Strategies to Help Patients Achieve Their Eating and Health Goals
(I Get It—We’re Talking Health Gains, Not Weight Loss!)
■The current state and failure of medical practice regarding outcomes such as weight and BMI and the need to refine our focus on health promotion and controllable lifestyle behaviors
■The argument for helping patients develop a psychological foundation for sustainable improvements in thinking and behavior regarding food, fitness, and wellness success
■The “wellness skill set” that patients can learn to sustain health-promoting behaviors
Right about now you might be relieved to know that diets have failed patients and not the other way around, and you also might be feeling a bit uneasy about having recommended calorie restriction to your patients in the past, albeit with the best of intentions. Moreover, you might be puzzled about the most effective approach to help patients attain—and maintain—their eating and fitness goals. After all, they look to you to provide information and strategies to guide them toward improved health. One point you might consider is that many patients actually have been succeeding at weight loss—but over and over and over again.
As health care providers, most of us were trained to define weight loss as the single most important outcome for our higher-weight patients. In medicine, we typically evaluate success in terms of health-related outcome parameters, and since the invention of the scale, a patient’s weight has always been the major part of the equation. In addition to weight, health status has been measured by BMI, which takes into account patients’ weight for their height in determining whether they are “underweight,” “normal weight,” “overweight,” or “obese.” Weight goals are so ingrained in our medical culture that we rarely question whether they represent a true measure of wellness for the patient. This sad reality is likely to be the case regardless of our health care discipline.
Brain food for providers: What do you find helpful about using patients’ weights to measure their health? What do you not find helpful? What other measures would you consider as equally, or more, important when evaluating overall wellness?
Brain food for patients: What would you like your doctors and health care providers to attend to and assess when determining your health other than weight loss? How do you feel when they overfocus on weight or BMI as a measure of wellness?
WEIGHT OR BMI ALONE IS AN INADEQUATE INDICATOR OF HEALTH
In assessing a patient’s level of wellness, there are several problems with relying on the number on the scale or on quantitative outcomes alone. First, weight and BMI may be useful for research purposes and convenient for tracking progress, but in a vacuum, “they are meaningless in determining someone’s health status.”1 Additionally, focusing on weight or BMI in lieu of other markers of health and well-being has unintended consequences in terms of causing patients to overfocus on them at the expense of other measures, including level of fitness, which research demonstrates is a better indicator of health.2 This overfocus breeds fear, stigma, and shame that can lead patients to give up on improving health-promoting behaviors altogether if they fail to achieve or maintain weight loss.
Moreover, weight loss, by itself, does not necessarily improve health, as evidenced by people who lose weight due to illness, anorexia, or depression, for example. A normal or low BMI may not indicate a healthy or lean body, because BMI tells us nothing about a given individual’s health habits, percentage of lean body mass or where fat is stored in the body. In fact, the medical literature suggests that even people of normal or low weight may have metabolic dysfunction and increased cardiovascular risk related to a relative excess of visceral fat stores3 4 resulting from such diverse factors as genetics, sedentary lifestyle, weight cycling, stress, hormonal factors, or an over-processed, low nutrient–density diet. Metabolic dysfunction related to excessive visceral fat stores can put patients at increased risk for cardiovascular disease, type 2 diabetes, and certain cancers, regardless of their BMI.5
Conversely, according to Dr. Carl Lavie, author of The Obesity Paradox, “When people start to develop exercise habits that improve their cardio fitness and muscle strength, everything else improves (i.e. body composition, overall health profile, risk for disease and death).”6 According to Dr. Lavie, “exercise and fitness can clearly protect you from death and disease regardless of weight.”7 The point is that thinness, BMI, and even lab values in and of themselves do not provide a complete or meaningful picture of either physical or psychological well-being, satisfaction, or happiness. We would do better to focus on lifestyle habits that actually do improve health, such as nutritious eating habits, consistent exercise, avoidance of smoking, stress management, adequate sleep, relational connection, and life balance. This attention to controllable lifestyle factors represents a major focus of Lifestyle Medicine, which we will discuss further in Chapter 8.
WHAT IS WEIGHT CYCLING AND WHAT ARE ITS DANGERS?
As discussed in Chapter 3, research indicates that weight loss in our society is likely to be temporary, because most people regain most or all of the weight they lose, only to start the process anew. Thus, the number on the scale on any given day does not necessarily represent the full measure of lasting success—or health—for the patient. Temporary behavioral change leads to temporary results, and external motivators rarely work as well as internal ones when permanent behavioral change is the goal. As we know from experience, lost weight will generally return when the diet or illness or other proximate cause ends, and many dieters lose and gain weight over and over again, a process known as “yo-yo dieting,” or weight cycling.
In her book, Health at Every Size, Linda Bacon, Ph.D., cites a study by Dulloo et al. that reports that weight fluctuation is an “independent risk factor for metabolic disease,” including diabetes, hypertension, and cardiovascular diseases, independent of body weight.8 According to research scientist and psychology professor Tracy Mann, Ph.D., an expert on the psychology of eating, dieting, and self-control, and the author of Secrets from the Eating Lab, a growing body of evidence suggests that weight cycling actually contributes to metabolic harm for the long term and may be more dangerous than maintaining a stable weight at the higher end of the weight or BMI recommendations: “The majority of the evidence suggests that weight cycling is associated with an increased risk of illness and death. Those studies find that you are better off maintaining a stable obese weight than starting obese, losing weight, and gaining it back.”9
From the literature and conclusions reviewed in Chapter 3, it would seem that a more appropriate wellness-promoting goal would be the avoidance of weight cycling by helping our patients achieve lasting, rather than temporary, behavioral change, since behaviors implemented consistently become habits and are more likely to stick.
LASTING BEHAVIORAL CHANGE REQUIRES A SOLID PSYCHOLOGICAL FOUNDATION AND SKILL SET
We know that permanent behavior change is not simply a question of motivation, and that, as Jennifer Taitz, Psy.D., author of End Emotional Eating, puts it, willpower “is less about will than it is about skill.”10 Rather, we need to help our patients recognize that lasting success in maintaining wellness-promoting attitudes (such as body appreciation) and lifestyle behaviors (such as “normal” eating, regular physical activity, effective stress management, adequate sleep, and maintaining healthy relationships) lies in mastering certain foundational beliefs, thoughts, attitudes, and learnable life skills that are actually effective in improving self-efficacy and thus driving permanent behavior change. You might be surprised to know that these foundational contributors to successful long-term behavior change are psychological in nature and include identifying and regulating emotions that trigger mindless and non-nutritious eating. Also important are skills related to mindful attention, self-acceptance, and autonomous motivation, as described by Beth Frates, M.D., and Margaret Moore, M.B.A., in the Lifestyle Medicine textbook chapter titled “Health and Wellness Coaching Skills for Lasting Change.”11 We put the cart before the horse when we encourage patients to white-knuckle nutritious eating and weight-related behaviors before they have the attitudes and skills to forge those behaviors into habits that sustain desirable outcomes.
The foundational beliefs, thoughts, attitudes, and life skills that characterize psychological well-being cannot be measured the same way that weight or lab values can, but they play an absolutely critical role in assuring lasting success for individuals who seek to achieve permanent wellness-promoting behavior change. They are fundamental tenets of the psychology of success, and, for the patient, they amount to nothing less than the deliberate, incremental creation of a new self-concept.12 It is this self-concept, coupled with a deeply entrenched internal locus of control and effective self-regulation strategies, that can motivate patients to commit to the consistent and sustainable thoughts and attitudes that drive wellness-related behaviors. Alas, we have been trying (to little avail) to heal our patients from the outside in rather than from the inside out!
It is important to understand that mastering the beliefs, feelings/emotions, self-talk, and attitudes that facilitate consistent wellness-promoting behaviors ultimately leads to improvements in health and wellness, with or without weight loss. Without a psychological foundation of self-efficacy and self-regulation in place, the behaviors we recommend and the outcomes we seek for our patients risk being unsustainable, like a huge house without a solid foundation. Once these foundational components are in place, however, lasting change is patient-motivated, patient-driven, and far more likely to be achieved and sustained for the long term.
Brain food for providers and patients: What life skills do you believe are essential to engage in good health care, especially around eating and weight concerns?
THE WELLNESS SKILL SET CAN BE LEARNED AND PRACTICED TO IMPROVE BEHAVIORS AND OUTCOMES
Please don’t let this new concept of a Wellness Skill Set scare you. You chose this book to learn a new way to benefit your patients. Success for them hinges, quite simply, on identifying and improving the conscious and subconscious set of beliefs that drive their eating, exercise, and other self-care behaviors. It also rests on the development of important life skills (including self-regulation) that improve our patients’ chances of implementing and sustaining those wellness behaviors over a lifetime. Once these life skills are learned, the patient benefits from enhanced awareness of and conscious attunement to internal sensations, cues, emotions, and needs, as well as a nonjudgmental, conscious appreciation of their values, strengths, and challenges.
People who have developed this skill set improve their ability to visualize their desired outcome and set and reach appropriate goals through planning, focus, consistency, and persistence. These competencies contribute to the development of enhanced self-efficacy and the generation of a positive self-concept, which may have been missing in the patient’s life, whether or not he or she realized it. With this awareness, an internal locus of control, and with deliberately chosen constructive beliefs, attitudes, and life skills in place, our patients will be better able to implement wellness-enhancing thoughts, as well as provider-recommended behaviors and actions, consistently, rather than engaging in the on-again, off-again dieting behavior that leads to stagnation and weight cycling.
IF NOT WEIGHT AND BMI, THEN WHAT PATIENT ATTRIBUTES DO INDICATE SUCCESS?
So what does success look like for the (formerly) dysregulated and now “normal” eater? On the surface, we may notice that these successful people maintain a comfortable weight, eat healthfully, exercise regularly, manage stress well, and have stable, mutually satisfying relationships. But what is truly foundational for them are the qualities that we cannot see. When it comes to the aspects of wellness that patients can control (outside of genetics, injury or illness, for example), successful people have eight common psychological attributes that are key to resolving dysregulated eating.
These successful people are (1) self-regulated, (2) self-compassionate, (3) attuned (to their strengths as well as to their appetites), (4) clear visualizers, (5) process oriented, (6) positive, (7) persistent (high frustration tolerance with the ability to delay gratification), and (8) consistent. The good news for those of us who were not born with temperaments which might lead us in these directions, or who have lost any innate predisposition to be this way, is that these attributes can be deliberately adopted, learned, practiced, and integrated into one’s life. Many of our patients are not even aware that they lack these attributes. Once they decide to adopt them, however, they are on the road to developing an internal locus of control and the power and self-efficacy that comes with it. Furthermore, these traits are interrelated, such that progress in one area can actually promote progress in the others, facilitating rapid growth and success.
Self-regulation
Most doctors and nonmental health care providers likely have never given much thought to this vitally important attribute of those who succeed at maintaining wellness-enhancing behaviors over the long haul. Albert Bandura, Ph.D., father of Social Cognitive Theory of human behavior, describes self-regulation as including “self monitoring of one’s behavior, it’s determinants, and its effects; judgment of one’s behavior in relation to personal standards and environmental circumstances, and affective self-reaction,” and as “provid[ing] the very basis for purposeful action.”13 Bandura notes that self-regulation is closely tied to self-efficacy, which he defines as “people’s beliefs about their capabilities to exercise control over their own level of functioning and over events that affect their lives,” and he adds, “People’s beliefs in their efficacy influence the choices they make, their aspirations, how much effort they mobilize in a given endeavor, [and] how long they persevere.”14
The ability to self-regulate is thus important to sustaining motivation as well as behavior, and many dysregulated eaters, due to the personality traits discussed in Chapter 4, including all-or-nothing thinking and tendencies toward perfectionism, are weak in this area. Moreover, many dysregulated eaters have self-regulation problems beyond their struggles with food. Consider a person who habitually stays late at the office in order to complete important projects, despite the fact that he or she is exhausted. Or the individual who alternates between TV binges and giving up TV for months at a time. Or folks who regularly ignore their internal signals and overdo exercise at the gym, then chronically suffer from soreness or injury that impedes their progress toward sustainable fitness.
It probably won’t surprise you to consider how these types of self-regulation problems affect many chronic dieters who are also high achievers. In order to excel and please others, many of us override our own feelings, needs, and desires for the good of the project, group, or organization. This makes us successful in our professional lives, for example, but may lead to physical and emotional depletion over time, increasing our risk of seeking solace through eating.
Effective self-regulation involves an individual sensing and identifying internal affective states (such as emotions and moods), recognizing dysregulation, and making corrections to move into greater balance. Skilled self-regulation (defined behaviorally as “the ability to act in your long-term best interest, consistent with your deepest values” and emotionally as “the ability to calm yourself down when you’re upset and cheer yourself up when you’re down”)15 is about maintaining life balance and adequate levels of emotional energy through intentional self-care not only when obstacles arise but even when things are going well, before you “need it.”
It includes planning ahead, commitment to preventive and ongoing self-care, self-attunement (not just to food but also to the need for rest, stimulation, companionship, nurturing, play, and self-expression), and ongoing attention to our mind-body-behavior connection. Self-regulation is rooted in awareness and self-attunement, acceptance of what you are experiencing in the moment, recognizing what you value, and making a commitment to acting in your own best interest, regardless of circumstances or events. It is thus, emotionally speaking, about designing your vision for your life deliberately and then responding, rather than reacting, to the vagaries of daily life, while each day making choices in accordance with your deepest values.
Jennifer Taitz, Psy.D., describes research indicating that people who binge eat struggle with skills related to emotional intelligence and emotion regulation: “Research finds that difficulty in identifying and understanding emotions, as well as problems regulating them, influences binge eating more than gender, food restriction, or overvaluing shape and weight do (Whiteside et al., 2007).”16 Taitz explains the importance of and interrelationship among awareness, emotional intelligence, and self-regulation in understanding dysregulated eating beautifully in her book, End Emotional Eating, which we highly recommend to providers and patients. In her chapter on mindfulness, she reminds us, “If you are in the habit of eating to stop feeling, you may confuse emotional pain with hunger . . . eating may serve as a way to avoid or escape emotions. When you bring awareness to your emotions, you may choose how to respond, rather than habitually reacting.”17
As you have learned in earlier chapters, many dysregulated eaters have weak self-regulation skills. They may skip breakfast because they have “more important” things to do, or sleep through their alarm clock after having stayed up too late the night before, and wind up hungry and depleted mid-morning when they encounter a plate of cream-filled donuts in the break room. Starving, they may down two of them, then binge at lunch an hour later because they believe they’ve already ruined the day by impulsively having eaten foods that are “bad” for them. This is in important and often overlooked reason that many motivated high achievers struggle with their weight. Their all-or-nothing thinking and overfocus on work over play that enhances their success in the outside world robs them of their attunement to their inner signals of hunger, satiety, anxiety, and frustration. When they become depleted, often because of lack of awareness and planning (due to focusing on what seem to them “more pressing things”), they react by trying to refuel with whatever food is available. They then react to that behavior with punishing, critical self-talk, generating a self-destructive vicious cycle.
At this point, you have likely figured out that successful self-regulation is intimately tied not only to keeping a clear vision in mind in order to execute it but also to maintaining effective self-care during the process of working toward goals. What types of thoughts and activities constitute effective self-care? Are we referring to the massages, shopping excursions, or mani-pedis that are the stuff of high self-esteem and indulgent self-care in media images and magazines? Hardly. According to Karen R. Koenig’s earlier works, Nice Girls Finish Fat and Starting Monday, stellar self-care includes such activities as setting appropriate boundaries with others, engaging in constructive, positive, and supportive self-talk, learning to be aware of, identify, and take responsibility for your feelings (a concept known as emotional intelligence),18 learning to meet the needs behind those feelings in constructive ways (rather than with food, alcohol, drugs, emotional freak-outs, or melt downs), keeping yourself intellectually challenged, getting timely medical checkups, planning ahead for sustenance and pleasure as well as for deadlines, and setting aside time to relax, sleep, play, dream, create, or do nothing.
The deliberate prioritization of life balance through the practice of excellent self-care enables patients to avoid becoming emotionally depleted and losing their motivation to persist in striving toward their goals when the going gets tough. Moreover, good self-care, when internalized as a habit, sends a message to the subconscious that one is deserving and worthy of kindness, nurturing, and support (sound like self-compassion, anyone?), and this attitude of worthiness and deservedness provides the foundation for ongoing, consistent commitment to thinking and acting in one’s own best interest. This habitual commitment to self-care and self-regulation results in increased self-efficacy and personal success in many areas of life, not only in health and wellness.
In his best-selling book, Goals! How to Get Everything Your Want—Faster Than You Ever Thought Possible, expert management consultant, trainer, and speaker Brian Tracy refers to this habit of clarifying values, planning ahead, and working on the plan consistency and in a regulated fashion as key to success in business.19 These success strategies, not traditionally part of medical education, can teach us a great deal about how to help patients sustain motivation. Tracy outlines his seven-step method for goal attainment in his book Change Your Thinking, Change Your Life. The steps include “decid[ing] exactly what you want” (understanding that the simple process of defining your goals makes it easier to prioritize your time well), writing down goals (which helps to clarify them and increase resolve), being willing to “pay the price” of total commitment, “mak[ing] a detailed plan” (organized in terms of priority and sequence), taking immediate and specific action, and working on the plan “every single day” (note the focus on process, rather than outcomes). The last step is “resolv[ing] in advance that you will never quit,” which, he states, gives you a “psychological edge.” He says, “Your willingness and ability to persist are what will eventually guarantee your success.”20
These steps, and the principles behind them, are as relevant to wellness-related goals as they are to business-related goals. They are part of the foundation of self-efficacy, which “correlates positively with success in all realms of personal endeavor,” including patients’ becoming “agents of change in their pursuit of well-being.”21 Contrary to what we may have internalized when we subjugated our own needs for sleep, self-care, and work-life balance in the interest of meeting the requirements of our medical, nursing, or other health care training, effective self-care makes us more resilient, more compassionate, and more effective in serving others, which takes us to the next important attribute of wellness success.
Self-compassion
Meaningful healing for the dysregulated eater requires the development and ongoing practices of awareness and self-compassion. These skills, foundational to emotional intelligence and positive self-regulation, constitute an important part of the work of being an adult, even if you missed out on learning them in childhood. Many dysregulated eaters criticize their bodies harshly and berate themselves for their shortcomings when it comes to eating behaviors. Some think that relentless self-criticism and ongoing “I’m good/I’m bad” thinking, on which diet-think is predicated, will “keep them on track” around food. On the contrary, it does nothing to encourage success, and everything to destroy it.
Research by Dunkley et al., cited by Jennifer Taitz, Psy.D., in her book, End Emotional Eating, indicates that self-criticism actually causes suffering and is tied to anxiety, depression, and eating disorders.22 Conversely, in an Adams and Leary study that she cites, self-compassion improves patients’ ability to stay emotionally regulated, and cope better with adversity without abusing food.23 Exercising self-compassion means accepting the body and the feelings that you have right now as the result of your best efforts to cope with life to date, rather than judgmentally criticizing yourself and engaging in negative, damaging self-talk over your “failure to achieve your goals.” Kristin Neff, Ph.D., psychology researcher and self-compassion expert, describes self-compassion as “a powerful form of emotional intelligence,” allowing you to be “aware of your feelings without being hijacked by them, so that you can make wise choices.”24 In fact, “you cannot live a happy, satisfying life without experiencing the full range of feelings—good, bad, or indifferent. If you shut them off, you’re asking for trouble.”25
Contrary to what many medical providers and dysregulated eaters have been conditioned to believe, mindful acceptance of and self-compassion for where you are at any given moment is not the same as giving up, and we as health care providers seem to have forgotten this—or perhaps we never knew it to begin with. Paradoxically, acceptance, defined as “a willingness to experience thoughts and feelings, even uncomfortable ones,”26 is actually a first step toward change, because it allows us to take responsibility for where we are now and know that we can respond differently in the future. Those who succeed at consistently eating, exercising, resting, and striving in health-promoting ways do so in large part because they do not allow themselves to become derailed by self-sabotaging thoughts or small failures. When they eat more than they intended, or skip a workout, they respond with awareness, self-compassion, kindness, and positive, inspiring self-talk, rather than with self-criticism, knowing that they have both the responsibility and the power to continuously improve their performance, rather than head for the leftover lasagna. Thus, as Taitz reminds us, “accepting emotions can help regulate emotions.”27 This is self-compassion and self-regulation at work, as in knowing when not to stop, but to keep going in the direction of our best life. In this way, as Taitz and Neff put it so well, “self-compassion, not self-condemnation, cultivates change,”28 by “provid[ing] emotional resilience and enhance[ing] well-being.”29
We know from Cognitive Behavioral Theory that actions are based upon beliefs and emotions. Mindful self-compassion allows us to feel our emotions without judging them or reacting to them with negative, downwardly spiraling self-talk. This allows us to keep our beliefs and thoughts rational and positive, which reduces feelings of overwhelm and despair when we fail to behave perfectly or achieve success (which, by the way, happens to us all). When we allow ourselves to experience our feelings, even negative ones, such as disappointment in ourselves for failing to meet our own expectations (very common with dieters) without judgment, we are able to process those feelings and not engage in psychologically self-degrading activities, such as punishing thoughts or reactive overeating.
There is a world of difference between acknowledging that you are disappointed or angry with yourself for mindlessly downing a bag of malted milk balls after a stressful day and feeling compassionate toward your own suffering, versus reacting to that same disappointment and anger by telling yourself that you are a loser and a failure who has no willpower and will never succeed at anything. In the first scenario, we are aware of our suffering and provide ourselves with a safe space to compassionately observe our feelings without piling on further pain through judgmental self-criticism. In the second scenario, we not only fail to manage the stress created by our circumstances but also add to it with our negative self-talk.
When we are compassionate toward ourselves, we can process negative or stressful feelings rationally, learn to manage them, move on, and try again (and again and again), using what we have learned. When practiced consistently, such a compassionate approach increases our psychological resilience, and we are able to continue to persevere in the face of setbacks without having to spend six months on a therapist’s proverbial couch in order to recover. It also helps us to manage stress, both from external circumstances and from the reactive self-talk that poisons our minds.
Over time, practicing self-compassion allows us to spend less time wallowing in and reacting to our shortcomings, disappointments, and the results that we don’t want, thus liberating mental space for us to appreciate the body that we have now and focus on what we do want. We are able to recover from negative experiences and emotions rapidly, rather than using them as an excuse to say harsh, disempowering things to ourselves—or eat mindlessly.30 With practice, we can reclaim the mental energy that we used to spend berating ourselves and, instead, use it wisely to focus on the stepwise process of realizing our dreams. People who have a healthy relationship with their bodies and with food treat themselves with kindness, respect, and compassion. They don’t demand or expect perfection of themselves 100 percent of the time, and they react to imperfection as par for the course and move on.
The result is that when these folks hit the potato chips after work, they do not talk themselves into a denigrating downward spiral that launches them into a full-fledged binge. They either eat a satisfying amount of chips guilt free or, if they overeat, give themselves retroactive permission and move on. By practicing self-compassion and the awareness that accompanies it, these successful people are often able to stop a reactive food escapade (a.k.a. binge) more quickly, which brings us to the topic of attunement. For more information on self-compassion in general and on managing emotions for dysregulated eaters, including exercises that can help patients practice this and related skills, we refer you to Kristin Neff’s Self-Compassion and Jennifer Taitz’s End Emotional Eating, respectively, both listed in the resources section at the end of this book.
Attunement (to appetites as well as strengths)
Another attribute that separates those who are successful at permanently mending their relationship with food from those who live on the diet-binge seesaw is their level of attunement to their internal environment. Most high achievers, approval seekers, and people pleasers are overly attuned to the expectations and demands of the outside world, be it to the requirements of their boss or their colleagues, their spouse, parents, or children. Successful self-regulators tune in to their physical and emotional sensations, and identify them and recognize them for what they are. “Oh, that feeling in my body is fatigue. I think I’ll take a short nap or rest my eyes for a minute,” they’ll say, rather than “I feel uneasy and overwhelmed. I need to get my work done, and I don’t have time to really identify what that sensation is. I might be hungry. I’ll try eating something to see if that helps, and hopefully it’ll give me the energy I need to keep going with this project.”
Successful self-regulators also tune into their internal hunger and satiety signals, and allow those signals to guide them in determining what, when, and how much to eat. These natural, innate (for the majority of us) cues, which many of us learned to override early on and have overridden for many years, can be reclaimed in the process of reregulating our eating habits through appetite attunement. We can also reclaim this attunement by practicing mindful eating, which involves cultivating nonjudgmental awareness and attending to thoughts, feelings, bodily sensations, appetite cues, and responses to food selection and eating.31 For more information on mindfulness as it relates to eating, as well as training resources for providers, we refer you to The Center for Mindful Eating (TCME) and its website at http://www.thecenterformindfuleating.org.
And speaking of attunement, one of the most noteworthy achievements of the past several decades when it comes to promoting healthful eating practices has been the development of an evidence-based approach to appetite attunement and wellness-promoting eating behaviors, known as Intuitive Eating. Developed by Evelyn Tribole, M.S., R.D., and Elyse Resch, M.S., R.D., F.A.D.A., C.E.D.R.D., both experienced in the treatment of patients with eating disorders, Intuitive Eating is a lifestyle approach that promotes appetite attunement and satisfaction for the eater. A person who eats intuitively makes decisions about what and how much to eat from an internal locus of control, rather than according to an externally prescribed dietary regimen. The patient gives herself “unconditional permission to eat” in a mindful, deliberate, attuned way that promotes satisfaction, self-trust, coping with feelings without using food, and enhanced self-efficacy.32
The evidence for Intuitive Eating in normalizing patients’ relationships with food, and promoting self-efficacy and improved health and wellness, is mounting. A recent literature review indicated that “intuitive eating is negatively associated with BMI, positively associated with various psychological health indicators, and possibly positively associated with improved dietary intake and/or healthy eating behaviours.”33 For more information, a directory of Certified Intuitive Eating Counselors, and additional training and certification opportunities for providers wishing to utilize intuitive eating principles to help their patients by becoming a Certified Intuitive Eating Counselor, we refer you to both the book Intuitive Eating, now in its third edition, and the website, https://www.intuitiveeating.com.
Learning to eat intuitively is empowering for patients because it is proof that they can trust themselves and take care of their needs by listening to and honoring internal body signals. This type of attunement and self-regulation has immense and far-reaching repercussions for other areas of well-being as well, because once attunement is achieved and self-care is a priority, the patient is then able to act in her own self-interest with greater self-efficacy in all of life. Learning (or, rather, relearning) intuitive eating is about proclaiming, “I can take care of myself!,” a profound statement for people who have agonized for years with what they perceived as an impossibility.
It is important to note that successful self-regulators also are attuned to their strengths and desires. Rather than focusing on their shortcomings or what they have failed to achieve, they deliberately zero in on what they did well or what they plan to achieve. They use their innate talents and attributes to their advantage when taking on a new challenge or in reflecting upon past failures and considering how to proceed more constructively. This strength-focused approach, also known as Appreciative Inquiry,34 is a foundational element of coaching psychology and success psychology, which we will discuss in more detail in Chapter 8.
Visualization
One helpful key to success is the creative process of visualization, which has been highlighted in the success psychology literature as foundational to goal attainment for years.35 36 Visualization is the fun part of goal setting, and it is a useful tool for enhancing clarity and goal achievement. Just as it is difficult to attain what you have never clearly imagined, imagining a goal—be it an A on your science test or a fit body—can set the subconscious stage for realizing it. Successful people visualize not only the outcome goal (the fit, comfortable body, the exemplary lab values, the clean bill of health from the doctor) but also the individual steps required to achieve it. And in this way, these successful people are also process oriented. They visualize themselves planning, preparing and consuming a gorgeous, fresh, green salad, they imagine themselves running on the treadmill or racing around outdoors with their children or grandchildren on a bright, clear, sunny day. They envision and clarify every detail of their potential success until it resonates with and becomes part of them.37 The process of dreaming, designing, and clarifying goals is another component of Appreciative Inquiry, to be discussed further in Chapter 8.
Process orientation, another trait of successful people, has several advantages over the traditional medical advice model of focusing on problem solving toward outcomes only (the body perfect, number on the scale, or lab values). Motivational theory tells us that, in general, people are more interested in their quality of life and what they value than they are in lab numbers, for example. As Rollnick, Miller, and Butler remind us in their book, Motivational Interviewing in Health Care: Helping Patients Change Behavior, “it is the patient’s own reasons for change, and not yours, that are most likely to trigger behavior change . . . the answers most likely lie within the patient, and finding them requires some listening.”38 It is often much more compelling for a sedentary Prince Charming, who wants to begin an exercise regimen, to consider visualizing the lifestyle choices that will enable him to climb the stairs to his ravishing Rapunzel without becoming winded than to consider what his doctor will say about his blood pressure numbers improving. Process orientation allows people to experience and prioritize the individual small steps that eventually lead to successful outcomes. In brief, people are motivated by what is important to them, and eliciting this by asking about patients’ Desires, Ability, Reasons, and Need for behavior change (the “DARN” statements of Motivational Interviewing),39 using open-ended “how” or “what” questions, can help patients progress to greater readiness for change.40
If they are able to remain mindful, attuned, and perhaps even enjoy the process or experience of becoming more active, for example, patients are more likely to soldier on than if activity is all about getting their BMI under 30 or lowering their LDL. Process orientation also allows patients to refine the vision and prepare for obstacles, including unconscious internal conflicts, which can then be addressed and resolved before they potentially derail the new behavior. Additionally, process orientation solidifies motivation, since visualizing the process (which is usually a synonym for work, commitment, or temporary discomfort, and not just arriving at the big, beautiful goal) requires a person to consider why they want this particular goal so badly and so quickly.41
Positive expectations
Well-being actually may be a more important determinant of wellness success than perfect lab values or an ideal weight on the scale, because well-being encompasses the moods, motivation, and positive outlook that fuel persistence and resiliency. It is consistent, sustained behavior that determines our outcomes. Resiliency, our positive expectation that repeated commitment to values-driven processes and goals will yield benefits, and willingness to persist in the face of adversity may be the fundamental attributes that separate those who succeed and thrive from everyone else.
In his book, Psychology of Success, Dr. Dennis Waitley reminds us that “success is a journey, not a destination. . . . You engage in living successfully on a daily basis.”42 The same could be said of well-being. He imparts to us that “lifelong success has several important ingredients . . . positive habits of thought and action that . . . [include] self-awareness . . . self-direction, self-esteem, self-discipline, self-motivation . . . and positive thinking and relationships.”43 In order for eating behaviors, which are important drivers of well-being and weight over the long term, to normalize or improve permanently, there must be an ongoing practice of mindfulness (defined as the “non-judgmental awareness of what is happening in the present moment”),44 deliberate, self-directed, positive habits and self-talk, and a shift inside the mind of the patient to an internal locus of control that generate the behaviors that determine these outcomes. As discussed previously, people are much less concerned with numbers than they are with their personal values, and only when wellness becomes a core value will the patient assume the responsibility to set clear, effective goals and act in his or her own best interest without prodding and cajoling from a doctor, diabetes educator, dietitian, or anyone else.
Persistence
Persistence is a measure of sustained behavior. It is defined as “the firm or obstinate continuance in a course of action in spite of difficulty or opposition.”45 It is a trait that can be either destructive or constructive. When we keep driving in a blinding blizzard in spite of the fact that we can’t see the car in front of us just because “we want to get there,” we’re not using our best judgment. We’d be better off pulling off the road until it gets plowed or the snow lightens up. The same is true if we’re running a marathon and start to experience pain in our chest. Sure, we’d love to finish the race, but we also want to live long enough to compete again if we’re smart. Pushing and overdoing to get something done are examples of persistence gone awry.
However, persistence can be our friend when we apply it to improving behavior and staying self-regulated. We do this by being dogged, reminding ourselves often that we have a worthwhile goal, appreciating how far we’ve come, telling ourselves how great we’ll feel when we have accomplished our task, visualizing whatever we’re doing as successfully completed, and being our own best cheerleaders. Persistence is, more than anything, rooted in ongoing, positive self-talk and effective planning and pacing (part of the all-important skill of self-regulation).
It may have a hint of “I’ll show ‘em” and not wanting to disappoint others. This is fine as long as we’re not all about approval seeking and proving our worthiness to ourselves or others. The best reason to persist is because confidence and self-efficacy (“the belief that one has the ability to initiate or sustain a desired behavior”46) grow from repeated successful action. Persisting toward a goal becomes easier when our goals are clear and aligned with our deepest values.
Consistency
Related to persistence, one of the biggest barriers preventing dysregulated eaters from reaching their goals is a lack of consistency with their well-intentioned efforts to change their behaviors in a way that promotes sustainable wellness. They engage in a new behavior—take a walk at lunch time, relax for 10 minutes when they arrive home from work, make sure to eat breakfast, or write a shopping list before they head for the market—sometimes but not all the time. They might do it for a week or a month and stop, or they might change their behavior from one day to the next.
To build habits, we must engage in the behavior we wish to have all the time. That tells our brain this is what we desire to happen, and allows the basal ganglia, a part of the brain responsible for habit formation, to turn those repeated behaviors into habit.47 48 Difficult as learning new behavior can be, we want to make sure not to confuse our poor brains by doing this, then turning around and doing that. It is repetition, context, and consistency over time (usually longer than patients—or doctors—expect or would like) that allow new learned behaviors to become habits, solidifying new, neural pathways and allowing old ingrained habits to atrophy and fade.49 If we only engage in a new behavior, say, sitting down while learning to eat mindfully, occasionally, we will be reinforcing both this behavior and also reinforcing old, unhealthy habits, such as eating while working on the computer, watching TV, or checking our phone messages. This dynamic is commonly known as a stand-off, and no progress will be made unless the new behavior is practiced consistently (far more often than the old one), and the change is implemented consistently for a certain period of time. In short, change only happens when we practice the new behavior more often (lots more often) than the old behavior.
Another barrier to consistency is that ongoing focused effort can wear us out. Patients will come in and tell you that they have been going to the gym and can’t figure out why they are not seeing progress. What they’re not telling you is that they have been going, but not consistently: that one week they go three times, another they go once for a half hour, and yet another week, they don’t go at all. They see themselves as being compliant with what is going to lead them to good health, while you see them as not doing enough or not doing it consistently.
Please do not panic. It is not your job to teach patients how to be consistent or self-regulatory. You have enough on your plate. For now, it is sufficient for you to understand the skills they often lack when trying to become more regulated, mindful eaters and consummate caretakers of their bodies. This understanding in itself will help you be more empathic and compassionate toward them. Hopefully, it will also help you be more compassionate toward yourself and the enormous challenge you’ve been up against.
In Chapter 8, we will do two things. First we will detail how to use proven psychological strategies and techniques to support your patients with eating problems, guiding them toward greater mental and physical wellness. Second, we will provide you with existing and emerging resources to support these efforts without adding more hours to your day.
Brain food for providers: Do your patients who struggle with eating and weight concerns have many of these competencies for success? Which do most of them lack? How could you help them recognize their importance and reinforce them in your office appointments?
Brain food for patients: Have you ever learned about the competencies for success? Which ones do you have already, and which do you need to learn? How might you enlist your providers’ help in building these competencies? How else will you learn them?
1.Reading over the competencies for success and recognize that you and your patients both need them if you are to help your patients who have eating and weight concerns succeed.
2.Thinking about your patients of high weights and identifying which qualities and skills they generally appear to lack in success psychology terms.
3.Considering your own personality and character traits, which ones have helped you succeed and which ones you might benefit from cultivating in the future.
4.Not to feel pressured that it’s your responsibility to teach life skills to your patients who suffer with body dissatisfaction, weight struggles, or eating problems.
5.Considering how hard or easy it will be for you to switch from thinking about measuring success in terms of outcomes to measuring it based upon indicators of patient well-being, including those related to awareness, self-acceptance, self-compassion, an internal locus of control, and the ability to self-regulate and respond constructively to challenges.
6.Taking time to think about how you will explain “wellness” measures and “success strategies” to your patients and how they might receive this information.
7.Talking with patients about their values and wellness vision and what kinds of support might help them connect to their goals.
Patients, try . . .
1.Determining which of your values will help you succeed at resolving your eating and weight concerns and identifying exactly why you wish to succeed in this area right now.
2.Rereading the success competencies section and considering whether there are new skills that will help you learn how to succeed.
3.Considering what your focus has been regarding wellness or weight and how that has affected your ability to succeed in attaining and maintaining your health goals.
4.Not feeling ashamed that you might not yet have mastered one or more of the skills you need and desire for success and, instead, being determined and persistent about acquiring them through practice, consistency and patience.
5.If you find that you lack many qualities for success, seriously considering working with a therapist or coach to help you develop them.
6.Shifting your focus from numbers (weight, BMI, etc.) equaling success to thinking, instead, about feeling good in your body and being proud of taking excellent care of it.