Saturday, June 28, 2014

The Nutrition Debate #222: Better Diabetes Self-Management with Cognitive Therapy

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.

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