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A Lifestyle Approach to Health & Fitness 6th edition • Reviewed and Recertified August 2010 by Linda Omichinski, rd

Accredited Continuing Professional Education Course

7950 Jones Branch Drive, 7th Floor, McLean, VA 22107 1-800-866-0919 • www.nutritiondimension.com

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Nondiet Weight Management 7950 Jones Branch Drive, 7th Floor, McLean, VA 22104 1-800-866-0919 (US & Canada) • 1-703-854-2531 (overseas) FAX:1-703-854-2531 • e-mail: [email protected]

Nondiet Weight Management A Lifestyle Approach to Health & Fitness 6th Edition • Revised August 2010 by Linda Omichinski, rd About the Author: Linda Omichinski, RD is a pioneer of the nondiet “health at every size” approach to health. An internationally known lecturer and promoter of self-empowerment techniques that de-emphasize weight as a measure of success, she authored the best-selling You Count, Calories Don’t, as well as numerous articles in professional and popular journals. Sine 1987, Linda is President of HUGS.com, which serves as a  center for information and resources about nondieting and receives thousands of internet visitors each week. Linda has developed a full line of programs/workshops and resources marketed through Hugs International Inc., including HUGS, The Alternative to Dieting, which is available through a network of licensed facilitators in six countries. HUGS stands for “Health focused, centered on Understanding lifestyle behaviors, Group supported, and Self-esteem building”. Education: BSc, McGill University. EXPIRATION DATE: Students of all professions must submit this course for credit no later than July 31, 2016. Credit will not be awarded for this course after that date.

Course Code: RD97, CHES97, FIT97, AT97 This course approved for RD, DTR............................7 CPEU CDM......................7 Clock Hours ACE....................................0.7 CEC (NATA) BOC..................... 5 CEU ABMP................................... 7 CEU

NSCA................................0.7 CEU ACSM................................... 7 CEU CFCS....................................7 PDU CHES.................................7 CECH

Copyright © 1995-2010 by OnCourse Learning Corporation No portion of this course may be duplicated without the written consent of the copyright holders. Edited by: Dales Ames Kline, MS, RD, CNSD Copyediting/proofreading: Rich Kline, Gwen Hulbert Design/production by: Knotwork Graphics

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How to Earn Continuing Education Credit 1. Read or watch the course material. Don’t forget to review the course objectives and take note of course tools available to you. The objectives provide specific learning goals and an overview of the course. Read the material in the order presented. If you need help with the material, please e-mail [email protected] with your specific question. We will forward your inquiry to the author, so allow adequate time for a reply. 2. CE credit will not be awarded for this course after July 31, 2016. 3. If you have an account on Nurse.com, TodayinPT.com, or TodayinOT.com, or NutritionDimension. com, please use that account username and password to sign in on ContinuingEduation.com. If you don’t already have one, please sign up for a user account. Click “sign up” or “login” in the upper right hand corner of any page on ContinuingEducation.com. If you have a CE Direct login ID and password (generally provided by your employer), please log in as you normally would at lms.nurse. com and search for this topic title. 4. Go to the “my courses” section of “my account.” Click on the title of the course you want to complete and then on “start course.” 5. Click “start test” to begin the exam. To earn contact hours, you must achieve a score of 75% on your multiple-choice exam for most courses. For webinar courses, you will need to achieve a score of 100%. You may retake the test as many times as necessary to pass. Clues are not provided on the exam. Certificates will be date/time stamped with the time and date of the day the user passes the test (Eastern Time, U.S.). 6. After successfully completing your exam click, “complete required survey.” In order to complete the test process and receive your certificate of completion, you must take a few moments to answer a brief survey about the course material. 7. After completing the survey, you will be taken to your transcript. Under Courses Completed, you can view, print, or e-mail your certificate. 8. Three months after you complete a course, you will receive an e-mail asking you to complete a followup survey. This is vital to our educational requirements so we can report our quality outcomes and effectiveness. We report course completions to National Commission for Health Education Credentialing (NCHEC) quarterly and The Association of Nutrition & Foodservice (ANFP, formerly DMA) monthly. Other professions should follow their certifying organization’s reporting instructions. We keep a record of course completions for 7 years. A Word About Copyrights:

We encourage health professionals to use material from this course in their practice. Please follow these guidelines: (1) Credit the author, OnCourse Learning Corporation and any referenced source. (2) Course material may not be sold, published, or made part of any program for which a fee is charged, without written permission from OnCourse Learning Corporation. (3) Inform OnCourse Learning Corporation by letter if you wish to make significant use of material from this course (e.g. if you wish to duplicate Appendix pages for a training session or patient handout).

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Contents 1 Introduction 3 Chapter One: The Need for a New Approach Traditional approach • Financial implications • A new approach • New indicators of success 15 Chapter Two: The Health at Every Size Approach Diet approach to weight management • Health at every size approach to weight management 21 Chapter Three: Nondiet Empowerment Why health professionals should consider a nondiet approach • Lifestyle adjustment Moving into the facilitative role • Enabling ownership •Transfer power Match language to intentions 31 Chapter Four: Applying the Nondiet Approach Chronic weight concerns • Diabetes and/or heart health concerns • Lifestyle issues 41 Chapter Five: Breaking the Failure Cycle What does having a positive body image mean? • Body type • Breaking out of the diet mentality 49 Chapter Six: Nondiet Nutrition Concepts How food affects the body/how the body uses energy • Eating regularly Getting the most energy by balancing meals • Tuning in to body signals Types and roles of fiber • Vegetarian eating 59 Chapter Seven: Moderating Dietary Fat Learning to enjoy foods with less fat • Gradually decreasing fat in meals Modifying recipes gradually • Using herbs and spices 71 Chapter Eight: Hunger and Fullness Focus on sustained energy and satiety • Skills to deal with psychological hunger Confrontation vs willpower Learning to meet your needs • Eating without guilt 79 Chapter Nine: Fluid Management Misuse of fluids • Is it really hunger or is it thirst? • Acquiring a taste for water • Caffeine 85 Chapter Ten: The Role of Exercise Becoming addicted to physical activity • Exercise facts and fiction Making a lifestyle change • Nondiet benefits of being physically active 91 Chapter Eleven: Lifestyle Strategies Eating out • Relaxation • Taking time for oneself • Dealing with stress positively Redefining health • Assessing progress 99 Chapter Twelve: Freedom from Counting for People with Diabetes Traditional method of treatment • Blood glucose levels and weight loss Practical application of the nondiet approach 105 Chapter Thirteen: Five Healthcare Myths 109 Chapter Fourteen: The Journey to Building Momentum and Unity for Health at Every Size 119 References 122 Appendices: Medical and Empowerment Models Hidden Sugars and Caffeine Case Studies Energy Expenditure for Various The Big Decision   Activities Sample Recipe Modification Relaxation Scripts Fluids and Their Functions Using Nondiet Approach in   Diabetes Treatment 133 Examination

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Learning Objectives Upon successful completion of this course the student will be able to: 1. Explain why dieting may fail to produce long-term weight loss. 2. Define “diet mentality” and identify three consequences of this belief. 3. List four ways studies that link obesity to health problems may be flawed. 4. Explain why weight loss may not be an indicator of improved health. 5. Describe how repeated attempts at weight loss through dieting can increase risk of physical and mental health problems. 6. List 10 alternative goals to weight loss as indicators of improved health. 7. Describe how the nondiet approach can be employed in therapeutic and lifestyle situations. 8. Identify five influences on body image and provide six suggestions for improving body image. 9. List five consequences of weight preoccupation. 10. Name and describe three basic body types. 11. Explain the role of carbohydrate and protein in appetite control. 12. Define the glycemic index and list six factors that affect glycemic response. 13. Explain how attempts to restrict high-fat foods may backfire. 14. List 10 possible indicators of rigid fat restriction. 15. List five indicators of an acquired taste for lower-fat foods. 16. Describe six methods of making gradual changes in food purchasing and preparation. 17. Contrast diet and nondiet approaches to portion control. 18. Explain how sensitivity to hunger, appetite and satiety signals can be enhanced. 19. Explain how dieting may influence cue sensitivity. 20. List 15 reasons — other than hunger — for eating. 21. Explain the role of fluids in the body, and list three ways fluids can be misused by dieters. 22. List five signs of dehydration. 23. Explain how clients can acquire a taste for less-sweet foods and fluids. 24. List six symptoms of exercise addiction. 25. Name and refute three myths about exercise. 26. List 11 indicators of lifestyle shift other than weight loss.

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Introduction

The purpose of this course is to give practitioners a practical guide for working with the nondiet approach to weight management, for it is in this approach, we believe, that the greatest potential for overall health and wellness lies. Traditionally, dieting or restrained eating — defined as the deliberate restriction or alteration of food intake in order to lose weight or to prevent weight gain — has been the pattern of eating employed by millions of people in order to reach a medically or societally prescribed body weight (Polivy and Herman, 1983). This magic formula — X pounds of body weight equals health, fitness and happiness — is not only unrealistic, but also dangerous to many people's physical and mental health. Although we define this course in terms of weight management, it will de-emphasize weight as a measure of success in lifestyle, health and fitness. This radical departure from orthodox health and fitness thinking recognizes one inescapable fact: for most people, diets don’t work. Despite high expenditures on diet programs and products and research efforts directed toward obesity treatment, decades of research have shown that both selfinitiated and professionally-led diet programs are largely ineffective for producing lasting amounts of weight loss. Repeated weight loss efforts may aggravate health risk factors and lead to serious side effects (Garner and Wooley, 1991; Ernsberger and Haskew, 1987). While this indicts dieting per se, it also draws into question the methods we use to measure success, and our effectiveness in diagnosing and prescribing weight management regimes. As health practitioners, we may feel we have failed when our clients return, unable to maintain the weight that dieting has temporarily provided, and perhaps in worse health. So, not only do we need a new approach for our clients to use, we also may need to change our thinking about our relationship with our clients. In some ways, we need to place the responsibility for our clients’ health back on the client — while giving them the tools to manage their own treatment and care.

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There are two facets to this home study course. It will provide you with the opportunity to find answers to many questions you may have had regarding measures of success and treatment for obesity, diet-sensitive diseases such as diabetes, and lifestylerelated conditions such as heart disease. And it will help you learn how to think differently about food and activity, and to move from using a diet approach to a true nondiet approach. You will also move from your role as a teacher to that of a facilitator. You will notice the phrase “true nondiet approach” in the last paragraph. This means that we will focus on health parameters instead of weight loss as a measure of success. For some, weight loss may be experienced as a side effect of this approach, although it is not the focus nor the measure of success or progress. Someone who is listening to body signals, being more active, and eating healthier foods may ultimately have their body weight decrease to their natural, healthy weight over time. However, those whose weight was not above their natural body weight, or who have a genetic predisposition to obesity and/or a history of chronic dieting, may develop healthier living patterns and still not experience weight loss. These individuals are still successful under the new measures of success we will establish here. Obesity treatment and prevention strategies must be thoughtfully designed and implemented to avoid a worsening of the preoccupation with weight and dieting, an overvaluation of thinness, and social prejudice toward the obese (ADA, 1989). The shift from using the traditional medical model of weight loss to the health-promotion model of healthier living is gaining acceptance. However, many health professionals are in transition between the two approaches. The result may be that our clients receive mixed messages. We talk about a “nondiet” approach to eating but still provide exchange “eating plans.” We talk about healthy lifestyles and improved wellness but continue to use thinness or weight loss as a goal. Thus, we imply that the way to an improved lifestyle is through structured living which will translate into weight loss. Healthy eating has become the latest diet fad. Low-fat and high-fiber are the new status icons for a health-conscious public. Instead of counting calories or exchanges, people are now counting grams of fat and fiber. Since the focus is still on choosing kinds and amounts of foods for the correct “numbers” rather than satiety and enjoyment of taste and texture, this type of program is a diet repackaged as healthy eating. Counting is counting; weight-loss programs are diets. The focus and the consciousness are identical — and so is the failure rate. Health and well-being can be achieved without significant weight loss in individuals whose weight exceeds recommended levels (Foreyt and Goodrick, 1993). People with weight concerns can be better helped by being encouraged to develop self-acceptance, eat healthier foods, increase physical activity, and avoid weight cycling (Parham, 1991).

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Chapter One: The Need for a New Approach

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n this chapter we discuss what we know about weight management and make a case for a new approach (which we call lifestyle education, to de-emphasize weight as a measure of success). Traditional weight management says: “A 3500 kcal energy deficit is needed to lose 1 lb of body fat. Therefore, a deficit of 500 kcal per day means a loss of 1 lb of body weight each week.” (Snetselaar, 1989). Health, happiness and fitness, it is assumed, naturally follow when enough of those weekly pounds are lost. However, the experience of most clients and health care practitioners reveals a much more complex interaction between mind, body and food. Indeed, the traditional approach leaves unanswered a number of questions:

Unanswered Questions About Diet & Weight • Why would someone attempt to lose weight in the first place? • Are all pounds equal when it comes to improving physical health? • Does a deficit of 500 kcal a day always lead to a loss of 1 lb a week? • Are all calories equal when it comes to loss or gain of body fat? • What effect does restricting caloric intake have on eating behavior? • Is the weight loss resulting from this approach permanent? • What effects do repeated attempts at caloric restriction have? • Does this approach have ethical implications?

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This chapter will address these questions, and concurrently provide a justification for a new approach to weight management. Why would someone attempt to lose weight in the first place? Typical answers are: to reduce health risks, and to improve body image. • Health risks. Being overweight has been associated with a variety of health problems, including cardiovascular disease, hypertension, diabetes, arthritis, gall bladder disease, and some cancers. Few would deny the health benefits of the population as a whole maintaining a desirable weight. However, the findings linking overweight to poor health, though they may be true for a specific group of people, may not be true for everyone. Careful screening and assessment must be used to determine whether any particular client would benefit from weight loss. This is true because there are several common design flaws in the studies that have associated being obese with having health problems. First, the studies do not control for previous dieting by the obese subjects, despite the evidence that dieting itself can lead to health risks (as discussed later in this chapter). This places all “overweight” people together — those who lose and gain or starve themselves on weird fad diets, and those who maintain a stable weight and generally meet their nutrient needs. Even though their weight may be higher than what is medically prescribed, stable obese people may be at a lower health risk than those who show repeated patterns of weight loss and regain. Given the societal pressure to lose weight, it is likely that many obese research subjects had dieted in the past or were dieting at the time of the studies. Thus, the health risks that have in the past been attributed to obesity may, in fact, be a result of attempts to lose weight. This lack of control is disturbing. Second, studies generally do not control for socioeconomic status, despite the fact that members of lower socioeconomic classes tend to weigh more than members of higher socioeconomic classes (Goldblatt, et al., 1965). Affluent subjects are likely to be better educated and to receive better medical care than less- affluent subjects, which results in a serious confounding of variables. Also important to consider is that, given the prevailing prejudice against large people in the health community (Marchessault, 1993), many large people delay seeking medical attention until their problems are more advanced and less treatable. Third, cigarette smoking, which is linked to many of the same diseases as obesity and which many people use as an appetite suppressor, is rarely analyzed separately from weight. It has been suggested that obesity and smoking are more likely to be linked in the lower socioeconomic classes (Andres, 1980). Fourth, there is an apparently natural trend to increase weight through the adult years. Since the risk for most health problems also increases as we age, it is important to consider whether a finding of increased health problems with increased weight may be a result of increased age, not necessarily increased weight. As well, it must be noted that not every study links weight with mortality or disease. Experts such as Ancel Keys (1992) have asserted that the evidence is inconclu-

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sive or negative, especially as it relates to cardiovascular disease. Even for those obese who are shown to be unhealthy, it does not necessarily follow that their weight per se is responsible for their ill health. Obesity is often associated with unhealthy practices; these associated factors may actually be responsible for health problems, and may need to be treated. For example, elevated free fatty acid levels that are characteristic of the obese have been found to correlate with chronic restrained eating in both obese and average weight individuals (Hibscher and Herman, 1977). This suggests that disordered eating rather than body weight may be responsible for the elevation. It may be that a high-fat diet and a sedentary lifestyle may promote heart disease while coincidentally promoting weight gain. Thus, adiposity and heart disease may be associated because they share antecedents, not because one causes the other. Correlation does not prove causation. Treating weight may not address the real problem. In fact, many people try to lose weight at the expense of health. Moderate weight loss (10 to 15 percent of body weight) has been found to decrease health risks and medical problems in 90 percent of obese patients (Blackburn and Kanders, 1987), resulting in improvements in heart function, blood pressure, glucose tolerance, sleep disorders and lipid profiles, as well as decreased requirements for medication, decreased incidence and duration of hospitalization, and decreased postoperative complications. Cardiovascular disease is reduced in women after moderate weight loss, even when they remain obese (Trembly, et al., 1991). Therefore, one could hypothesize that it was actually the behavior changes that resulted in improved eating and activity habits that, while resulting in weight loss as a side effect, are the true cause of improved health status. Thus to focus on “weight maintenance” rather than “behavior maintenance” misses the point. Many obese/large people are healthy. There are risks associated with obesity, but there is not any evidence that people cannot be or are not healthy at any weight. • Body image. Over the past 10 years, a number of studies have shown a rise in the prevalence of body image problems among both men and women. The most fundamental reason for this dissatisfaction is an increasingly thin standard of beauty (for women) and muscularity (for men). Role models on television and billboards and in fashion magazines are virtually always thin. Our standards of beauty have become increasingly unrealistic and distorted. Marilyn Monroe was 5'2" and weighed 140 lb — was she unattractive? Because of the belief that body size and shape are totally under a person’s own control, men and women sometimes enter diet and exercise programs with unrealistic expectations. Attempting to reconcile expectations and reality may have psychological and physical costs. Feelings of shame, failure and deprivation, yo-yo dieting and, in men, the use of male hormones and steroids are common. These issues will be discussed further in a later chapter.

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Are all pounds equal when it comes to improving physical health? Many obesity studies were done with all male subjects. It is difficult to say whether these results can be generalized to women, particularly given the findings about the importance of fat localization. Recent evidence suggests that the connection of obesity to some disorders may be due not to the amount of fat but to its location in the body. Kuhn and Rackley (1993) and Angel, et al. (1994) have reported that waist circumference, not weight or Body Mass Index (BMI), is the anthropometric measurement most closely associated with cardiovascular risk factors. Abdominally localized fat (sometimes referred to as the android pattern or apple shape) appears to significantly increase the risk of cardiovascular disease, diabetes, hypertension, and cancer. This pattern of fat localization is more common in men than in women, who are more likely to have fat located in the thighs and buttocks (the gynoid pattern or pear shape) (St. Jeor, 1993). In fact, dieting may cause an unhealthy shift in fat deposits. Studies of animals and humans who have been deprived of food (whether intentional or accidental) show that surplus fat is accumulated when food supplies are restored, perhaps as a hedge against future famines (Bennett and Gurin, 1982). The increase in obesity usually occurs in the abdomen (Rodin, et al., 1990). This upper body adiposity poses many more deleterious health effects than does the same degree of obesity located on the lower extremities (Bjornthorp, 1985). Simply weighing a person does not tell us anything about their body composition. Thus, a muscular individual may have a higher weight without any greater chance of developing health problems. Focusing on weight loss as an indicator of improved health has a similar limitation — by developing healthier living patterns, one’s body composition may change. This may result in a loss of body fat, a slight increase in muscle mass and a smaller waistline with little or no change in body weight. So even if weight remains stable, there may be reduced health risk for an individual. The Body Mass Index BMI (weight in kilograms divided by height in meters, squared) is becoming more commonly employed as a method for assessing an individual’s health risk. Assessment based on relative weight-for-height has many of the same limitations as body weight when used as an indicator of progress towards a healthier lifestyle for several reasons. First, a high BMI is not always related to “overfatness” since the BMI does not take into account body composition or fat distribution. Many muscular or short, stocky people have a high BMI but are not necessarily at increased health risk. Second, the BMI is considered appropriate only for adults 20 to 65 years of age, since it cannot account for patterns of growth for adolescents or the typical decrease in height with advanced age. It is often inappropriately applied to adolescents. Third, and perhaps most important, the focus is still on changing one’s weight to produce a lower BMI (as there is little one can do to increase one’s height!). This continues to promote weight preoccupation by focusing on changes in weight towards an ideal or goal weight.

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Because we do not know how to define which sorts of overweight are medically important, decisions to treat are based more on general assumptions than on actual risk. This results in treating many individuals who are not even at medical risk due to their weight. Does a deficit of 500 kcal a day always lead to a loss of 1 lb a week? Basal metabolism is the energy needed to maintain the body’s functions, exclusive of digestion and activity. For example, the body must have energy for the beating of the heart, for breathing, for the operation of vital glands, for blood circulation, for maintenance of body temperature — in short, for mere survival. Basal metabolic energy needs vary somewhat from one individual to another — some people need more than others. The speed at which the body operates and requires energy for survival is termed the basal metabolic rate (BMR). It has long been suspected that dieters may fail to keep off their weight because their bodies become more efficient, in effect burning up calories sparingly, although studies have not consistently shown changes in metabolic rate following diet cycling. Most recently, Leibel et al. (1995) measured the energy expenditure of obese and normal-weight subjects and found that the metabolic process of subjects in both groups adapted to a lower body weight with a reduction in energy expenditure. However, the obese subjects had an approximately 33 percent greater reduction in energy expenditure. Maintenance of a body weight about 10 percent below usual weight resulted in a mean (± standard deviation) reduction in total energy expenditure of 6 ± 3 kcal/kg fatfree mass per day in non-obese subjects, vs 8 ± 5 kcal in obese subjects. Leibel et al. attribute the frequently observed long-term ineffectiveness of obesity treatments to the fact that “Maintenance of a reduced or elevated body weight is associated with compensatory changes in energy expenditure, which oppose the maintenance of a body weight that is different from the usual weight.” Thus, chronically reducing one’s caloric intake by 500 kcal per day may result in reduction of the requirement of calories, leading to a much slower weight loss than would be expected. Are all calories equal when it comes to loss or gain of body fat? Food can only provide energy for the body by undergoing considerable processing after being eaten. In fact, the release of energy from food in itself requires energy to facilitate the digestion, absorption, transport, metabolism and storage of the various nutrient components of the food that is eaten. In recent years, investigators have found evidence that the body may be able to convert dietary fat into body fat with greater ease than it can convert carbohydrates (starches and sugars) into body fat. In other words, it takes more energy to convert carbohydrates into fat tissue than to convert fat calories into fat tissue. Thus, more carbohydrate calories are expended and less stored as fat than are fat calories. Experiments at the University of Massachusetts Medical School suggested that if

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one consumes 100 excess carbohydrate calories, 23 of those calories are used to process the food and 77 kcal are stored as body fat (reserve energy). In contrast, if one consumes 100 excess fat calories, 3 kcal are used to process the foods and 97 kcal are stored as body fat. Fat may be metabolically prone to storage since its profile is already very similar to that of the fat found in one’s body. So it takes less calories, energy, or heat to convert the fat in food to body fat (UC Berkeley, 1988). Therefore, all calories are not equal when it comes to loss of body fat tissue. The macronutrient (protein, carbohydrate, fat) composition of one’s eating pattern will affect the degree of fat deposition or loss. This is illustrated by the example below. If you took an individual who ate 2000 kcal in his or her diet in which 40 percent came from fat and replaced half of the fat calories with calories from carbohydrates, you would be exchanging 400 fat calories for 400 carbohydrate calories. The metabolic savings would be only about 80 kcal/day, but due to the energy costs of storing carbohydrates as body fat, the exchange could account for a loss of about 2 lb in three months. In this instance, the total number of calories is not changed, it is the distribution of the calories or the redistribution of the macronutrients that is being changed. Keeping the calories constant minimizes the drop in metabolic rate, or may actually negate it entirely. Also, 400 kcal of carbohydrates consists of a lot more food than 400 kcal of fat (Omichinski, 1993a). What effect does restricting caloric intake have on eating behavior? To be a successful dieter, one must learn to ignore or distrust inner signals of hunger, appetite and satiety and instead depend on external references, such as foods allowed/not allowed, suggested frequency of eating, and weighed or measured portion sizes. As a result, most chronic dieters have lost the ability to eat in response to physical needs and may be more susceptible to overeating for environmental (“because it’s there” or “because it’s lunch time”) and emotional reasons (Polivy and Herman, 1983). Focus on the external goals of adherence to a diet plan and weight-loss indicators can lead to perfectionist tendencies that often result in a loss of control. Dieters and eating disorder patients develop similar thinking patterns in relation to food: foods are either “good/diet” foods or “bad/bingeing” foods; as either “good/small/low energy” amounts or “large/diet-breaking” amounts (Polivy and Herman, 1983). If dieters eat “bad” foods or foods in “large” amounts they perceive that they have “blown” their diet for today or this week — so they might as well keep eating and start over tomorrow. The pattern of thinking and behaving described above is commonly called “the diet mentality.” This mentality, or lifestyle perspective, is likely to result in weight obsession, poor self-image, disordered eating patterns, and disordered lifestyles, often marked by excessive or inadequate exercise. Berg (1994b) has concluded that chronic restrained eating has been linked to overwhelming hunger, weakened control over food intake, heightened responsiveness to external hunger cues, and possible risk of bulimia. Surveys indicate that at least 80

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percent of young women in treatment for bulimia were attempting to lose weight when they experienced their first binge-purge episode (Wooley and Wooley, 1984). Approximately 50 percent of individuals undergoing weight-loss treatments have some degree of nonpurging bulimia (Goodrick and Foreyt, 1991). This phenomenon can lead to more serious degrees of purging bulimia or anorexia. Both eating disorders are extremely hazardous to an individual’s physical and emotional health and carry their own high mortality rates. Is the weight loss resulting from this approach permanent? Successful weight loss is difficult, especially long term. While almost any treatment causes some weight loss in the short run, research indicates that most weight loss is not sustained (National Institutes of Health Technology Assessment Conference, 1992). Brownell and Jeffery (1987) examined the results of controlled trials of behavior therapy for weight loss. These data, published in selected journals, suggest that current programs offered in research settings can deliver reasonable initial weight losses, but that weight regain tends to occur after treatment ends. Follow-ups beyond 1 year showed a trend toward consistent weight regain. The difficulty with maintaining weight loss is also documented in a study by Kramer, et al. (1989), which followed 152 people for 4 or 5 years after a 15-week behavioral weight loss program: fewer than three, on average, were at or below their posttreatment weight on all follow-up visits. Weight regain following very-low-calorie diets is also common. Wadden, Stunkard and Liebschutz (1988) found that people who received very-low-calorie diets alone initially lost 14.09 kg (30.93 lb) on average, but had regained all but 3.76 kg (8.27 lb) of this 3 years later, even though at least 53 percent of them (8 of 15) had received additional therapy. Hoevell, et al. (1988) concluded that only 10 percent of people who lose 25 lb (11.36 kg) or more will remain at their desired weight beyond 2 years. Therefore, short-term weight loss is of questionable clinical value, since the health benefits associated with weight loss are likely to be sustained only if this loss is maintained over time (Robison, et al., 1993). What effects do repeated attempts at caloric restriction have? There are physical and psychological effects of repeated caloric restriction. • Physical effects. Repeated unsuccessful attempts at long-term weight loss can increase health problems. It is well known that continued dieting can result in inadequate nutrition, fatigue, weakness, and sudden death from cardiac arrhythmia and gallstones (Berg, 1994a). It is generally believed that obese pre-menopausal women are at low risk for osteoporosis. However, Bacon, et al. (2000) found that obese pre-menopausal women who are restrained eaters (chronic dieters) can have reduced bone mass. The authors attributed the finding of low spinal bone mineral content to the effect of dieting on a skeletal site consisting primarily of trabecular bone. Calcium in trabecular bone is more labile. It is possible that with chronic dieting, there may be selective mobility of calcium

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in the trabecular, non-weightbearing bone, especially if calcium intake is deficient. Thus, chronic dieting can affect the long-term health of the spine. Because virtually all weight-reduction methods are only temporarily effective, they can be indirectly hazardous due to the adverse consequences of the regaining phase. Ernsberger and Haskew, in an extensive alternative review of the health risks of obesity, present a thought-provoking hypothesis that many of the hazards associated with fatness may be mainly related to rapid regain of weight, not to obesity itself. They report that when dogs, swine, rats or mice are repeatedly deprived until they lose 20 percent or more of their body weight, then are allowed to regain the weight, they develop high blood pressure, damaged blood vessels, and heart disease similar to that seen in overweight humans. As illustrated below (Omichinski, 1993a), recent data from the Framingham Heart Study indicate that patients who have even relatively small weight fluctuations are at greater risk of death from coronary heart disease (CHD) than those who have maintained a stable, although higher, weight (Lissner, et al., 1991). While a weight loss seemed to produce a 20 percent decrease in risk for CHD, a similar weight gain resulted in a 30 percent increase in risk for CHD.

Weight Loss/Gain & CHD Risk Regaining 10% weight = 3 0% increase in risk 10% weight loss = 20% decrease in risk

(Omichinski, 1993a)

Weight fluctuations are most strongly correlated with increased risk in the youngest age groups (30 to 44 years). This group was more frequently engaged in dieting practices. Thus research has shown that even small repeated cycles of dieting and weight regain may increase a patient’s mortality and morbidity, not decrease it as commonly assumed. We don’t know if weight loss actually improves medical conditions in the long term because dropout and relapse rates are so high that few studies have been carried out. As well, the high relapse rate of dieting has led many chronic dieters to weight-loss techniques such as fasting and purging that are more dangerous than maintaining their original weight. When this is added to the fact that many of those treated were not even in jeopardy from their weight, it appears that we may be hurting these individuals. The chart below summarizes the physical risks of repeated dieting.

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Physical Risks of Repeated Dieting • Inadequate nutrition • Fatigue • Weakness • Cardiac problems • Gallstones

• Hypertension • Reduced bone mass • Alterations in metabolism • Alterations in body fat deposition • Increased cardiovascular risk

• Psychological effects. Repeated unsuccessful attempts at lasting weight loss can also seriously affect the dieter’s psychological well-being. Psychological stress has a dual origin: stress associated with societal pressures and discrimination, and stress associated with failed dieting attempts. Thus the traditional treatment for obesity, dieting, may have the same negative psychological impact as obesity itself (Brown and Jasper, 1993). With each weight-loss attempt, clients often experience increasing failure (Wooley and Wooley, 1984). Failed dieting attempts further diminish a client’s already low selfesteem, increase depression, and lower feelings of self-empowerment. Discrimination and low self-esteem cause many clients to view weight- loss programs as infallible and place the burden of failure upon themselves, as illustrated in the following example of a case report. Edna is 42 years old and weighs 240 lb — 20 lb below the top weight she reached in her mid-30s. At that time she lost 60 lb through her participation in a proprietary weight loss program. During the following 7 years she repeatedly tried to reverse her continued gaining, but with very little success. Now, driven by disgust with her large size, Edna’s trying once again. She labels herself a failure, but she’s flinging herself again into the effort. She talks about being slender for her college reunion. In spite of all our best research efforts over the recent decades, we have been able to do very little to improve the prognosis for lasting slenderness for people like Edna. Perhaps “thin forever” is not the most appropriate goal for her. I’d like to suggest that many of the satisfactions she is seeking can be achieved through alternative goals. — Ellen Parham, 1991 Another psychological aspect often overlooked is the financial burden placed on dieters. Every year numerous new weight-loss programs are marketed and more than $33 billion spent on weight-reduction products (including diet foods and drinks) and services (Committee to Develop Criteria..., 1995).

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Psychological Risks of Repeated Dieting • Heightened responsiveness to external food cues • Weight obsession • Poor self-image • Disordered eating patterns • Disordered lifestyle (e.g. excessive or inadequate exercise) • Increased incidence of eating disorders • Increased sense of failure • Financial burden • Increased pressure to conform to society’s unrealistic standards

Does this approach have ethical implications? Perhaps the most serious consequence of defining success in terms of caloric restriction to produce weight loss involves the reinforcement of our cultural obsession with slimness (especially for women) and the strengthening of social prejudice against obesity (Tisdale, 1993). It is estimated that 50 percent of adolescents and young women are dieting at any one time even though at least half of these individuals are already at or below normal weight (Rosen, et al., 1990). It has been stated that “a clear case cannot be made for a positive proportion of benefits to harms for overweight persons who enter a weight-loss program (excepting, perhaps, the morbidly obese)” (Lustig, 1991). In other words, if there is any question as to whether dieting may be harmful when we cannot show that it has long-term benefits, there is no ethical reason to continue to condone it as a healthy practice. Obesity is the result of a complex interaction of medical, psychological, behavioral, social, and cultural factors which vary greatly among individuals. Focusing on weight can obscure or even exacerbate these factors (Wooley and Wooley, 1984; NIH, 1992). The result is treatment that deals with symptoms rather than causes, and is likely to create more problems than it alleviates. The risks seem to far outweigh the possible benefits of short-term weight reduction (Ernsberger and Haskew, 1987).

A NEW APPROACH For all of these reasons, defining success in obesity treatment in terms of caloric restriction to produce weight loss is no longer appropriate. Most weight-loss programs measure success solely in terms of the number of pounds or kilograms lost per weightloss attempt. They do not take into account the quality of the process used to achieve weight loss or the likelihood of sustained weight loss. Because caloric restriction to produce weight loss without maintenance is not beneficial and potentially harmful, weight-loss programs could be discontinued and replaced by health-oriented, lifestyle change programs. Treatment must “focus on

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approaches that can reduce risks independently of weight loss” (NIH, 1992). Some professionals may continue to justify dieting because they are not aware that a true alternative exists — an alternative that is not a diet repackaged as healthy eating. That alternative is the nondiet approach to healthier living. This true nondiet approach helps clients take the focus off their weight and calorie counting and by shifting their attention to other goals, such as healthier eating, enjoyable physical activity, and a positive self-image, as recommended by Health and Welfare Canada (1988). By providing clients with the tools that will enable them to be successful in developing healthier, more enjoyable eating and activity patterns, a healthier lifestyle will develop regardless of their weight. By shifting the focus from weight to other goals, such as healthier eating, enjoyable physical activity and a positive self-image, health professionals can now help clients take steps toward health at any weight.

NEW INDICATORS OF SUCCESS Success can be measured on a variety of levels. Long-term amelioration of medical problems and health risks, and improved quality of life, with or without weight loss, are the most important measures of success (Robison, et al., 1993). Short- and medium-term changes also could be defined and measured regularly during treatment. These include obvious changes in health-related behavior patterns such as decreased reliance on medications, increased physical activity, reduced fat intake, and normalized eating. Physical indicators of progress towards a healthier body fat distribution include the waist circumference and the waist-hip ratio (WHR). Because abdominal or android obesity has been demonstrated consistently to be associated with risk factors for diabetes and heart disease, any reduction in the waist circumference or in the WHR could be used to indicate progress towards a healthier body fat distribution regardless of weight loss (Angel, et al., 1994). Constant comparison with an “ideal” measurement can be avoided since the value for the waist circumference or WHR at which risk of morbidity and mortality increases significantly for both men and women of various age groups remains to be determined. While Bjornthorp (1985) has suggested specific WHR values of 1.0 for men and 0.8 for women where risk may begin to increase, and there is increasing risk with increased values, at this time no scale of measurement or “continuum” showing increasing probability of developing health problems is available. As well, new measures of success must account for improvements in psychological functioning. Although conventional belief holds that underlying psychological problems don’t play an important role in obesity, evidence is accumulating to the contrary, particularly with respect to eating disorders and severe obesity. For many individuals, unhealthy lifestyle patterns can have powerful coping benefits (Ciliska, 1990). For such individuals, confronting and overcoming these barriers is a true measure of success, whereas weight-loss attempts may only lead to more shame, continued cycling, and repeated failure.

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New Measures of Success • • • • • • • • • •

Improvement in health risk factors Improvement in medical conditions Improved quality of life Improved psychological functioning Decreased reliance on medications Positive self-image Enjoyable physical activity Healthier, normalized eating Reduction in waist measurement or waist-hip ratio Reduced fat intake

As summarized in the chart above, there are many indicators of progress towards a healthier lifestyle that can be used to replace weight loss. The following chapters will provide practitioners with an alternative approach to offer clients who seek caloric restriction to produce weight loss in the belief that this is the approach to a healthier body and improved self-image. This new nondiet approach to lifestyle education promotes independent self-reliance, where self-acceptance and the ability to nourish one’s self for health and energy, rather than weight loss, are the new goals.

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Chapter Two: The Health at Every Size Approach: Extreme Thinking and the Middle Path

The irony underlying the media-trumpeted “obesity epidemic” is that diets go hand-in-hand with obesity. While people may believe that dieting is a health-oriented response to the problem of obesity, we now understand that people on diets do not have normal, healthy relationships with food, and are therefore destined to fail in their quest to lose weight; and will in fact likely gain more in the long run. So the diet industry, while ostensibly responding to the “obesity epidemic,” is in fact feeding it; and the only people who win in the end are those who pocket the substantial profits from the latest diet book. The Western medical establishment generally assumes that being large is a health hazard. In their eagerness to help their patients conquer obesity, however, efforts by medical and dietetic practitioners to help may actually mask what is essentially fat prejudice. Zeal for improved health can become rigid belief that obesity is the enemy that must be defeated at all costs, the costs of course being accrued by the patient in the forms of lowered self-esteem, unhealthy adherence to unrealistic diet plans, exercise addiction, disconnect with their own bodies. Irony again: these problems can be linked to being large as well. Apparently dieting won’t fix them. The Health At Every Size (HAES) movement is the response to the destructive beliefs of the obesity/diet dyad. HAES reminds us that those costs accrued by the patient may be too high, or just as harmful in the opposite direction. In recognizing the correlations between obesity and dieting, and in reminding us that being thin does not guarantee one is healthy any more than being large guarantees ill health, HAES offers tremendous help. However, as with any social paradigm shift, the pendulum can swing to both extremes before it comes to rest in the middle. In their fight against fat prejudice, HAES believers can be as zealous and rigid as obesity critics.

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Can you identify aspects of the purist, all-or-nothing mindset in yourself? What is your enemy, obesity or fat prejudice? If you are a practitioner or educator, your clients or the people you work with do not require nutritional or HAES purity from you; they need you to recognize that each of them is on his/her own path, to accept the reality of that person’s path, and to meet him/her on it, gently helping guide and shape their journey to a healthier, happier place. The counsellor is not the judge of the client’s shortcomings, but the pragmatic accepter of the client’s truth, even if you don’t initially agree with it. Judging and condemning such people will not help you to help them. If you do not take a pragmatic, accepting approach, whatever your personal philosophy, you will lose the client, and will have failed in your goal to help. Given what we now understand about the obesity/diet dyad, then ideally you are helping your clients go through a process, as in the HUGS program, to convince them to stop self-defeating dieting, learn to love and accept themselves as they are, and to learn how to have a healthy relationship with food again, as well as to live a healthier, happier life. This process can help people gain improved physical and mental health, and quality of life. Diet thinking means perfectionist, all-or-nothing negative mindsets and beliefs, and one of the best ways to help your client is to replace those beliefs with something realistic and positive for their lives. Chronic dieters who come to HUGS for help are people used to living by rules arbitrarily assigned to them by the latest diet plan. They do not know how to govern their own lives to make their own decisions around issues of food and physical health. The facilitator seeks to get them off the false rules and to learn to take responsibility for their own choices. Practitioners and educators should ask themselves: what is your personal goal for your clients or the people you work with? What do you think they need from you? What do they HAVE to do to succeed? If they HAVE to do anything, then they are being led into perfectionist, diet thinking again; and, by the way, how do you measure success? It may be difficult for dieticians in particular to avoid automatically talking about numbers of daily servings, and serving sizes, and measuring salt, fat and sugar content in everything the client eats. All of this is in aid of endorsing a healthy, balanced diet; but of course, it’s still a DIET – this approach is putting the client right back on a “plan,” and missing the point of HAES altogether. Health behavior change cannot be achieved by imposing your own rigid set of beliefs on others. You have to know what their beliefs and goals are, what their concerns are within the realities of their own lives: you need to understand “where they are coming from.” If you don’t, they likely will not take your message onboard themselves, and you will fail to help them. This is true at the community health promotion level, as well as for individuals. For example, the perennially popular public health initiative: the stop-smoking campaign. Everyone knows that smoking is bad for you, that it can cause cancer and kill. In countries with universal healthcare, treating smoking-related cancer is a public expense as well as a personal tragedy. A sensible solution, therefore, is to get people to stop smoking. Demographic reality: rates of smoking are very high among the homeless

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population. Follow the logic, however, of designing a public health intervention to encourage homeless people to stop smoking. Explaining to a panhandler who lives on a sidewalk grate, and who may freeze to death tomorrow night if he doesn’t get assaulted for his shoes, that his smoking is the real hazard, is entirely useless. Given the lifestyle described, smoking is the least of his worries and probably the only pleasurable thing he does all day. This person’s values and list of needs more likely begin with personal safety and shelter; concern for negative health behaviors is right at the bottom of the list, if it is there at all. There is no way an appeal to stop smoking will reach this individual until his other needs are met. By the same token, as a practitioner or educator, approaching others with purist enthusiasm for your personal philosophy and ignoring an individual’s list of needs will also get you nowhere.

CASE STUDY A recent reality television show — aimed at helping large individuals lose weight and improve their health and lives by assigning a team of professionals to help them in areas of food, exercise, and self esteem — featured a client who was an obese chronic dieter and binger. Very unhappy with herself and her home life, she was addicted to bingeing on convenience and prepared foods, and convinced that carbohydrates were the enemy. This is, of course, anathema to a dietician. The nutritionist assigned to help, rather than accepting the reality of the client’s situation and misguided beliefs, and trying to gently guide her to a healthier “place,” took an inflexible, rule-bound approach, imposing a great number of behavioral changes on the client all at once, requiring her to eat according to new “healthy” rules, and to give up coffee, among other things. The result after a couple of weeks was a slightly hysterical client suffering from headaches, insomnia and constant hunger, as well as panic at being forced to eat more carbohydrates than she was comfortable with, as she truly, deeply feared carbohydrates as a food group. In fact, she stated her firm belief that carbohydrates were not necessary at all, refusing even to eat carrots as they were “high in carbs.” The client was convinced she could not follow the nutritionist’s plan, and worried she would fail. When she sat down to discuss her fears and concerns with the nutritionist, the practitioner was adamant that her plan be followed, that there was no room for flexibility based on the client’s reality. What she said to the client was “I can’t work with you if you continue to stand in your own way.” This touchy-feely New Age language is in fact passive-aggressive code for “I won’t work with you if you don’t follow my rules.” The nutritionist then refused to continue with the client, got up and walked away, leaving the client alone on camera in a flood of tears. This case study clearly illustrates the problems of rigid, purist approaches, and the futility of trying to effect health behavior change by imposition of beliefs and rules. The client’s weight issue was caused to a great extent by being on diet plans, but the practitioner attempted to impose yet another plan (even if it was supposed to be healthier and based on the food groups, etc.). The client learned nothing about herself from this;

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further, it was a plan the client could not comfortably follow. The practitioner did not acknowledge or deal with the client’s personal issues and wants. Finally, the plan imposed too many changes on the client at once, completely disrupting the life she was comfortable with. This is the ultimate irony: the client has been repeatedly set up to fail by years of false diet plans, and then is set up to fail by the person to whom she turned as her last hope for help, and then is abandoned by this person when she inevitably does fail. The client is left feeling like a complete failure again, and the practitioner has failed to help her. At the other end of the pendulum swing, HAES practitioners may have difficulty in supporting clients who have beliefs that counter the HAES philosophy. Case example: a client who is clinically obese approaches a HAES-oriented practitioner for help with self-acceptance, but is also seriously considering some form of diet, or, more drastically, surgery to “fix” her weight problem more quickly. This person may be honestly unhappy with her appearance as a large person; and, given the cultural issues surrounding obesity and the social disadvantages that can attach to it, this unhappiness has a legitimate basis. Unfortunately, surgical intervention is gaining wider acceptance as a “solution” to weight issues. This is, of course, a social problem that the HAES movement seeks to address; but taking a pure HAES stance with the client, refusing to discuss the existence of surgery as an option, and ignoring her very real dissatisfaction with herself, will not help you to help her. She will willingly move on to a practitioner who will support her choice for a rigid diet or weight loss surgery. Purists think you should tell people that weight loss isn’t important, but this is how you lose people: they won’t listen and they are gone. In another example, while being large does not mean one is not healthy, an individual may believe that some measurable health problems, such as diabetes or hypertension, could be ameliorated by weight loss. A counsellor who ignores these health concerns and adheres inflexibly to HAES philosophy will not reach this client either, and is more likely to lose him to someone (like his doctor) who will put him on a diet plan. The greatest help you can give such clients is to take an accepting approach, which will allow you the time to work with them and to gradually educate them on a healthier life-view and wean them away from harmful beliefs and behaviors. Change can only come successfully one step at a time, and small steps at that. (In HUGS these are called “baby steps.”) You cannot simply order clients to stop being influenced by false social values surrounding beauty and self-worth. You cannot tell them to stop drinking coffee, start a new exercise program and completely change their eating habits all at once. This sets them up to fail again. As you lead people through their individual journeys, be open to what the process also teaches you about your own beliefs, and about issues such as perfectionism, control and acceptance. Remember that pendulum swing? An effective approach rests in the middle.

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Diet Approach to Weight Management Diet Program (restrictive eating) i.e. Weight Watchers

Start: "Wrong" Weight

Plan actually goes here:

End: "Ideal" Weight

Plan promises to go here:


Deprivation, will power, failure
food as the enemy
All-or-nothing
Control, perfection
Self rejection

End up heavier YO YO

DIETS

Emotional toll:

Health risk:

Deprivation leads to binging. Lower self-esteem through perceived failure.

Greater risk for diabetes, heart disease, and high blood pressure.





20

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Health at Every Size Approach to Weight Management A HAES approach, such as HUGS, changes the perception of one's body weight to what is naturally meant to be, exploring all the issues that influence body size. Health

➔

➔

➔

Dieting History

Set Point

Body Size ➔

➔

Activity/ Joy of Movement

➔

Stress

Body Image

Dieting Client • Desires weight loss • Diet treadmill • Frustration • Disordered eating • Low self-esteem • Perceiving "ideal" self

Results • Off diet treadmill • Accepting what you can't change • Reduced frustration • Normalized eating • Improved self-esteem • Quality of life • In some cases, weight loss

HAES Approach • Self-acceptance • Non-dieting • Perceiving self realistically

The above diagram illustrates how a dieting client (in left column) and the HAES approach (at right) combine together (in center) to help the client develop a healthier lifestyle and improve quality of life. The results show what the client and a HAES approach can build together.

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Chapter Three: Nondiet Empowerment

The long-term success rates of dieting to achieve permanent weight loss cited in the literature are very familiar to most practitioners. Outpatient clinics’ appointment books feature a parade of past weight-loss clients. Those who we thought were successful come back for another weight-control diet, most of them heavier than when they were first seen. We had done everything our training had taught us to do. We developed meal patterns that moderately restricted caloric intake and accommodated the client’s usual eating patterns. We encouraged exercise and supported and coached clients during weekly follow-up visits. Despite the educating, planning, hand-holding, and good intentions, we realized that what we were doing was not working in the long run. Why did we fail? Or did the clients fail? More to the point, is the entire approach a failure? We argue for the last option.

WHY CONSIDER A NONDIET APPROACH Some health professionals may argue that weight loss is necessary to reduce one’s risk for disease. This assumption can be challenged by reflecting on these points: • If there is no proven effective method of achieving weight loss, why do we continue to prescribe it? • Are health problems associated with obesity caused by repeated weight-loss attempts ? • Is it ethical to help clients attempt weight loss when they’re likely to fail? • Are the 2 to 5% who maintain weight-loss preoccupied with food and weight? Are they undereating and/or overexercising to maintain an artificial lower weight? • If losing and regaining is more harmful than stabilizing at a higher weight, why do we continue to focus on weight loss as a measure of success?

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LIFESTYLE ADJUSTMENT “I don’t want to change my lifestyle — I want to diet.” This is what most people say when confronted with a new way of thinking about lifestyle, weight and fitness. This is analogous to the “quick fix” school of medical care: treat, don’t prevent. It’s easier for people to just follow a prescribed regimen than take charge of themselves. Change is always difficult at first, but once clients believe that they have the ability to find a comfortable balance of food, activity, and life attitudes, they can break free from diet sheets and meal plans forever. Clients make changes simply because it makes them feel good and gives them more energy (Omichinski, 1995). Weight loss, if it occurs, is incidental. Changing a way of life and thinking is a step-by-step process of preference changes. Once progress towards a healthier lifestyle has begun, it is maintained because the clients are learning and improving, not because they are following a plan. They feel a sense of accomplishment. They are not controlled by a diet. Rather, they are empowered to effect change and take charge. Empowerment comes from having a sense of mastery or being in charge, which helps build self-esteem, which enhances empowerment, and so on . . . Dieting is different. Weight loss from following a rigid diet is usually temporary. The new diet is too drastic to be maintained; it is artificial and unpleasant; it is physically and emotionally stressful. So the client stops dieting and resumes old eating patterns. The diet controls the client; the client is not in control. The client lives by the diet sheet. He may lose weight, but has learned nothing about eating or himself. Realistically, a client can’t eat this way for the rest of his life — depriving himself, always thinking of food. An alternative approach promotes self-reliance to maximize potential for health and wellness. The emphasis is on leaving behind disordered eating patterns (that often result from chronic dieting) and optimizing nutrition, rather than achieving weight-loss. The nondiet intervention focuses on self-esteem and self-acceptance issues, on how to resist the cultural pressures to be thin, and on eating for health rather than weight loss. The chart on the following page contrasts the traditional medical (diet) approach with the empowerment (nondiet) approach in counseling issues. The goal of each model is to assist the client to better health, but the diet model has built-in limitations because of a single closed goal. (Appendix #1 gives details.) A nondiet approach gives health professionals many new issues to consider in their interactions and interventions with clients. It takes courage to relinquish traditional medical models, and as we counsel clients to abandon diets and embrace healthier living, we must also provide new signposts to guide them in their journey. Clients have told us that health professionals often deliver counseling and education in a way that rekindles the defeatist chronic dieting syndrome.

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Diet vs Nondiet Thinking on Key Issues Issue Expectation

Medical Model (diet) compliance

Empowerment Model (nondiet) self-awareness

Method

behavior modification, control personal responsibility, choice

Information

filtered (“need to know”)

free

Progress

any weight loss

gradual lifestyle changes

Success

external goals: weight loss

internal goals: self-acceptance

Effect

immediacy

gradual change

Result

daily management

quality of life

Responsibility practitioners in charge

individual in charge

Self-esteem

only after weight loss

natural self-nurturing cycle

Setback

failure

self-discovery, process

Exercise

no pain, no gain

energetic daily living, fun

Food

enemy: deprivation, willpower

friend: enjoyment

Language

“Should I have it? ”

“Do I need it? Do I want it?”

Thinking

“I need it all or nothing at all.” “I can have it if I really want it.”

Attitude

perfectionist, rigid

flexible: goes with the flow

Choice

diet in control; no choice

person in charge, decides what and when to eat

Hunger

out of touch with physical hunger; eats in response to stress

in tune with internal cues, physical hunger; does not use food to deal with stress

(Omichinski, 1993b; 1995)

Are we giving our clients mixed messages? Reflecton the messages posed in the chart on the following page.

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Mixed Messages • Weighing clients to assess health, implying that an improved lifestyle will translate into weight loss • Using “slim,” “trim,” or implying weight loss in title of your program • Using a diet approach: focusing on quantities, meal plans • Prescribing rate of change, not letting client change at comfortable rate • Implying that clients don’t have to accept responsibility for their health • Not allowing clients to gain confidence by taking responsibility • Expecting the client to conform to rigorous, unrealistic routines (Omichinski, 1993b)

Society has begun to accept that diets don’t work. Clients are looking for answers and directions toward a healthier attitude around food and activity and gradually “letting go” of the goal of weight loss. Health professionals in the old mind-set can sabotage clients’ efforts to move away from the diet approach to life. We can best assist them with an empowerment approach to their health issues.

REDEFINING HEALTH A refocused definition of “health” is a starting point for this approach. A meaningful and tangible definition has been developed, which translates into the language of both health professionals and clients. For the professional, health is defined as an independent, nondieting lifestyle characterized by nourishing eating and activity patterns, and self-acceptance. For the client, health means putting aside the scale, calorie counting and fat gram levels. It means listening to your body for signals that mean “enough” and “more,” and discovering individual patterns for food and activity levels that keep you energized. It means finding the strength to accept yourself just as you are and get on with life. Clients can simultaneously be large, healthy and happy if they demonstrate the characteristics of this definition. These new parameters could replace weight standards and diet preoccupation in your clinical approach (Omichinski, 1995).

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MOVING INTO THE FACILITATIVE ROLE The first step to offering the client an empowerment approach is to understand your new role as counselor. You are now a facilitator, adding a new dimension to the traditional role of teacher. Expertise and education are not abandoned; rather, knowledge and objectivity are redirected. It’s natural for clients to want diets from us because they want to lose weight. We may think fulfilling this request is the best approach — but is it? Does the client really want a diet, or merely the sense of security that comes from a piece of paper, telling them what to do? As health professionals, are we listening to the client, or staying in our own comfort zones by providing an individually prescribed diet sheet? A facilitator explores the client’s understanding of and experience with dieting by asking probing, open-ended questions that gently challenge personal myths and understanding. The type of questions that create this atmosphere of trust are shown in the chart below.

Establishing Trust • What makes you think you need to lose weight? • What makes you think there is something wrong with the way you are now? • How do you feel when society tells you to look a certain way? • Do you have to feel this way? • What will happen if you don’t accept yourself?

A recent counseling experience might further clarify this style. “Alma” came for an initial assessment about diabetes. We worked through the nondiet nutrition concepts that would enable her to stabilize her blood glucose levels. A week later she called to tell me it wasn’t working. She wanted to lose weight, and she needed a diet sheet. Was it appropriate to give Alma what she wanted, a diet sheet? The medical model says yes. I analyzed what Alma told me. What prevented the nondiet approach from working for her? Maybe she wasn’t a candidate for this approach. Was having a diet sheet an attempt to control at least one aspect of her life? As I probed further, Alma opened up. She felt overwhelmed:

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• Her daughter was always unloading her problems in her own life; • She was dependent on her husband for transportation; • She had lost interest in life and was bored frequently; • She took no time for herself; • She ate to suppress these feelings (she ate for psychological hunger, not just physical hunger). Identifying these situations enabled us to explore possibilities to break this negative cycle. Alma became aware that she was eating for reasons other than physical hunger. She could see that she needed to make her own decisions about more than just what food to eat.

ENABLING OWNERSHIP In order to make a nondiet approach work, practitioners must move into a facilitator role, working with the client by exploring, challenging assumptions and framing open-ended questions. Part of this approach is to explore the failure of diets with the client, by eliciting acknowledgment from the client that diets don’t work. Simply telling them does not allow the client to take ownership of the idea, a vital breakthrough in consciousness. Through examining their past dieting experiences, you can assist them in coming to the conclusion themselves. The following dialogues contrast the traditional method of providing information with an explorative approach (Omichinski, 1993b). Discussion issue: “I need a diet to feel in control.” Often clients think they want a diet because this is what they are used to following. For the same reason, they look at weight loss as a measure of success. Here is a supplemental role-playing exercise that brings out the issues. Dietitian: Have you ever been on a diet before? Client: Yes, several times. Dietitian: Did it work? Client: Yes, while I was on it. Dietitian: Can you follow a diet for the rest of your life? Client: No, not for the rest of my life. Dietitian: So it doesn't work. No one can realistically follow a diet for the rest of their lives. It isn't because you don't have enough willpower or discipline. Diets don't work. Evidence suggests that 95 percent gain back weight and then some within a five year period. The next scenario sets the stage for the client being responsive to a new approach.

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Dietitian: When you focus on weight loss as a measure of success, how do you feel when you don't lose weight? Client: Like I failed. Dietitian: Did you fail? Client: Yes. Dietitian: Actually you didn't. Because of our genetic predisposition and history of chronic dieting, we may not always be able to lose weight. Client: But I need to lose weight. Dietitian: What has happened in the past by focusing on weight loss? Client: I ended up being more preoccupied with food, maybe undereating and overexercising until I lost the weight. Dietitian: Did you enjoy the process? Client: No, I felt deprived, almost punishing myself for the way I looked. Dietitian: So you were happy to arrive at your goal weight and go off the diet? Client: Yes, I was happy it was over. Dietitian: Would it be different if you enjoyed the process, actually got hooked on your new lifestyle? Client: Probably, but I can't imagine it happening. Dietitian: Let's explore this further. Why do you start dieting? Client: Because I look in the mirror and hate the way I look. Dietitian: Does it motivate you? Client: Yes, I'm really strict with myself and watch what I eat. Dietitian: And then what happens? Client: Well, I can't stand it any longer and I go off the diet. Dietitian: What if you were shown how to feel good about yourself right now? Client: I couldn't do that. Dietitian: But if you could? Client: Well, I would probably have more energy and interest in taking care of myself for a longer period of time. Dietitian: In other words, "feeling good" would not be dependent on weightloss? You would actually be allowed and encouraged to feel good? What a freeing effect it would be! Client: How do we begin? The client ends up reflecting on her own thinking pattern, being convinced that diets and weight loss are no longer what she desires. Additional case studies are presented in Appendix #2.

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Another important step is to jointly identify weight cycling and a history of chronic dieting in the client’s health profile. This will impact the client’s ability to lose weight with a healthier lifestyle. However, when we focus on healthier living per se and not weight loss, improved lifestyle for the client is the desired result. The client’s weight will stabilize, decrease, or slightly increase depending on the genetic profile and previous history of chronic dieting.

TRANSFER POWER Become an enabler of healthier living by transferring “power” for decisions to the client. With the empowerment model, we assist the client in identifying what steps they are making in the process of healthier living, not what they are not doing. We, as facilitating agents in this process, desire changes to be permanent. We can assist clients in reflecting on their true lifetime goals, thus yielding more emotional and physical health benefits. For example, how can clients experience the enjoyment of increased activity? Possibly by experimenting with different activities to find one they enjoy. We can suggest they model others who partake in activity for the fun of it. In our new role as facilitators, we enable the client to explore the options, but the final decision is up to the client. The type of questions we can ask include: “How can you extract the most enjoyment from your food?” The answers you would want to draw from the client could be those in the following chart (Omichinski, 1995).

Enjoying Food • Pay attention to what you are eating • Allow yourself to taste and savor food without guilt • Eat regularly. Don’t come to the table starved and then eat too fast • Notice the texture of foods • Expand the variety of foods eaten

Clients begin to appreciate the flavors, textures and subtle changes in making slight shifts toward a lower fat eating pattern. The process takes time and is enjoyable, resulting in preference changes.

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MATCH LANGUAGE TO INTENTIONS Do you use words like “overweight”? Use the word “large” instead. Do you focus on weight as a measure of success? Replace with the word “health.” Are you able to present the educational information with a health focus? Focus on lifestyle changes, not weight loss. Do you give clients the final choice? Extract lifestyle experiences from your client. Using this information, you can identify and personalize the choices available to the client. Here is a helpful list to cue you further about the art of changing language and using positive expressions of encouragement.

Using appropriate language Medical model (diet) preach compliance control adherence should must prescribe best for you approval limit regimen will power

Empowerment model (nondiet) enable examine explore identify study reflect enjoy extract most enjoyment empower experience delightful choice (Omichinski, 1995)

This nondiet health-enhancing paradigm focuses on wellness solutions and rejects weight-loss dieting and food restraint. This approach offers a journey of self-discovery, not tests of willpower. It celebrates self-esteem, diversity and accepting people as they are, not judging and putting others in molds. It encourages people to get on with living and stop putting their lives on hold while waiting to be thin (Berg, 1992).

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Chapter Four: Applying the Nondiet Approach

It is very difficult for people who have spent years fighting their weight to suddenly accept that significant weight-loss is unrealistic and unnecessary. Parting with the weight loss myth is painful but perhaps not as painful as a lifelong pursuit of false hope and the delay of positive lifestyle changes that can improve health and well-being (Lemaire, 1993; Kirkland and Anderson, 1993). The clients who are candidates for a nondiet lifestyle approach are those who identify that they need to do something (other than entering another weight-loss program) about their eating and activity patterns and self-acceptance. People who are not appropriate candidates for this approach are those who may have a strong belief that they need to, and can, lose weight in order to feel better about themselves. These people are not yet ready for this approach. Let them go. They will need to diet a few more times and hear the message several more times, perhaps from different sources, to give up on the dieting. Dieting to them is comfortable, it’s what they know, and it takes time to move through the process to accept that what they have done all these years has not worked and will do more harm than good. They may find it easier to live in the short term even though the long term will mean even more weight gain. “Just one more time,” or “After I lose the weight” are parts of the dieters’ philosophy that just don't want to let go. In one particular instance, I remember someone calling me up after they heard me on the radio and asking me if I had been on a certain program two years previously. She indicated that she had heard me then, too, but was only listening with half an ear and that now she was ready to hear my message. It takes time for people to move to the state of readiness after years of dieting.

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The nondiet approach to weight management can be applied in many situations. The principles and techniques presented in this course were originally developed to assist people who were chronically concerned about their weight, and people with Type II diabetes and/or heart-health concerns. This approach can also be applied to address a variety of lifestyle concerns.

CHRONIC WEIGHT CONCERNS For several years now, the authors have participated in a 10-week group-counseling intervention, employing the nondiet approach. This intervention was designed to help chronic dieters, binge eaters, compulsive eaters and those preoccupied with weight, overcome their dependence on external sources of control and learn to nourish and accept themselves (Omichinski, 1993). Most clients who came to the nondiet program had extensive histories of failed dieting attempts, while others simply wanted to take steps toward achieving a healthier lifestyle. Participants in the nondiet program were predominantly female (94 percent) and between 36 and 50 years (47 percent); 25 percent were between 21 and 35 years; 20 percent between 51 and 65 years. Few participants were under 21 or over 65 years. Over 80 percent of participants attended eight or more of the 10 sessions — on average 8.3 sessions — much better attendance than the 20 to 50 percent dropout rate typical for weight-loss programs. To assess the frequency of thinking or behaving in a manner consistent with chronic dieters before and after participation in the program, we had participants complete self-administered quizzes at the first and last class of the intervention . A sixpoint response scale (1 = always; 2 = very often; 3 = often; 4 = sometimes; 5 = rarely; 6 = never) was employed. A higher quiz score indicated a more independent, nondieting lifestyle with nourishing eating and activity patterns and higher self-acceptance. Data collected at the classes held in 10 cities across Canada in 1992 and 1993 — a total of 26 classes — were subsequently published (Omichinski and Harrison, 1995). Two hundred fifty-three participants completed the pre-quiz; 208 (196 female; 12 male), average age 43, completed both the pre-and post-quiz. The direction and magnitude of changes and effect of sex, age, initial score, and number of classes attended were measured. Participants made statistically significant changes in scores for each of the 16 statements, as well as for total scores. Men reported a significantly lower frequency of dieting attitudes and behaviors than women on the pre-quiz, but not on the post-quiz. Age and number of classes attended were not associated with changes in quiz scores. Therefore, a lifestyle perspective consistent with dieting thoughts and behaviors and low self-acceptance can be improved by participation in a nondiet lifestyle program.

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Lifestyle Quiz Scale Statement Scores Statement Self-Acceptance Scale I’m unhappy with myself the way I am. I am preoccupied with desire to be thinner. I weigh myself several times a week. I’m more concerned with the number on the scale than my own overall sense of well-being. I think about burning kcals when I exercise. I engage in all-or-nothing thinking. I tend to feel that if I can't do it all or do it well, what’s the point? I try to be all things to all people. I strive for perfection in my life. I criticize myself for not achieving goals. Total scale score

Mean score Pre-quiz Post-quiz

Change*

2.8 2.7 4.2 3.6

4.0 4.2 5.5 5.2

+1.2 +1.5 +1.3 +1.6

3.2 3.2

4.5 4.7

+1.3 +1.5

3.0 2.9 2.6 28.2

4.1 4.0 4.0 40.2

+1.1 +1.1 +1.4 +12.0

2.4

4.1

+1.7

2.5 2.5

3.9 3.8

+1.4 +1.3

3.0 3.0

4.1 4.4

+1.1 +1.4 +1.5 +1.1

Self-Nourishment Scale I’m out of tune with my body for natural signals of hunger and fullness. I eat for reasons other than physical hunger. I eat too quickly, not taking time to focus on my meal and taste, savor and enjoy my food. I fail to take time for activities for myself. I fluctuate between periods of sensible, nutritious eating and out-of-control eating. I give too much time and thought to food. I tend to skip meals and eat early in the day, so I can “save up” my food for one big feast. Total scale score

2.8 4.6

4.3 5.7

20.8

30.3

+ 9.5

Total quiz score:

49.0

70.5

+21.5

*The differences in means for each statement, two sub-scale scores and the total score were significant at P