The purpose of this book is to help doctors and health care professionals treat patients with eating and weight concerns more successfully. Our aim is to enhance the mental and physical health of patients by educating their providers about practical, hands-on strategies, techniques, and tools from the fields of eating and success psychologies. These are approaches that we doubt you learned in your professional training, but they can make all the difference in treating your patients and helping them have a positive relationship with food and their bodies. The psychological principles that we teach for guiding patients toward wellness are timeless and enduring, unlike ever-changing scientific theories on exactly how to eat and exercise.
Our hope is that people with eating and weight concerns will also read this book and take its message (if not the book itself!) about their desire to be treated with dignity and respect no matter what their size or eating problems to their health care providers. Our intent is to give them validation and courage to be candid with their clinicians about what is and what isn’t helpful to them in the provider-patient relationship. Through honest conversation, our aim is to put providers and patients on the same page about what will help them become successful in reaching their mutual goals.
Helping Patients Outsmart Overeating will teach you and your patients how to best use your limited time together to address behaviors such as binge eating, emotional and compulsive eating, mindless eating, run-of-the-mill overeating, and chronic weight cycling. Rest assured, we’re not trying to turn doctors into eating disorders’ therapists, nor do we view using basic psychological approaches during a medical visit as a substitute for patients getting additional, targeted clinical help for their eating problems.
The “psychology of eating,” a term with which both providers and patients may be unfamiliar, is the study of how, when, and why we eat. It is not about “what” to eat, and this is not a book about nutrition. In a way, it’s about everything but food—understanding the effect that mood, ingrained beliefs, emotions, stress, appetite cues, self-talk, trauma, social support, self-care, unconscious intrapsychic conflicts, a balanced lifestyle, and life skills have on our relationship with it. The “psychology of eating” is focused on enhancing mental health, mindfulness, self-care, emotional regulation, and life skills, which will lead to improved attunement to appetite, more nutritious food choices and appropriate food portions, and the development of consistent exercise habits to promote ongoing good health. Think of it as creating lasting change from the inside out, unlike diets, which promote temporary change from the outside in, assuming that a thinner body will lead to increased happiness.
Thought leaders in the field of eating disorders have known for more than three decades that it is less the “what” of eating than the “why” and “how” that make all the difference in people developing a positive relationship with food. The “psychology of eating” is mindful of nutrition, but it is not focused on calories, carbohydrates, fat and sugar grams. Its ultimate goal is to teach patients how to develop a positive, “normal” relationship with food, which means:
■Feeling deserving enough and empowered to take good care of one’s body, which includes developing and sustaining internal motivation for this essential task.
■Holding a belief system and engaging in positive self-talk, which are congruent with and generate positive health practices.
■Not dieting or thinking of food in “good” or “bad” moralistic terms.
■Making health and wellness one’s focus, not a number on the scale.
■Developing appetite attunement regarding hunger, food choice, and satiety.
■Ending emotional and compulsive eating.
■Using food primarily for nourishment and occasionally for pleasure.
■Developing effective life skills to increase self-care and manage stress and distress without turning to food, promoting consistency which helps sustain positive behavioral change.
■Resolving underlying, mostly unconscious, internal conflicts, which can otherwise interfere with attaining and sustaining eating and fitness-related goals.
Helping Patients Outsmart Overeating seeks to transform patients from being dysregulated eaters (restricting food which leads to overeating which leads to restricting food, etc.) into “normal” eaters—people who eat (mostly) when they are hungry, make nutritious and satisfying food choices, eat with awareness and an eye toward enjoyment, and put down their knives and forks when they have had enough. Though deliberately not weight focused, “psychology of eating” strategies set the stage for patients to end dysfunctional food patterns and eat more nutritiously, which may result in weight loss and maintenance of a natural, comfortable weight.
In this book, we are addressing patients who have eating attitudes or engage in eating behaviors which prevent them from feeling empowered, comfortable, sane, and relaxed around food. When we refer to “doctors” or “clinicians,” our aim is to include all health care providers—nurses, nurse practitioners, dietitians, diabetes educators, therapists, eating and life coaches, and others—who care for patients with eating or weight concerns.
Our ultimate goals are to change the conversation between patient and professional (and among professionals), to advance the state of the art in the treatment of eating and weight concerns, and to support providers in successfully encouraging patients to improve their attitudes and habits around food in order to eat both “normally” and healthfully. This approach employs helpful practices from motivational theory, eating psychology, and success psychology, in order to empower and support patients in making cognitive, emotional, and behavioral changes that promote long-term health. A sample of this collective wisdom encourages health care providers to help patients by:
1.Focusing on both mental and physical health improvement, leading to enhanced patient self-efficacy and sustainable wellness, rather than on weight loss, as the ultimate goal.
2.Using motivational interviewing, appreciative inquiry, and other success-promoting methods that help patients take responsibility for setting and reaching realistic health goals.
3.Using words, tone, and body language that are constructive, engaging, empathic, honest, compassionate, realistic, respectful, and, above all, nonjudgmental about weight and size.
4.Avoiding weight shaming, stigmatization, and lecturing or preaching about what they should or shouldn’t put into their mouths or how vigorously they should exercise, and instead empowering patients to operate from a mindset of self-acceptance, self-compassion, and an internal locus of control.
5.Recognizing that eating and health concerns are highly complex, biopsychosocial phenomena, involving genetics, environment, life history, self-talk, temperament, emotions, psychology, biochemistry, trauma, and much more.
6.Understanding that the inability to resolve eating and weight concerns is often rooted in (conscious or unconscious) internal conflicts regarding worthiness and deservedness of good mental and physical self-care, and that sustained health maintenance takes root only after these conflicts are resolved.
7.Reinforcing that small, incremental steps count; practice makes progress (not perfection); consistent, constructive thoughts and behaviors lead to success; and it is more beneficial to focus on what patients are doing right than on what they are doing wrong or have yet to do.
8.Recognizing how trauma, abuse, neglect, poverty, class, race, poor self-efficacy, life skill deficits, depression and anxiety disorders, among myriad factors, often underlie or exacerbate eating issues, and helping them access appropriate help or treatment for these issues.
9.Listening to them talk about their physical ailments without turning them into “weight problems” (along with medical staff insisting they get weighed, this is higher-weight patients’ most common complaint about doctors and health care practitioners).
10.Recognizing how clinicians’ own eating or weight struggles or biases may color their attitudes in addressing patients’ food issues and get in the way of providing effective and caring treatment.
Helping Patients Outsmart Overeating is written by an experienced pediatrician and a seasoned eating disorders’ clinician, both of whom have had their own mega-eating struggles. Both authors have experienced the misery of yo-yo dieting, sneak eating, binge eating, food deprivation, weights traveling up and down the scale, and relationships with food that could at best be called dysfunctional and, at worst, downright self-destructive.
One of our major goals is to eliminate the blame and shame felt by both parties when patients fail to follow their health care providers’ nutritional and activity-related advice for the long term. Playing the blame game is a barrier to clear and open communication and what providers and patients most want: successful, sustained improvement in wellness-promoting attitudes and behaviors.
Providers are not to blame. They attended medical, nursing, or other professional schools and entered their respective fields to prevent and cure illness and improve and save lives, not to spend an inordinate amount of time nagging and badgering patients into making healthy lifestyle changes (most of which their patients already know they need to make). Like the rest of our culture, most clinicians have been hoodwinked into believing in the long-term efficacy of diet programs, pills, and surgery. And many have also bought into our culture’s rampant fat phobia and prejudice. How could they not?
Patients are not to blame either. They, too, have been conned by the diet industry and our culture’s obsession with thinness rather than wellness. Anyone who has ever dieted is intimately acquainted with why restrictive eating doesn’t work for the long term due to pervasive feelings of deprivation, the exhaustion of unending self-control challenges, metabolic compensation and weight-loss plateaus, and inevitable rebound eating. This pattern produces a repetitive diet-restrict-binge, “yo-yoing” cycle that often leads to energy depletion, frustration, feelings of helplessness, plummeting self-esteem, and a sense of despair, in addition to deleterious physical and metabolic consequences. Until our patients confront the psychological roots of this revolving-door pattern and develop more effective life skills and appropriate mindsets, admonitions to eat less and move more will do little to help them.
A major challenge in writing this book has been finding an appropriate term to describe the patients we seek to help. The most commonly used terms for this population in the medical vernacular are “overweight,” “obese,” or “morbidly obese.” Because these terms reflect a judgmental, weight-normative approach and, therefore, carry negative connotations, they did not fit the bill. It’s obvious that no patient wants to be called “obese,” and even the seemingly innocuous “overweight” is a judgment that being in excess of a particular number means patients are automatically unhealthy, which is patently untrue. Many other factors, aside from weight, contribute to good or poor health.
Several studies on how patients feel about the terminology used to describe their weight and size by medical providers tell us that, indeed, language matters to them a great deal. Themes from research include avoidance of return medical appointments if doctors used stigmatizing language1 and the fact that some populations might consider being called “overweight” and “obese” an indication that they are “unmotivated, depressed and do not care about themselves.”2
The same difficulty is found with the term “weight problem,” in that research cited in Chapter 3, “How Diets Kill Motivation and Make People Fatter,” tells us that how much people weigh is not a particularly effective tool in measuring overall health. It is not weight per se that is the problem, but rather dysfunctional eating, sedentary lifestyles, and inadequate self-care strategies, along with other factors such as genetics and biology, which are not under the patient’s voluntary control.
Lest you think that we are simply being excessively politically correct by challenging the common usage of “overweight” and “weight problems,” we assure you that our sole purpose is to do what is in the best interest of patients to become healthier, not adhering to some model of political correctness. As the saying goes, when you’re a hammer, everything looks like a nail. Using terminology that makes weight the problem will not lead to effective, holistic treatment or to a satisfactory, sustainable resolution of patients’ eating problems. If it did, there would be no need for this book.
Our conviction is that words spring from beliefs. If we believe that something is wrong with the patient because they are outside of certain weight norms, we are making a negative judgment about them. Why not call them what they are: high or higher weight, which is descriptive without making a judgment? By taking a more weight-inclusive approach, providers enable themselves to see the patient in context, rather than simply as a number on the scale. Research indicates that this weight-inclusive approach is better for both patient and provider.3
Chapter 1 validates doctors’ frustrations about patients not heeding their advice to eat less and move more, and Chapter 2 provides the patients’ perspective of struggling—and, more often than not, failing miserably—to permanently improve their eating and health and their unhappiness with how doctors treat them and their weight concerns.
Chapter 3 presents evidence for why diets don’t work for the long term and actually can make people regain more weight than they originally lost—not to mention how dieting increases stress and frustration and lowers self-efficacy, which often triggers mindless eating. In Chapter 4 we describe common personality traits of the dysregulated eater, as well as the effects of abuse, trauma, and mood disorders that can exacerbate dysregulated eating behaviors, and in Chapter 5 we focus on how to help patients become “normal” and nutritious eaters.
Chapter 6 gets up close and personal, describing how practitioners’ own battles with food and the scale may get in the way of discussing patients’ similar concerns. Chapter 7 details how the doctor-patient collaboration can produce successful, lasting resolution of patients’ eating and weight concerns through the use of appropriate, nonjudgmental language, empathy, compassion, and motivational interviewing, among other strategies. Finally, Chapter 8 discusses how collegial and ancillary support networks and learning about Intuitive Eating, the weight-inclusive approach to health, and Lifestyle Medicine principles can support both patients and clinicians in reaching their goals.
At the end of Helping Patients Outsmart Overeating, there is a bibliography and listing of helpful books, websites, and resources for patients and practitioners for ongoing education and support.