What "Behavioral Change" Looks Like From the Front Lines: Visiting Jefferson Hospital

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 2013.⁴ And yet behavioral change remains elusive for many of the 78.6 million Americans that CDC estimates are obese in the United States.⁵

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.

“EVERY PATIENT IS TRULY DIFFERENT”

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.”

“ARE THEY IN THE TRENCHES LIKE ME?”

The promise of the new therapies to treat diabetes has been tempered by efforts to hold down costs, which may not be fully explained to providers like Coco. A trend among pharmacy benefit managers (PBMs) to seek discounts by offering exclusive deals for a single therapy in a class means constant change for those on the front lines. A patient who is doing just fine on a new SGLT2 inhibitor or injectable often has to shift to a new one—typically at the start of a new calendar year—if the health plan or PBM changes to a different preferred therapy.

But Coco remains enthusiastic about many of the new therapies, especially the SGLT2 inhibitors. Glycemic control is excellent relative to other therapies and so is adherence, she said. Plus, the class works with all insulin types, which makes prescribing easier. Coco said her experience is consistent with reports in Evidence-Based Diabetes Management that the class has positive effects on hypertension, so therapy for high blood pressure can be reduced or eliminated.⁷

Coco said she wishes she had grant funds to send her most motivated patients to the full schedule of food classes that Marco teaches. While she believes the price is a great value, “for people on Medicaid it’s not affordable.”

As much as she can, Coco takes time to teach her patients about diet, exercise, and the connections to their diabetes and weight gain. “An informed patient is someone who does better,” she said, and unfortunately, sometimes physicians are not well suited to the task. “Overweight patients are not taught, and they are instantly judged,” she said. “With someone like Cheryl or me, it’s different. I can’t tell you how many times patients have written to me, ‘Nobody’s ever explained this to me. No one has ever told this to me.’”

She has heard about movement toward value-based reimbursement, and not everything she has heard makes her happy. CMS has announced that starting in 2016, 30% of all Medicare reimbursement will be tied to alternate payment models, with that share rising to 50% by 2018. Coco shares the concern among clinicians at urban hospitals that even if they achieve significant progress with their patients with diabetes, the American Diabetes Association targets for A1C of < 7% and < 8% for certain populations (history of hypoglycemia, limited life expectancy, or vascular complications) may be out of reach.⁸ (The National Quality Forum standard used by CMS to rate accountable care organizations is < 8%.) CMS’ failure to account for populations that urban teaching hospitals serve is a source of some controversy; an August article in Health Affairs found that 1 in 3 teaching hospitals was penalized under all 3 such measures used by Medicare.⁹ A study presented in March 2015 at the annual meeting of the American College of Cardiology raised similar concerns; it found that urban teaching hospitals scored higher than suburban counterparts on quality measures for treatment of myocardial infarction but still had higher mortality rates because of the underlying health conditions of the populations they served. The study’s presenter, Jacob A. Udell, MD, PhD, said the implications for CMS reimbursement policies are significant.¹⁰

For Coco, such policies ignore the time it takes to care for and educate the very ill patients who come to her clinic: “If I start with an A1C of 14% or 16%, even 18%, and I get them down to 9% or 10%, I’ve done a really good job,” she said. “That might be all I’m going to be able to get them to.”

“I’m only supposed to get 20 minutes for an appointment—sometimes I stay 40 minutes.” Some of her patients are “65 years old; they need a knee replacement&mdash;they’re not going to go run a marathon. I have them doing chair exercises. But I’m not going to get reimbursed because I didn’t get them to 7%? That’s very upsetting. That’s so wrong,” she said.

“These people making the rules—are they clinical? Are they in the trenches like I am?”

”I KNOW MYSELF SO WELL NOW”

Cheryl Marco doesn’t let people off the hook. She asks each participant in the Comprehensive Weight Management Program to state why he or she wants to lose weight, and vague answers like “health” are not allowed.

She recalls 1 severely overweight patient with T1DM, who arrived with an oxygen tank and a wheelchair. The woman’s goal: She wanted to shop for clothing at a regular department store, “like Macy’s.” As the pounds came off, the oxygen went first, then the wheelchair. “The day she was able to drive here was a cause for celebration,” Marco said.

But the woman was not finished. She was not satisfied until she had lost enough weight to shop in a department store, freed from the “plus size” department. “Things like being able to tie your own shoes—not having to buy shoes with Velcro&mdash;things like being able to ride the rides at the amusement park&mdash;those things help people stay motivated along the way,” Marco said.

Identifying those interim benchmarks, such as getting into a pair of high-heeled shoes, helps patients stay focused on their goals. And that’s important when a coworker brings in donuts or friends try to lure them into eating things they shouldn’t.

Most of all, Marco’s sessions help those who have struggled with their weight for years, or perhaps all their lives, to get past the self-blame that is so common. “When you’re in a room with 10 to 12 overweight people, there’s a lot of negative self-talk going on,” she said. “There are problems that have to be solved if they are going to be successful.”

The session on willpower seemed less about Marco telling the women what to do than drawing out of them what they could do for themselves. One woman had stopped driving to the meeting to save money on parking, and soon realized how changing buses and walking added up to plenty of exercise. Another told her family to stop leaving bread on the counter. A third admitted that she now looked forward to the daily weigh-in that Marco recommends to keep track of progress.

After years of feeling they had no control over their weight, the women knew what to do. Said one, “I know myself so well now.”

References

1. Cheryl Marco, RD, LDN, CDE, Inspire Award Winner. Optifast website. https://www.optifast.com/Pages/inspiration/contest/inspire-award-winners/cheryl-marco.aspx. Accessed August 10, 2015.

2. Simon B, Treat V, Marco C, et al. A comparison of glycaemic variability in CSII vs. MDI treated type 1 diabetic patients using CGMS. Int J Clin Pract. 2008;62(12):1858-1863.

in-diabetes-prevention-treatment-research-to-descendat-Jefferson-Symposium.aspx. Philadelphia, PA: Jefferson Hospital; October 7, 2013.

4. Search of terms “behavioral change” and “obesity” in PubMed on August 10, 2015.

5. Adult obesity facts. CDC website. http://www.cdc.gov/obesity/data/adult.html. Updated June 16, 2015. Accessed August 10, 2015.

6. Caffrey MK. AMA, CDC launch Prevent Diabetes STAT to prevent more cases of type 2. Am J Manag Care. 2015;21(SP5):SP152.

7. Smith A. Studies are showing SGLT2s also help control hypertension, eliminate some side effects. Am J Manag Care. 2015;21(SP5):SP156-SP157.

8. Executive Summary: Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014; 37(suppl 1):S5-S13.

9. Kahn CN, Ault T, Potetz L, et al. Assessing Medicare’s Hospital pay-for performance programs and whether they are achieving their goals. Health Aff. 2015;34(8):1281-1288.

10. Caffrey MK. Hospitals in low-income areas scored high in MI care, even if patients had poor outcomes. Am J Manag Care. 2015;21(SP7):SP233.

3. Renowned leaders in diabetes prevention, treatment, research to descend at Jefferson Symposium [press release]. http://www.news-medical.net/news/20131007/Renownedleaders-

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