Who Decides Options for Diabetes Treatment?

My recent post, ADA Consensus Statement Admits Recommended Lifestyle Intervention Fails; Solution: Medication, generated an interesting mix of emails and comments that deserve some attention.

In the comments, Kevin Dill wrote:

"On the one hand I agree with your position about the need to reduce carbs for diabetics. On the other hand,...I know from first hand experience in dealing with memebers of my own family that trying to get some people to change thier dietary paterns is an exercise in futility and they would be better off if they had just started the meds early."

In my email, I've received similar comments:

"Eating a low-carb diet isn't always easy or within the budget of many people. It looks easy on paper, but in practice it is harder than it sounds, especially with busy lifestyles and an environment where "the bad foods" are everywhere. If you don't consider that a lot of people with diabetes won't change their diet, the recommendation to follow a low-carb diet is going to be as useful as the recommendation to follow a low-fat diet - it will do nothing to change things if it's not followed."

"I've seen so many people around me diagnoised with type II diabetes, it's scary! For so many it is just easier to pop a pill and eat what you want and not have to think about what you're doing to your body every time you eat something you shouldn't. I don't agree with the first step being a diet and drugs combination, but honestly, I'm not sure that many people would follow a low-carb diet since it is more expensive and eliminates so many things people are used to eating."

"Too many people believe they have to have a bucketload of carbs to be healthy, diabetes or not, and when everyone is saying you need carbs it's hard to believe that reducing them is going to be good. I think most people know what they're eating isn't good for them, but they do it anyway. Expecting them to follow a low-carb diet is like expecting a pig to fly because you tape paper wings to it."

"Diabetes is one scary disease and even when you're diagnoised, you think you can still keep doing what you've been doing and let modern medicine take care of keeping you alive and healthy. You think this because it's hard to accept what you're eating actually might be the reason you now have diabetes. It's easier to accept your body malfunctioned and you now have this disease than to think you might be responsible for your body getting diseased. Recommending a low-carb diet is dangerous ground for the ADA. If they take that direction, it implies the diet advice we're all getting is wrong and might be causing diseases like diabetes. It also tells patients in no uncertain terms their eating habits are the cause of their disease. So instead of going down that path, it's easier to avoid the whole mess and start drugs early to slow down the inevitable that is going to happen if the diet isn't changed. Telling people to change their diet is hard, most don't want to, it's just easier to add something (drugs) if you can keep your old habits and not make changes that aren't easy."

Eye-opening comments!

So, first let me say that I don't think that only a low-carb diet should be recommended, nor do I think that initiating a drug at diagnosis is necessarily a bad idea.

What I find irresponsible is that, in the light of the realization "current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes;" and the emerging hard data of dietary modifications (low-carb) that are resulting in statistically significant improvements, evidence is being ignored in favor of a pharmaceutical intervention added to the failed dietary intervetion that remains unchanged and unchallenged.

The position of the ADA, concerning low-carb diets, was previously that there was no evidence of any benefit and only potential harm; in June that position suddenly changed when data was published finding statistically significant improvements, below target HbA1C levels and reduction and/or elimination of diabetes medications after following a truly low-carb diet for 22-months. The study was in addition to the dozens already in the literature that found benefit and improvement in those with diabetes; this one though was longer though and more difficult to dismiss.

Some may recall that in June I noted in ADA Acknowledges Low-Carb Diets Help Control Blood Sugar, that American Diabetes Association [ADA] spokesman Nathaniel G. Clark said in an updated WedMD article, "We want to promote a diet that people can live with long-term. People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time."

Which brings me back to the comments left and emailed.

I'll be the first to acknowledge starting and maintaining a carbohydrate restricted diet can be difficult. We live in a world that seems to revolve around carbohydrate foods - bread, potatoes, pasta, rice, corn - it's difficult to imagine a meal not including one or more of the above; and oftentimes difficult to imagine a day without something sweet.

Part of the problem, as I see it, is perspective; the other presentation.

We've been told for many years, and now firmly believe, that a healthy diet revolves around carbohydrate; and without the majority of calories provided by foods rich with carbohydrate a diet is somehow lacking and unbalanced for the long-term for essential nutrients, taste and palatability.

It's difficult for many to adopt a totally alien approach to eating - let's not kid ourselves, in the world we live, a low-carb diet is totally alien. Adding to the difficulty is the message that a low-carb diet is deficient, unhealthy, unbalanced, untenable, dangerous and a just a fad that is best ignored.

But such sentiments betray the evidence that shows statistically significant improvements in those who adopt and maintain a truly low-carbohydrate diet.

Much of the difficulty today is not so much the diet itself is difficult, it's that the message of fear and intimidation is so loud from the powers that be - they admit the evidence is there, but cannot bring themselves to follow through with an evidence-based appraoch and recommend it as an option, even cautiously.

I'm not insisting on a ringing endorsement here - what I want to see, and belive is a scientifically supported, evidence-based approach, is to present a carbohydrate restricted diet as an option to any individual diagnoised with pre-diabetes or type II diabetes.

It is true that not everyone is going to want to or be able to modify their diet, but for those who want to try and can, restricting carbohydrate may mean a life free from pharmaceuticals for years and every patient deserves to know the option is there and the evidence to-date is compelling.

It should be the patient's choice if they want to try the scientifically supported carbohydrate-resticted diet or follow the new algorithm of lifestyle intervention with medication.

At the moment, no choice exists while at least two options are supported by the evidence - the low-carb diet or the new algorithm.

Instead of providing healthcare professionals and patients with both options, they're being told not to bother with carbohydrate restriction because they can't do it anyway.

Rather than even cautiously communicate to patients that a potentially powerful dietary intervention may be an option they wish to weigh for risk and benefit, the ADA specifically cautions against a low-carb diet to both professionals in the healthcare community and patients.

An evidence-based approach demands that hard data over-ride opinion, consensus, and dogma.

In this instance, the data is there yet dismissed by those who know better and are tasked with the responsibility to objectively evaluate and review the evidence; they're able to admit the current-day management of diabetes has failed, yet unable to grasp why it has failed.

They're able to admit the data shows following a low-carb diet can result in improvements, yet are unable to bring themselves to even cautiously suggest it be weighed as an option, as a first-line non-pharmaceutical approach for those who prefer to exhaust options before starting a life-long regiment of drugs.

As I said earlier - perspective and presentation are at the heart of why the science is being ignored in favor of opinion.

Perspective here is the ADA holds that while the data from low-carb studies is compelling, no one wants to follow a low-carb diet. Throw in a few contextually inaccurate scare tactics along the way and the ADA has abandon evidence-based medicine and now holds their own opinions and beliefs higher than the data.

Repeat the message often enough, and the healthcare professionals, who would jump at the opportunity to offer the option of a low-carb diet to their patients who prefer a "diet-only" approach, are left with too little science and data to effectively use such an option in their practice.

Repeat the message often enough, and even those patients who would jump at the chance to make dietary changes to avoid taking medications are left with the impression that a low-carb diet isn't worth a second look due to the presentation of information they hear.

I understand the ADA position, that because the current-day management has failed, a more intense approach may slow the insidious progression of type II diabetes if implemented early.

I find it intolerable, however, that the ADA will not at least cautiously present the evidence that clearly finds when a low-carbohydrate diet is adopted and maintained, statistically significant improvements are realized in those subjects who comply with the dietary protocol.

We know and they know the current dietary recommendations are not a long-term benefit to those diagnoised with diabetes. We also know that the emerging data - both short and now long-term - from low-carbohydrate trials is compelling and supports it as an option. I can even live with a cautious option - but the continued dismissal of relevant data is not only irresponsible, but outright negligence!

The belief that no one wants to follow such a diet, or that few can in the long-term, is nothing more than the ADA deciding for the patient what course of management they will be offered and more specifically, the ADA abandoning evidence-based medicine and digging their heels into the muck of dogma and opinion.

Personally, if every person diagnoised with type II diabetes decided they prefer the pharamaceuticals rather than the diet, that's fine with me.

But, shouldn't it be up to the the patient to make that decision and not the ADA?