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Evidence-Based Diabetes Management September 2015
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What "Behavioral Change" Looks Like From the Front Lines: Visiting Jefferson Hospital

Mary K. Caffrey
Evidence-Based Diabetes Management gained exclusive access to the Comprehensive Weight Management Program for a view of what "behavioral change" really means for patients overcoming obesity and for the clinicians managing their care.
Each of the 7 women took her seat at the table, and most waited for a single grocery bag to be dropped at her feet. A bundle that contains 800 calories a day for an entire week takes up remarkably little space, but none of the women in that room at Jefferson Hospital in Philadelphia, Pennsylvania, remarked on the size of the bags or their contents. 
They were not here to talk about food. That would come later. 
Before they would learn how to eat all over again, the women had to learn to recognize both the physiological and behavioral triggers that had brought them here in the first place. 
Their guide would be Cheryl Marco, RD, LDN, CDE, who has spent just over half of her 30-year career at Jefferson, where she is the director of its Comprehensive Weight Management Program. In that time, Marco has won awards from Optifast, coauthored peer-reviewed articles,1,2 and appeared at symposia to highlight the program.3
But most of her time is spent with patients—up to 100 a week. Many have tried and failed at other diets, having never fully grasped the meaning of “behavioral change.” The concept is mentioned often in papers and at conferences as the key to reversing the US crisis with diabetes and obesity.
The terms “behavioral change” and “obesity” appear together in 132 articles in PubMed, including 39 just since 2013.And yet behavioral change remains elusive for many of the 78.6 million Americans that CDC estimates are obese in the United States.
Jefferson Hospital allowed Evidence-Based Diabetes Management to visit with Marco and with Lisa Coco, CRNP, CDE, to learn what “behavioral change” means to those on the front lines at an urban hospital. While Marco works with patients who have tried almost everything to lose weight, Coco’s patient population includes “the toughest of the tough.” Jefferson’s Department of Endocrinology, Diabetes and Metabolic Diseases works with patients with both type 1 (T1DM) and type 2 diabetes mellitus, including those enrolled in clinical trials.
While Coco said some of the newer therapies, especially sodium glucose cotransporter-2 (SGLT2) inhibitors, are effective in helping patients with diabetes achieve glycemic control, creating and sustaining behavioral change are hard work, and socioeconomic factors make a huge difference. It’s essential to encourage patients to eat properly and exercise—and Coco emphasized the need to encourage them, because therapy alone is not enough. As the CDC’s Ann Albright, PhD, RD, put it last spring in launching the Prevent Diabetes STAT initiative: “You can outeat any medication.”6
The women had come on this particular day to talk about willpower, which Marco described as a muscle: It is strongest early in the day, and it gets weaker as people tire, as stress accumulates, and as the number of decisions mounts throughout the day. Understanding willpower, said one woman, had taught her to steer clear of a certain Chinese restaurant during trips through her neighborhood. “I don’t walk that way any more,” she said. 
In a separate interview, Marco said that participants in the weight management program learn specific strategies: Grocery shopping should be done early in the day, when it’s less tempting to buy unhealthy snacks. These hours are also a good time for preparing evening meals to be eaten later; cooking when one is hungry makes it easy to indulge while cooking. Much of behavioral change means learning to plan ahead to reduce the number of late-day decisions, Marco said; this limits the opportunity for unplanned eating in an impulse-driven culture.
Behavioral change also means making one’s health a priority, instead of being overwhelmed by work and family matters. “Every single one of us is putting our job before ourselves,” a woman told the group, as the rest nodded in agreement. Another shared how she sat her husband and daughter down to set the ground rules when she started Jefferson’s program—if she would be following an 800-calorie diet for 12 weeks, they would have to cook their own meals for a while. “Kids have to be told,” she said.
The patients who come to Marco typically have a body mass index of 30 or higher; most are women, and many are motivated after experiencing a health scare related to their weight. The program requires a commitment of time and money. The full program, which has 3 phases, costs $600 for 8 months; patients also spend $105 a week on replacement meals for the first 12 weeks, which is offset by what they are not spending on food at home. The program is not covered by insurance. All must attend an orientation session and have medical clearance to participate.
For the first phase, each participant is required to take part in weekly counseling sessions. The early sessions are not about food—topics include the genetics and physiology of obesity, as well as metabolic syndrome. Patients also learn “why we are biologically driven to eat what is in front of us,” Marco said.
When patients understand the science behind their size, “It’s a huge relief for the patient to learn that this is not a character flaw,” Marco said. “I’m not overweight because I’m an inferior human being.’”
Why meal replacement for weight loss? Marco said the strategies for weight loss and long-term weight management are not the same; for patients with diabetes, taking the pounds off quickly can mean getting them off some medications (Jefferson’s program advertises an average 15% to 20% weight loss). This can mean reducing side effects and even putting money back in their pocket. 
Once patients have completed the first 12-week phase, they transition to a second phase, called “Beyond Diets,” which includes sessions on carbohydrates, superfoods, meal planning, and how to eat in restaurants. These classes enroll a mix of graduates from the 12-week meal replacement program and others who simply want to learn about healthy eating; some are patients with diabetes referred by Coco. A third phase, for maintenance, provides long-term support for keeping weight off.

Lisa Coco is running late. She rounds the corner at full speed, while her face stays turned in the direction of her last patient, as she gives a final set of instructions. 
Twenty minutes per person is not enough for much of the population Coco serves, which includes some of Philadelphia’s poorest and sickest patients who start out with glycated hemoglobin (A1C) readings of 14% or higher. Coco sees wealthier patients, too, and she’ll tell you upfront that it’s easier to lose weight and get diabetes under control when you live on the higher end of the economic ladder.
“I don’t like treating people off an algorithm, because every single person is truly different,” she said. “This patient I just saw—this is why I was late—she has an adult child in her 30s who is autistic.”
Coco knows that the challenge of caring for the adult child affects the patient’s ability to manage her diabetes. “There are so many factors,” she said, still catching her breath. For patients on Medicaid, simple things like getting testing supplies covered can be a challenge. 
Coco holds a copy of a blood sugar chart and shows how the patient had recorded a blood sugar reading each day, giving Coco valuable information to direct her treatment. “Labs are great, but I need sugars,” Coco explained. When a patient has trouble getting testing supplies, “I have to write letters; I know how to work around it. But it’s a huge issue.”
She sees inner-city grandparents who are caring for grandchildren, patients who are overweight who she knows would benefit from talking a daily walk. “But if you walk outside, you may take a chance that someone is going to mug you or beat you up.” The violence is why Coco sees young patients who are overweight, from being inside playing video games.
In her view, getting overweight diabetic patients to exercise is more difficult than getting them to change their diet, in part because of these barriers. A daily swim in a pool would do wonders for her patients who need knee replacements, but for many, “there’s absolutely no access.” 
But when Coco can get patients with diabetes to exercise, it works. “Walking is the single best thing; it uses the excess sugar in the blood.” She tries to get patients to start with a 10-minute walk and gradually increase the time; later, she encourages them to walk with half-pound weights.
Praise works, and so does understanding that progress may be measured in small steps, Coco said. “Once in a while you get through.”

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