Article Type : Short commentary
Authors : Wood M, Ebe K and Bando H
Keywords : Japan LCD Promotion Association (JLCDPA); Non-Adherence; Healthcare System; Polypharmacy; Nutrition; Low-carbohydrate diet (LCD)
Non-adherence to medical and dietary therapy can hinder effective therapy and lead to poor outcomes in diabetic patients. Adherence is multi-factorial and related to socioeconomic, healthcare system, medical condition, co-morbidities, therapy polypharmacy, complexity, and patient. Explanations for adherence can be broadly divided into intentional and non-intentional. Unfortunately, data about adherence to diabetes medications are limited and mostly observational. Focusing on social aspects of common reasons for non-adherence may contribute to improved adherence in diabetes patients. The Japan LCD Promotion Association (JLCDPA) has been promoting comprehensive diabetes education since 2013. Organizations affiliated with the JLCDPA provide instruction on nutrition, low-carbohydrate diets (LCDs), food, cooking, well-being, medical devices, and more
Type
2 diabetes (T2D) is a growing problem worldwide. Sequelae from diabetes cause
great societal and individual burdens. Adherence to therapeutic regimens can
lessen these burdens. Reasons for non-adherence are variable and multifactorial
and can be divided into intentional and non-intentional factors. As a result,
data studying adherence are limited to mainly observations that are muddied by
a platitude of factors that can be seen in Figure 1. For example, depression
appears to be bi-directional with diabetes sequelae, while patients with
pre-existing depression appear to experience more sequelae [1]. One of the most
cited reasons for non-adherence is the complexity of therapy. Only one-third of
T2D patients were compliant with their OHAs in a retrospective cohort study
where an inverse association between the number of tablets and adherence was
found [2]. Another study claims that adverse effects (AEs) and perceived drug
efficacy better explain non-adherence than polypharmacy alone [3]. The authors
of a 483-participant cross-sectional study found adherence to diabetes
medications to be 63.1% and largely determined by self-efficacy and social
support intertwined with patient neuroticism [4]. A systematic review concluded
that drug toleration, dosing frequency, depression, and doubts about drug
efficacy all contribute negatively to adherence [5].
Sequelae
of diabetes usually occur years after the initial diagnosis. As a result,
patients may be relatively asymptomatic and can hold false beliefs about their
disease status. Understanding the pathophysiology of the disease, mechanisms of
therapy, and role of therapy could help patients ease doubts about drug
efficacy. Socioeconomic issues are very complex, are associated with education
status, and are likely to be improved with education as well.
Rational for LCD Education and
Measuring Dietary Adherence
Patient education is the number one method to combat non-adherence. Dietary adherence in T2D patients was compared between a low-carbohydrate, ketogenic diet (LCKD) and a low-glycemic index diet (LGID) in a 24-week-long randomized clinical trial [6].
The
LCKD group was told to eat ad libitum while the LGID group was told to eat at a
daily 500 kcal deficit. Both groups utilized lay-press diet books, handouts,
and dietician guidance. Adherence was comparable between groups as 21 of 38
LCKD participants (55.3%) and 29 of 48 LGID participants (60.4%) completed the
trial. The rates of adherence in this study are comparable to studies on
diabetes medication adherence [2,4,5]. The primary tool that we use is dietary
intervention with the LCD. There are increasing data to support the LCD as a
highly effective and safe treatment modality for diabetes [7]. Interestingly,
the LCKD had greater improvements over the LGID in HbA1c (-1.5% vs -0.5%, p =
0.03), body weight (-11.1 kg vs -6.9 kg, p = 0.008), and medication reduction
or elimination (95.2% vs. 62%, p <
0.01) in the study mentioned above [6]. We also observed weight, triglycerides,
and glycemic control improvements in 2,699 subjects with diabetes, metabolic
syndrome, or both when implementing a strict LCD [8]. Adherence to medications
is typically done by patient self-reporting or pharmacy records. Diets can be
monitored via self-reported recall, diet journals, recall questionnaires, urine
urea to creatinine ratio, and ketone body measurements, among other methods
[9]. The variability in reported adherence is because patients can feel social
pressure to report a certain way or have difficulty recalling what they ate.
Blood ketone levels are increased to about threefold in four to five days [8].
For these and other reasons, we rely on serum acetone, serum 3-hydroxybutyrate,
and urine ketone bodies, among other biomarkers, to monitor super LCD adherence
(Figure 2).
LCD Education and Implementation
The JLCDPA is a non-profit incorporated association founded in 2013 that aims to provide a wide range of diabetes treatment and treatment services to medical professionals, people with diabetes, people with pre-diabetes, and the families of diabetes patients.
There
are 75 affiliated clinics and hospitals associated with the JLCDPA. Numerous
cooperative organizations provide low-carbohydrate-related food, support, or
services. Biannual LCD journals and frequent mail magazines are disseminated.
Seminars geared toward medical professionals, and cooking workshops are
continuously being organized. Social media and online videos are also provided
free of charge by the JLCDPA and its affiliated organizations. The JLCDPA has
four main goals to achieve through promoting LCDs:
1. Decrease
in complications and deaths due to diabetes
2. Diabetes
prevention and early detection of pre-diabetes
3. Eradicate
the health damage caused by the spread of diets with little medical evidence
4.
Significant reduction in medical costs
Not
every patient will require the same degree of rigidity, so we have separated
LCD into three tiers based on a percentage of total dietary carbohydrate
intake. Super LCD, standard LCD, and petit LCD are defined as 12%, 26%, and 40%
of daily caloric intake from carbohydrates, respectively [10]. Giving
flexibility to patients based on disease severity and preference could improve
dietary adherence. Simple instructions are helpful to prevent non-intentional
causes of non-adherence as well. Super LCD, standard LCD, and petit LCD can be
explained by limiting carbohydrate-rich foods (e.g., rice, bread, and pasta) to
0, 1, or 2 meals a day, respectively (Table 1). There is also an LCD food
pyramid to give patients visual context [11]. Takao Hospital provides 2 to
4-week-long comprehensive inpatient education and treatment for diabetes
patients. Intervention with the traditional CRDs is given for 2 days, followed
by the super LCD for either 12 or 26 days depending on the length of stay.
During this time the patient’s glucose is monitored by CGM to optimize the
diabetes regimen. Registered dieticians extensively discuss dietary goals.
Wellness is integrated via counselling, tai chi, and community building. In
brief, patients learn the basic pathophysiology of diabetes, how diet and
medications affect blood glucose, the benefits of good glycemic control, how to
monitor disease status, and how to utilize all available resources. In
conclusion, adherence to medication and dietary therapy is essential for
positive outcomes in diabetic patients. Data studying adherence in diabetes
therapy are limited. Variability in reported adherence can be variable among
studies due to differences in how adherence is measured or the population of
the study.
Strategies
to improve adherence are likewise varied and patients are likely to benefit
from simpler customized plans. LCDs can lower the number of medications and
make adherence easier to achieve. Comprehensive diabetes education from
abundant affordable and free easily accessible high-quality sources is
important. Addressing social issues and personal well-being is likewise likely
beneficial. We hope that this review can bring more attention to unravelling
questions regarding adherence and guide progress in understanding and improving
diabetes therapy adherence.