Introduction

Type 2 diabetes mellitus (T2DM) is a metabolic disorder characterized by chronic hyperglycemia due to defects in insulin secretion and/or action [1]. The prevalence of diabetes has reached alarming levels worldwide. In 2014, the World Health Organization (WHO) reported that 422 million people were living with diabetes, with 3.7 million annual deaths attributable to diabetes and its complications [2].

A major challenge in diabetes management is ensuring patient adherence to treatment and lifestyle recommendations [3]. Patient non-compliance with medications is widespread and is linked to poor glycemic control, higher hospitalization rates, and increased mortality [4]. Psychosocial factors, including depression, diabetes-related distress, and health beliefs, often contribute to suboptimal self-care in diabetes [5]. Therefore, interventions targeting behavior change and psychological support have gained attention as complements to standard medical therapy.

Cognitive behavioral therapy (CBT) has been explored as a strategy to improve diabetes outcomes [6, 7]. CBT is a form of psychotherapy that helps individuals modify dysfunctional thoughts and behaviors, which in the context of diabetes can translate to better medication adherence, dietary habits, and coping strategies.

We identified and analyzed a series of five cases from a primary care clinic in which a CBT-inspired behavioral-metabolic approach was being applied in routine care. The behavioral component was not a formal, manualized CBT protocol. All counseling was delivered by the treating physician, who applied selected CBT principles, including cognitive reframing, problem-solving training, and structured goal setting, to support adherence to diet, medication, and lifestyle. The same core behavioral framework was applied to all patients, but session content was individualized based on each patient’s difficulties. Because no standardized CBT manual was followed, we describe the intervention as CBT-inspired rather than formal CBT. The CBT-inspired protocol was delivered by the treating physician as part of routine care at a primary care clinic. The physician is a family physician with a public health specialty and extensive experience in diabetes care and patient-education programs.

The basic principles of the CBT-inspired program in addressing T2DM adopted by Dr. BAM:

• 1.

  Cognitive behavioral training program:

  • a.

    Sessions of explaining the diabetes, current disease status, treatment goals, medications being given, and involving the patient totally, and explaining all aspects of illness.

  • b.

    Provide an open channel for patients’ support, questions, and concerns (e.g., Facebook^®, WhatsApp^®, phone calls).

  • c.

    Regular follow-up for adherence check, reinforcement, reassurance, and encouragement.

• 2.

  Medication optimization:

  • a.

    Stop using any drug acting mainly on the pancreas.

  • b.

    Withdrawal of any type of insulin gradually.

  • c.

    Using alternative drugs acting on the liver, intestinal tracts, and kidneys.

  • d.

    Vitamin B12 will be supplied because of possible deficiencies after medications.

• 3.

  A structured low-carbohydrate diet:

  • a.

    Patients were educated to avoid simple sugars and refined carbohydrates, focusing instead on vegetables and lean protein.

  • b.

    They were advised to limit fruit intake (due to high fructose content) and eliminate sugar-sweetened beverages and trans fats (hydrogenated oils) from their diet.

  • c.

    The eating pattern was modified to only two meals per day (a late morning meal around 11 AM and an early evening meal around 6–7 PM) with no snacks in between.

  • d.

    If hunger arose between meals, patients could have water, unsweetened tea (green or black), or a simple salad as alternatives.

• 4.

  Lifestyle modification:

  • a.

    It is recommended to practice an evening walk for at least 20 minutes.

  • b.

    It is recommended to sleep at least 7 hours/day.

• 5.

  Preliminary consent of the service user in using the program and to fully cooperate with the training physician.

• 6.

  The service user is aware of his illness, and he must participate actively in decision-making and self-management.

• 7.

  Looking for social support services for patients incapable of buying medications.

The rationale for combining behavioral counseling, aggressive dietary restructuring, and medication optimization was to simultaneously address three contributors to uncontrolled diabetes: behavioral barriers, excessive carbohydrate intake, and pharmacologic overstimulation of insulin secretion. This integrated strategy is consistent with recent American Diabetes Association (ADA) recommendations favoring weight glycemic control and use of agents with cardiovascular and renal benefit [8, 9]. Hence, the present report was motivated by the observation that this real-world clinical practice was producing outcomes that appeared disproportionate to the available resources and warranted formal scientific description and contextualization within the existing literature.

Timeline

The key clinical characteristics, intervention components, and outcomes for all five cases are summarized in Table 1.

Narrative

Diagnostics

A full clinical assessment was performed for all patients at baseline and follow-up, including laboratory evaluation (HbA1c, renal function, lipid profile when available), anthropometric measures, and BP monitoring. Laboratory tests were performed in accredited local laboratories following standard reference ranges.

Case 1 (F, 78 y)

• Baseline: HbA1c 11.7%; weight 97 kg; serum creatinine 1.4 mg/dL; long-standing T2DM.

• Follow-up: HbA1c 6.1%; weight 90 kg; creatinine 1.1 mg/dL.

Case 2 (M, 55 y)

• Baseline: HbA1c 11%; obesity; erectile dysfunction; normal vital signs.

• Follow-up: HbA1c 6.7%; weight −5 kg; symptomatic improvement.

Case 3 (M, 45 y)

• Baseline: HbA1c 14.5%; weight 115 kg; long-standing insulin dependence; surgery deferred due to hyperglycemia.

• Follow-up: HbA1c 8.1%; weight 98 kg; cleared for surgery; improved functional status.

Case 4 (F, 50 y)

• Baseline: HbA1c 14.5%; weight 118 kg; hypertension; LDL 285 mg/dL.

• Follow-up: HbA1c 9.0%; weight 110 kg; LDL 196 mg/dL; improved BP control.

Case 5 (M, 58 y)

• Baseline: HbA1c 11.4%; weight 122 kg; serum creatinine 1.7 mg/dL; hypertension; dyslipidemia; edema.

• Follow-up: HbA1c 7.1%; weight 108 kg; creatinine 1.1 mg/dL; improved BP and reduced edema.

All laboratory measurements were performed at accredited local laboratories.

Patient perspective

Patient perspectives were obtained through open-ended questions during routine follow-up visits and documented in the clinical notes. No validated questionnaire was used, and responses were summarized qualitatively. Themes were summarized descriptively from clinical notes; no formal coding was done. All participants reported a sense of empowerment from understanding the behavioral logic behind glucose fluctuations. Several described improved family relationships and self-esteem. They felt they were controlling their disease themselves, not the disease controlling them. One of the patients reported, “I feel like I have no diabetes anymore”. Most patients reported the same themes.

Discussion

This case series represents an analytical examination of a real-world behavioral-metabolic practice observed in a routine primary care setting in a low-resource environment. Although the uncontrolled design limits causal inference, several consistent patterns across the five cases help illuminate how structured behavioral support, carbohydrate reduction, and rational medication adjustment may work together to improve glycemic control.

This case series illustrates that marked short-term metabolic improvement is achievable in severely uncontrolled T2DM within routine primary care when three levers are pulled together: (1) a clear behavioral structure that builds adherence and self-efficacy, (2) a significant reduction in dietary glycemic load with simplified meal timing, and (3) pharmacotherapy aligned with insulin-sparing, cardio-renal-protective principles. Across five patients with very high baseline HbA1c, the magnitude and consistency of HbA1c reduction, weight loss, and improvement in symptoms and cardio-metabolic markers suggest a synergistic effect that exceeds what would be expected from any single component delivered in isolation.

A central interpretation is that the “CBT-inspired” element functioned less as psychotherapy and more as an adherence and problem-solving framework embedded into medical care. In uncontrolled diabetes, the barrier is often not knowledge of “what to do” but the repeated failure to translate intentions into daily decisions under stress, social pressure, habitual eating, and low perceived control. The counseling approach in these cases explicitly targeted those barriers: patients were guided to reinterpret glucose readings as feedback rather than failure, to identify triggers for nonadherence, to create practical coping plans, and to set observable short-term goals. This aligns with evidence that CBT-based interventions improve diabetes distress, depressive symptoms, treatment adherence, and quality of life in adults with T2DM, with modest improvements in HbA1c when CBT is delivered as a stand-alone intervention [6]. In the present series, the behavioral component likely amplified the impact of dietary and medication changes by reducing “behavioral dropout”, strengthening self-monitoring, and sustaining consistency long enough for metabolic improvements to emerge [10, 11].

Medication adjustments aligned with contemporary American Diabetes Association Standards of Care, which emphasize person-centered selection of glucose-lowering agents with proven cardiovascular and renal benefit and recommend minimizing use of agents associated with hypoglycemia and weight gain, such as sulfonylureas, when effective alternatives are available [12, 13]. The medication rationalization strategy, particularly favoring reduced reliance on insulin secretagogues, may have complemented the metabolic effects of dietary change [14, 15]. As the current series is not about judging guidelines or testing specific therapies, the aim was to use an insulin-sparing approach [16].

Dietary restructuring and meal timing were likely major drivers of rapid glycemic change [17]. A strict reduction in refined carbohydrates coupled with a defined two-meal pattern may reduce post-prandial glucose changes, simplify decision-making, and extend fasting intervals that can improve insulin sensitivity in some individuals. Unlike complex diet prescriptions that require extensive counting or frequent meal planning, the two-meal structure is cognitively simple: fewer eating episodes, fewer opportunities for glycemic spikes, and fewer moments requiring willpower. Studies in T2DM have shown that reduced meal frequency and time-restricted eating can improve weight and glycemic control [18, 19], and systematic reviews support the potential of low-carbohydrate strategies for diabetes improvement and, in some cases, remission [20, 21]. Resembling the intermittent fasting techniques, which have been proven for their efficiency in controlling weight and improving blood sugar [22–25]. This approach aimed to reduce continuous glycemic spikes and possibly improve insulin sensitivity by extending the fasting interval between meals [17, 26, 27].

Each patient underwent individualized educational sessions to understand the nature of T2DM, the impact of diet and exercise, and the rationale behind their medication changes. Misconceptions and beliefs (for example, passive attitudes about diabetes or doubts about their ability to influence their health) were addressed through cognitive techniques. Patients were guided to set realistic goals and to self-monitor their blood glucose and adherence. The primary care physician regularly engaged patients in problem-solving discussions to overcome barriers, thus applying CBT principles to enhance self-efficacy and motivation.

The program emphasized the patient’s active role and required a preliminary commitment from the patient (and family, when applicable) to adhere to the plan. Follow-up visits were scheduled approximately every 4–6 weeks to monitor progress, reinforce behavioral changes, and adjust the plan as needed. Social support was encouraged; family members were involved in diet planning and reminded to provide encouragement rather than tempting the patient with non-compliant foods. No formal control group was used, but each patient served as their own control by comparing baseline and follow-up outcomes. Patients were able to contact the physician for questions and concerns, in addition to receiving support whenever they needed, which helped in reinforcing the behavioral changes and counseling.

Medication optimization may have complemented these behavioral and nutritional changes by removing therapies that can conflict with weight loss efforts and by prioritizing agents that support cardio-renal outcomes [28]. Insulin and sulfonylureas can cause low blood sugar and weight gain. When patients experience hypoglycemia, they often become afraid of it happening again. This fear can lead them to eat more carbohydrates “just in case,” even when they are not hungry. By reducing these medications in appropriate patients, this fear may decrease, making it easier for patients to follow dietary recommendations [18, 29]. Meanwhile, continued use of metformin and selective addition of dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium-glucose cotransporter-2 (SGLT2) inhibitors provided glucose-lowering support with a lower hypoglycemia burden and potential renal and cardiovascular benefits, broadly consistent with contemporary guideline directions [30, 31]. Importantly, the approach in this series suggests a practical clinical sequencing: medication de-intensification (especially insulin tapering) becomes more plausible when dietary glycemic load is first reduced, and follow-up is sufficiently close to respond to early instability.

Quality-of-life changes reported by patients, improved energy, reduced fatigue, improved erectile function, and a subjective sense of “control”, matter clinically because they likely act as reinforcement loops that sustain behavior change. For many patients, early symptomatic improvement is more persuasive than abstract risk reduction. Weight loss and improved glycemia are both associated with better sexual function and general well-being in T2DM, and the present narratives suggest that symptom relief may have strengthened motivation, creating a self-reinforcing cycle: adherence, improved readings/symptoms, higher self-efficacy, continued adherence [32, 33].

“Remission” of diabetes is discussed in the medical literature [34–36]. Some patients in this series approached remission criteria; longer-term follow-up is needed before such a conclusion can be drawn. Even if patients can discontinue diabetes medications, they remain at risk for hyperglycemia if healthy behaviors are not maintained. The outcomes of this series are consistent with the findings of large lifestyle-focused trials such as the DiRECT study, where intensive diet-induced weight loss led to diabetes remission in a significant proportion of patients [37, 38]. However, our approach differed by explicitly incorporating CBT-inspired techniques to reinforce adherence. Unlike classical CBT protocols targeting comorbid depression, our program applied behavioral principles to diabetes self-management more broadly. This aligns with a growing body of evidence that psychosocial interventions can support diabetes remission when combined with metabolic strategies [39, 40].

A notable aspect of this case series is the setting: a primary care clinic in a low-resource region such as Palestine, where access to multidisciplinary diabetes services, dietitians, psychologists, and diabetes educators is limited [41, 42]. Prior observational work in similar contexts shows that simplified, physician-delivered behavioral and nutritional programs can achieve meaningful improvements when more intensive services are unavailable [43, 44]. The consistency of the present outcomes with the literature suggests that structured counseling delivered by an experienced primary care physician may be a pragmatic, scalable strategy for systems that lack specialist infrastructure. This aligns with global recommendations emphasizing behavioral counseling and carbohydrate reduction as first-line interventions that can be delivered in primary care [45].

The magnitude of HbA1c reduction observed in this series (ranging from 38 to 48%) is substantially greater than the 1.0–1.5% mean reductions typically reported in pharmacological trials. This finding should be interpreted in the context of extremely high baseline HbA1c values and the concurrent implementation of multiple interventions, including intensive carbohydrate restriction and the use of insulin-sparing therapies such as metformin and SGLT2 inhibitors, in patients with marked insulin resistance or failing prior regimens.

Although rapid glycemic improvement has historically raised concerns regarding early worsening of diabetic retinopathy, particularly when achieved through insulin intensification, emerging evidence suggests that in patients with very poor baseline glycemic control, early normalization may reflect reversal of glucotoxicity rather than pathological overcorrection. Importantly, the present case series does not permit conclusions regarding long-term microvascular or mortality outcomes, and sustained benefits require confirmation through longer follow-up and controlled study designs [46].

As with all case series, the findings must be interpreted cautiously. The small sample size (five patients from a single clinic) limits generalizability, and the absence of a control group limits conclusions about causality [47]. The patients included may represent self-selection, as motivated patients might be more willing to participate in the program. The magnitude of glycemic improvements likely reflects the synergy of multiple interventions rather than CBT alone. The short follow-up period prevents assessment of long-term sustainability or relapses. Moreover, psychological outcomes were not assessed using validated tools, and follow-up durations varied between cases (3–6 months, although follow-up visits were scheduled every 4–6 weeks; real-world variability occurred based on patient availability and clinical need), limiting conclusions about the specific mental health benefits of CBT. In addition, safety monitoring should have been more intensified, as combining strict carbohydrate restriction with SGLT2 inhibitors may increase the risk of euglycemic diabetic ketoacidosis in certain contexts, which did not occur in the current series. As multiple components were delivered simultaneously, this case series cannot determine the independent effect of CBT-inspired counseling. The behavioral component likely functioned as an adherence-support mechanism for diet and pharmacotherapy, consistent with literature showing that psychosocial engagement enhances diabetes self-management. The heterogeneity of patients in this series, including differences in age, disease duration, comorbidities, baseline treatments, and social circumstances, limits generalizability. Outcomes may reflect a combination of high patient motivation, close follow-up, and context-specific factors that may not be reproducible in broader populations. As a descriptive case series, the findings should be viewed as hypothesis-generating rather than confirmatory.

Future research should test this integrated model in a prospective design with standardized behavioral content, predefined safety monitoring, and longer follow-up. Practical next steps include: (1) a pilot pragmatic trial in primary care comparing this structured behavioral-metabolic package to usual care, (2) measurement of adherence, diabetes distress, and self-efficacy using validated scales, and (3) evaluation of durability at 12–24 months with standardized remission criteria. If efficacy and safety are confirmed, such an approach could offer a realistic pathway to large glycemic improvements and potential de-intensification of therapy in settings where patients have limited access to multidisciplinary resources.

The approach used here (brief structured behavioral counseling, defined meal timing, carbohydrate reduction, and medication rationalization) may offer a feasible model for integration into routine practice, especially in low-resource settings. Potential barriers include limited consultation time and variability in patient engagement. Future work should evaluate whether similar metabolic improvements can be sustained long term and whether outcomes can be replicated in broader populations.

Conclusions

This case series provides real-world evidence that intensive behavioral and medical interventions can lead to improvements in uncontrolled T2DM. Although causality cannot be established, the cases highlight both the potential for diabetes remission in routine practice and the importance of incorporating behavioral principles into standard care. Future controlled studies are needed to disentangle the relative contribution of CBT components, validate long-term sustainability, and determine how such programs can be systematically integrated into health systems.