Retrospective #222: Better Diabetes Self-Management with Cognitive Therapy

The day after the 2^nd of the last two bombs dropped in my inbox (see Retrospective #221), another one “exploded.” “Better Diabetes Self-Management with Cognitive Therapy,” is a Medscape Psychiatry Minute by Dr. Peter Yellowlees. As my readers know, I believe that self-management of Type 2 diabetes should be advocated by physicians and in the medical literature. Patients should be more involved in their own Type 2 diabetes care. So, what was this all about?

The video synopsis, with accompanying transcript, “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. Note: “adherence and depression.” The work, with 87 adults, was done at Massachusetts General Hospital in Boston.

It was an expensive, randomized controlled intervention in a hospital environment, with a “usual care” component and a predictable outcome: the intervention group (depressed patients with uncontrolled Type 2 diabetes), received CBT 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.” The “better” adherence outcome was not surprising, but what interested me was the outcome that, “…both groups being less depressed.”

Hmmm. Both groups took their pills, monitored their blood glucose and had A1c tests, and both groups ate the same horrible hospital food, so presumably the adherence end-points and A1c improvements of the intervention group were a result of their CBT treatment therapy. And because both the intervention and control groups saw themselves as receiving this expensive “care,” both groups came out less depressed! Well, that’s good for both patients and the psychiatrists who, after all, needed to feel that they’re helping patients, not least to justify the cost of the study.

Not to put too fine a point on it, in the ABSTRACT the only mention about depression was this: “For depression, there was some evidence of continued improvement post-treatment, but no between-group differences.”

I don’t mean to be critical of Cognitive Behavioral Therapy. I actually think CBT is good. 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! Isn’t everyone depressed when the medical therapy prescribed, including weight loss advice, isn’t working?

I guess it never occurred to these docs (they’re psychiatrists) that Type 2 diabetes is a disease of hormonal disregulation caused by insulin resistance arising from impaired glucose tolerance: in other words, carbohydrate intolerance. And the most effective treatment protocol, rather than “adherence” to a pharmacotherapy treatment regimen, is to dramatically curtail intake of dietary carbohydrates! (Good luck with that on hospital food!)

But that’s what I did. When, at my doctor’s suggestion, I started to eat a Very Low Carbohydrate diet (just 20 grams of carbs a day!), I was on three different classes of oral anti-diabetic medications, and maxed out on two. The first day I had a hypo, and I called my doctor. He carefully (and very quickly, all in the first week) drastically reduced my meds. It left me with only one, a small dose of Metformin (500mg, once a day). That was 17 years and 150 pounds ago.

Dietary “adherence” with Very Low Carb, is, for me, easy because on Very Low Carb, you’re never hungry. Medication and self-monitoring adherence will improve too as you will look forward to daily and weekly improvements.

I don’t need expensive therapy, although I don’t knock it. Do whatever works for you. The important thing is to choose the right dietary therapy for treating Type 2 diabetes. If you’ve been diagnosed with pre-diabetes or Type 2, Learn what carbohydrates are. Test your blood sugar regularly. “Eat to your Meter.” Your doctor and you will both approve of the weigh-in and lab results, and you won’t need a psychiatrist (for this), because as you lose weight and get better lab results, you will be less depressed. Your medication (if required) and self-management adherence will improve, at minimal cost to you and society. And your mood will be permanently elevated.