The Nutrition Debate #230: Frustrated by Failure? Solution: Lower the Standard of Care!

“Tight Glycemic Control More 'Burden' Than Benefit for Many,” this Medscape Medical News piece proclaimed. It really got my blood boiling. Later, I recognized that “anyone with a clinical practice” would relate to this sentiment, as one of the authors says in the online article in JAMA Internal Medicine. But the proposed “solution,” in the salutary guise of “patient-centered care,” is to “personalize treatment.” Sounds promising, but look carefully at the confirmation bias in their hypothesis. Consider also the tendency to blame failure-to-successfully-treat on the patient (rather than the treatment) and then to assign the failure to the patient’s “burden” of treatment, thus relieving the patient of the moral burden for failure.

The primary end-point was “to estimate the treatment burden vs. benefits from intensive vs. moderate glycemic control in patients with type 2 diabetes.” The outcome: “Using a simulation model [carefully constructed by the researchers to confirm their hypothesis?], the researchers discovered that for patients with type 2 diabetes who are on metformin and have an HbA1c below 9%, adding other antidiabetic therapies to try to lower glucose further may only confer modest benefits 15 to 20 years later.” Even though, citing the UK Prospective Diabetes Study (UKPDS), the authors acknowledge that “Lowering HbA1c delays the onset and slows the progression of early microvascular disease.”

So, what do we learn here? The new standard of care “for many” is an A1c <9% for an average glucose reading of 212? And for these “many,” the treatment plan, described as having “a low-treatment burden,” is simply to prescribe metformin and do nothing else? Because the benefit gained, depending on age when diagnosed, is only “modest”? What, pray tell, could lead anyone with a clinical practice to reach this conclusion? Could it be the failure of the “treatment” modality?

This study was carried out by doctors from “the University of Michigan and the VA Ann Arbor Healthcare System.” Not to slam yet another VA facility, but – I have to wonder – are the vets at this VA facility subjected to this lower standard of care?   If true, shame, shame on these doctors. But, maybe I’m just piling on. Maybe, by JAMA Internal Medicine publishing this piece, they too are advocating a broader application of this lower standard of care. I’ll have to read the comments.

Why lower the standard of care? Because, “for patients older than 50, especially, any potential benefits are often outweighed by ‘burdens’ of lifelong treatment – such as substantial weight gain from sulfonylureas, the need to frequently inject insulin, or the risk of hypoglycemia.” Well, patients older than 50 includes “most” people initially diagnosed with type 2 diabetes, so this new paradigm would then thus apply to “most.” NB: The authors, to their credit, do make an exception for “the 15% to 20% of people who have very high HbA1c’s and require more aggressive treatment to manage the disease.”

The authors state that the decision to “start new medications” (beyond metformin, assuming metformin is tolerated) should be “based on individual circumstances and preferences.” “These are important decisions,” they say, “because type 2 diabetes is a chronic disease that requires lifelong treatment. Thus, shared decision making, in which patient preferences are specifically elicited and considered, appears to be the best approach to making most decisions about glycemic management in patients with type 2 diabetes.” Don’t doctors take primary responsibility for patient care anymore?

But the most disingenuous statement in this article was this: “What really surprised us was you end up with a reduction of quality of life for many patients – basically those who are a little bit older when they are diagnosed or those who really don’t like their treatments.” Don’t like their treatments? If the treatment “really bothers you, then you just need to understand that you have a slightly higher risk [according to the ‘simulation model’ they’ve constructed] of these complications, and it may not be worth treating to prevent that,” they concluded. Now that’s confirmation bias for you.

It’s true: Some people can’t tolerate metformin even if it is titrated. And some anti-diabetic meds do cause weight gain, and injecting insulin is a “bother” and certainly can cause weight gain and does entail a risk of hypoglycemia. But do these “constant annoyances of having to be on a medication and experience the side effects” constitute a “burden” that exceeds the benefits of having improved glucose control? Or is this construct just rationalization to justify a failed treatment plan?

And if the treatment plan included dietary changes such as carbohydrate restriction, would not the benefits of losing weight, taking less anti-diabetic oral medications, and stopping insulin injections altogether, far exceed the “burden”?

I know people who tell me they could “never” give up bread, pasta, rice, corn and potatoes, or beverages sweetened with sugar or HFCS. “I really wouldn’t like that treatment,” they say. But…you know what? It really works.