestyle interventions, nutrition counseling, and group medical visits should be reimbursed at meaningful levels.
  
• Medical education: Encourage critical thinking that goes beyond dogma and blind belief. Expand curricula to include nutrition and nonpharmacologic therapies proven to optimize metabolic health. For example, exposure to approaches like ketogenic diets shouldn’t be dismissed just because they challenge traditional dietary dogma.
  
• Infrastructure for behavior change: Fund the integration of health coaches, dietitians, and community-based programs into primary care. Physicians can’t do this alone.
  
• Innovation in treatment models: Encourage the testing and adoption of therapies that go against the common narrative, such as ketogenic diets for diabetes, PCOS, and even mental illness. These approaches won’t fit neatly into the old low-fat narrative, but they can deliver transformative benefits.
  

Toward a True Focus on Metabolic Health

The current system sets physicians up to fail at prevention and succeed at prescription. But the metabolic health crisis is too big to solve with medications alone. We need bold reforms that make metabolic health—not pill counts—the centerpiece of care.

That means rethinking incentives, reimagining education, and embracing innovation, even when it challenges long-standing dogma. Doctors can and should be allies in this effort, but they need a system that empowers them to do more than write prescriptions.

The bottom line: we can’t blame individual physicians for failing to solve the metabolic health crisis—but we also don’t have to accept a system that makes failure inevitable. The opportunity is here for innovation, policy reform, and a new era of medicine truly focused on health, not just healthcare.