Determination Is the Key
by Joyce Green Pastors, dietitian,
and Terry Saunders, psychologist, Charlottsville, VA
Over the past few years, we have been providing lifestyle change counseling to selective patients with diabetes. These patients have agreed to be videotaped with the purpose of using segments of the videos for a professional education workshop.
Our first videotaped patient was a complex case—a 48-year-old female, severely obese, with a history of yo-yo dieting, an eight-year history of type 2 diabetes, and very insulin resistant. The patient had a history of hypertension, heart disease, and depression and had been a smoker since age 16. Along with these factors, she had a complicated challenging social and financial situation, with three children ranging in age from 12 to 28, all living in the same home, and a husband who had died of cancer six years previously.
We began our first taping session just before Thanksgiving, which we initially thought was a mistake given the challenge of making lifestyle changes during the holiday season. We completed a lifestyle assessment and set some initial goals regarding awareness—determining a baseline of physical activity and becoming aware of late-night snacking patterns. The patient wanted to focus on just getting through the holiday.
We suggested working together to develop a plan for handling the holidays—something she could commit herself to and feel confident about. Specific aspects she was concerned about were baking, eating pies, and buffet-style eating throughout the day. Based on our philosophy of developing patient-centered goals and beginning with small, realistic, and achievable goals, we identified and agreed on three behavioral goals—eating two pieces of pie during the Christmas week, drinking sips of water while baking, and eating meals sitting down.
Her house was a focal point for visits by family and friends, who always dropped in expecting to find good things to eat. We discussed the possibility of having a family conversation to solicit support and develop some alternatives to the family traditions.
All of this sounded good in theory, but at the end of that session, we both had a sinking feeling that very little would be achieved. So much was stacked against the possibility of success—her history of weight gain during past holiday seasons, her pattern of overindulgence and sedentary living, and the long history of unhealthy family eating traditions. We really wanted her to succeed, but we didn’t have a lot of hope.
The videotape of our next session after the holidays is a classic example of body language speaking louder than words. To our surprise and jubilation, she went on to report that she had lost four pounds and bubbled over with excitement as she told us about her successes and new family traditions. She had talked with her children before Christmas about the behavioral goals we had agreed on, commented on how difficult it would be, and mentioned that it would be nice if they could just forego tradition. They proceeded to make suggestions about how they could add a fruit platter and fresh vegetable tray to the table instead of other high-calorie and high-fat choices.
And here was the holiday gift for us. For years, we had been casting ourselves as firm believers in empowerment and the patient-centered approach to behavior change. But what this showed us was that however much we might have believed intellectually in the approach, we still didn’t fully believe that people can change their habits. This was an especially powerful realization because we would be the first to point out how little confidence others, the prime example being physicians, often show in the possibility of positive behavior change. We were reminded to look inward, re-examine our own beliefs, and recognize our own capacity to stereotype people based on their weight, past history, personal preferences, and family traditions.
Underestimating Is Under Serving
by Gary Scheiner, exercise physiologist, Philadelphia, PA
In modern day health care and patient education, one of the underlying rules we are told to follow is to cater to the lowest common denominator. In other words, assume that every patient we see knows nothing, has little motivation and subpar intelligence, and will do as little work as possible on their own behalf to manage their diabetes. When it comes to teaching diabetes self-management, I have found that nothing could be further from the truth.
To set low standards and low expectations is a disservice to everyone we counsel. The modern, effective techniques for managing diabetes—carbohydrate counting, insulin/medication self-adjustment, and record keeping/analysis—can be learned and implemented as easily by those in a low socioeconomic groups as those in the highest groups. In fact, because those classified as disadvantaged have traditionally been treated as such for so many years, the change in approach often inspires significant changes and great results.
One client who comes to mind is a middle-aged gentleman from the inner city who happened to have a learning disability. However, once we get past phrases like “welfare” and “3rd-grade reading level,” we come to find that this is a man who follows instructions meticulously and takes great pride in keeping good written records.
Teaching this man carb counting and insulin dosage adjustment was a snap with a few simple charts to aid in his decision making. Setting up an organized record-keeping system allowed us to fine-tune his plan. Eventually, he seemlessly transitioned from a two-shot-a-day plan (using premixed insulin), to a basal/bolus injection program, and finally to an insulin pump.
Along the way, his hypoglycemic episodes all but disappeared and his A1C stabilized at a level just above normal.
If a man like this can learn and apply modern management techniques, just about anybody can. We as health professionals must look past the superficial characteristics of our clients and aim much higher with each and every one. In other words, assume that each of your clients is intelligent, motivated, and eager to apply exactly what you teach. Then no one will be under served.
Believing in People’s Strength
by Geoff Williams, physician, Rochester, NY
I first met Nancy in 1997 when she came to me as a new patient. She was 50 years old and told me that she had gained 100 pounds after her second marriage. She is now divorced again and working as a secretary at a suburban school district. She was quiet during the interview and would consider each question I asked carefully before answering. She struck me as a kind person. Her medical problems included all the parts of metabolic syndrome (high blood pressure, obesity, elevated cholesterol) and degenerative arthritis. She would often go for long periods of time without coming back, but then would come in for a cold or back pain. I asked her why she wouldn’t come in to see me more regularly, and she said she felt like a failure when she came in, and often she felt she should not come in out of embarrassment.
Her weight continued to climb, reaching a maximum of 274 pounds (BMI of 45 kg/m2) in the spring of 2002. On the day that she came in for a physical exam, I told her I thought that she might have diabetes and asked her to go for a glucose tolerance test. She asked me if I thought diabetes might be reversible. I said that she could certainly improve her diabetes control, if not eliminate the diabetes, if she found a way to be physically active for an hour a day and focus on eating a healthy diet.
Since then she has reported exercising for 30–60 minutes a day and has stayed on her Weight Watchers diet. She has progressively lost 78 pounds, her blood pressure has fallen enough to reduce both of her medications, and she has no sign of diabetes by blood sugar. I asked what made the difference for her to change her life in this way. She said that I had told her that she could do it, but that it would be hard work.
Nancy has truly inspired me as a health care practitioner.