The very
next day after the 2nd of the two bombs dropped in my inbox (see The
Nutrition Debate #221 here), another
one “exploded.” I am interested whenever diabetes self-management, in contrast
to “treatment” by clinicians, is advocated in the medical literature. Type 2
diabetes patients need to be more involved in their own care.
“Better Diabetes
Self-Management With Cognitive Therapy” is a Medscape Psychiatry Minute by Dr. Peter Yellowlees. The video synopsis,
with accompanying transcript of a paper, “A randomized controlled trial of
cognitive behavioral therapy for adherence and depression (CBT-AD) in patients
with uncontrolled type 2 diabetes,” appeared in Diabetes Care. The Medline ABSTRACT appears here. The work,
with 87 adults, was done at Massachusetts General Hospital in Boston.
The
“better” outcome is not surprising, of course, and is not what interested me
about this study. This was just another expensive, “randomized controlled
trial” in a controlled hospital environment with a “usual care” component, and
with a predictable outcome: the intervention group (depressed patients with
uncontrolled type 2 diabetes), received cognitive behavioral therapy and, after
4-, 8-, and 12-month follow-up time points, “maintained 24% higher medication
adherence, 17% greater adherence to self-monitoring of blood glucose, and lower
A1c values, with both groups being
less depressed.”
Hmmm. They
took their pills, had blood tests, and their A1c’s were lower. Both groups were exposed to the same hospital food as part of their
“usual care,” so presumably the A1c improvement was a result of their
“treatment” protocol: taking their meds. And because both the intervention and
control groups saw themselves as receiving this expensive “care,” an outcome
was that both groups came out less depressed! Well, that’s good for both
patients and the psychiatrists who, after all, need to see themselves as
helping patients (not least for the support they received).
Not to put
too fine a point on it, in the ABSTRACT the only mention in RESULTS about
depression was this: “For depression, there was some evidence of continued
improvement post-treatment, but no
between-group differences” (emphasis mine). One must conclude,
therefore, that the cognitive behavior therapy did not help with depression
since both the intervention
group and the control group saw “some” improvement.
I don’t
mean this to be critical of Cognitive Behavioral Therapy (CBT). In fact, I
think CBT is a good thing. My main frustration with this study is that these
seriously-ill, hospitalized patients, all with uncontrolled type 2 diabetes,
were being taught, through CBT, “adherence:” Take you pills and test your blood
regularly to see how sick you are and how much sicker you’re getting. No wonder
they’re depressed! Aren’t we all when the medical therapy we’ve been prescribed
doesn’t work?
I guess it
never occurred to these docs (they’re psychiatrists, after all) that type 2
diabetes is a disease of hormonal disregulation caused by insulin resistance
arising from impaired glucose tolerance/impaired fasting glucose: in other
words, carbohydrate intolerance. The most effective treatment protocol, rather
than “adherence” to a pharmacotherapy treatment regimen, is to dramatically
curtail dietary carbohydrates! (Good luck with this with hospital food!)
But that’s
what I did. When I started, at my doctor’s suggestion, to eat a very low
carbohydrate diet (Atkins Induction: 20g of carbs a day!), I was on three
different classes of oral anti-diabetic medications, and maxed out on two.
Within a day, I was getting hypos, and I called him. He carefully (and very quickly) titrated the meds. I was
left me with only one, a small dose of Metformin (500mg once a day). That was
12 years and 125 pounds ago.
Dietary
“adherence” with Very Low Carb, is, for me, easy (and delicious). I don’t need
expensive therapy, although I don’t knock any kind of therapy. Do whatever
works. The important thing is to
choose the right therapy for treating type 2 diabetes. If you’ve been
diagnosed with pre-diabetes or type 2, self-management (under supportive
medical supervision) is the most effective course of action, and the most
effective self-management protocol is diet. Learn what carbohydrates are. Test
your blood sugar regularly, including post prandial, to see what the foods you
eat do to your blood sugar, and adjust what you eat accordingly, i.e. “Eat to
your Meter.” Your doctor should approve of the results (outcomes), if not the
methods. Hopefully he/she will do both.
And as you lose gobs
of weight and gain energy, you and your doctor will see results in your A1c’s,
your lipid panel (e.g. HDL-C and triglycerides) and your
inflammation markers. With outcomes like these, you too could be less
depressed”!!! At minimal cost (perhaps more test strips and some good butter), and
you did it yourself! Now that’s good
self-management.