New “patient-centered approach” to treating diabetes

Each year a group called the European Association for the Study of Diabetes (EASD) hosts an annual meeting. This year’s meeting (the 48th) was in Berlin, Germany. And while I didn’t attend, you can bet I didn’t miss their biggest announcement…

Together with the American Diabetes Association (ADA), the EASD released a new position statement on the treatment of type 2 diabetes.

And indeed it was an eye-opener!

Their new recommendation to physicians is to adopt a “patient-centered approach” to treatment. One that puts the patient’s condition, desires, abilities, and tolerances at the center of the decision-making process. To essentially work with the patient to set the goals and methods of treatment.

Imagine that! A treatment approach that involves considering the actual patient, and not JUST the condition. What a revelation.

But, before you get too excited…

I’m all for allowing the patient to weigh in on their abilities and share their desires. But, if you ask me, this statement sounds more like a lot of back-peddling and less about “innovation” and “progress.” My guess is they’ve finally realized they’ve led patients and medical professionals astray. And rather than admit to it…it’s easier to turn the blame back on the individual.

Now, at one time, I’ll admit even I would fall into the trap of blaming the patient. But, as I’ve grown and changed both personally and as a practitioner over the years–through my patients, my research, and my involvement in the issues–my approach and my attitude continues to change over time as well (hopefully for the better). That’s one of the reasons I love writing these Reality Health Checks, by the way, so you can share in this growth with me.

But as I was saying…I, too used to blame the patient from time to time. But having had the opportunity to dive much deeper into the research on public policy this past year, I have come to realize that the “establishment” has a much greater influence on the public’s decisions about food and health than you could ever imagine. And this of course ends up influencing the food manufacturers on certain choices even more (and vice versa). It’s a vicious cycle. With you and me caught in the middle of it all–between government agencies, medical associations, Big Pharma (of course), and big food!

So, the public isn’t totally to blame.

Following is a great quote about the big announcement from a story on Medscape News:

“In light of the increasing complexity of glycemic management in type 2 diabetes and the wide array of antidiabetic agents now available, as well as uncertainties about the benefits of intensive glycemic control on macrovascular complications, a joint task force of the EASD and the ADA sought to develop recommendations for the treatment of nonpregnant patients with type 2 diabetes to help clinicians determine optimal therapies.”

Ok, ok…maybe it’s not such a great quote to read. After all, it’s way too long and filled with a lot of jargon. Not to mention a bunch of double-talk. So let me translate it for you…

“In light of the increasing complexity of glycemic management in type 2 diabetes…”

In other words: “We don’t know what to do because what we have told people to do is wrong.”

“…and the wide array of antidiabetic agents now available…”

In other words: “Big pharma is breathing down our necks to endorse more medications and to approve medications, despite the fact that many have been shown to be deadly shortly after being released.”

“…as well as uncertainties about the benefits of intensive glycemic control on macrovascular complications…”

Really?! It has been known for years that the risks of increasing glycemic control far outweigh the benefits.

“…a joint task force of the EASD and the ADA sought to develop recommendations for the treatment of nonpregnant patients with type 2 diabetes to help clinicians determine optimal therapies.”

In other words: “We don’t believe educated physicians can make decisions for themselves.”

Of course, even I have to admit, it’s not all bad… What you may not know is the drug companies have been pushing for what we call an algorithmic approach to medicine–or as I like to call it, “cookbook” medicine. And miraculously, these agencies are finally admitting here that it just doesn’t work. There are so many variables in the billions of people on this planet that one size does not fit all.

So their new plan is to have the physician and patient combine the best available evidence with clinical expertise and patient preferences to determine the course of treatment. Treatment that may include lifestyle interventions such as physical activity, and dietary advice.

Which of course, would be great if this were to actually happen. But let’s be realistic for just a minute…

As a regular practicing physician, I can’t help but ask…how will doctors have the time to create this dialog with their patients when insurance companies only give them 10 minutes per patient.

And when it comes to considering patient preferences, how realistic are they really going to be? After all, what do you think most patients are really going to prefer when it comes to diet and exercise?

If I had my way, I would eat ice cream every day–that’s my preference. But the fact is, it’s just not healthy and I’ve learned not to do it. And I have to tell patients every day that they can’t do things they may want to do in order to achieve and maintain their goals. But I also remind them that it can be easier than they think not to give into every whim. And that, with some practice and education the healthy things really will become their preferences.

I wish someone had told me that when I was younger, so I wouldn’t have this lifelong struggle that I do.

Here are a few more interesting points from the new position statement:

1. Diet, exercise, and education as the foundation of the treatment program. Physicians should encourage as much physical activity as possible, aiming for a minimum of 150 min/week, consisting of aerobic, resistance, and flexibility training.

   It’s hard for me to argue with this one!

2. If newly diagnosed patients are at or near the HbA1c target of less than 7.5% and they are highly motivated, they should be given a trial of lifestyle changes for 3 to 6 months with a goal of avoiding pharmacotherapy.

   Could it be? Are they really suggesting not placing people on medications? Keep reading…

3. But for patients with moderate hyperglycemia or for whom lifestyle changes are expected to be unsuccessful, anti-diabetic drug therapy, usually with metformin, should be initiated. If lifestyle efforts are eventually successful, drug therapy may be modified or discontinued.

4. First of all, how do you know they will be unsuccessful at lifestyle changes until they try? But ultimately, this one’s hard to believe. Discontinuing a medication? That’s sacrilege! Just don’t see it happening.

There is much more from this report…I have only begun to scratch the surface. And while I had a lot of fun picking it apart today, I do have to admit…it is refreshing to know that the agencies are finally beginning to understand that long-term care and goals are much more important than immediate changes in blood levels.

As I always say, we should be treating the patient and not their numbers.

Source:
Medscape. Oct 02, 2012.