Many health professionals are in transition

A paradigm shift from weight loss to healthy living

(used with permission from Healthy Weight Journal, May/June/93)

by Linda Omichinski, R.D.
The shift from using the traditional medical model toward the health promotion model is gaining acceptance. However, many health professionals are in transition between the two approaches. The result may be mixed messages in the approach that we are using. When a client walks into our office still wanting weight loss and a diet, do we still provide this service? Or do we focus on lifestyle change and still continue to measure success by the number on the scale i.e. weight lost? Using weight loss and thinness as goals, we are just changing our methods. What must change are our goals.

Some health professionals may argue that weight loss is necessary to reduce one's risk for disease. Let's challenge these assumptions by reflecting on these questions:

• If there is no proven effective method of achieving weight loss, then why do we continue to prescribe it?
• Are many of the health problems associated with obesity the result of repeated attempts at weight loss?
• Is it ethical for us to assist clients in another attempt at weight loss only to set them up for failure as the inevitable weight gain occurs?
• For that 2 to 5 percent who maintain the weight loss, are they constantly preoccupied with food and weight, are they undereating and/or overexercising to maintain this artificial lower weight?
• If losing and regaining weight is more harmful than stabilizing at a higher weight, why do we continue to focus on weight loss as a measure of success?

In order to help move us in this new direction so that we can become more effective in our counseling, let's look at a case in point.

Lia, a 21-year-old young female came in to see me. She didn't need much convincing that diets don't work as she indicated that she was heavier because of dieting.

Lia recognized that diets make you fatter; however, she still desired weight loss. She didn't change her goal. She still wanted to be thin and thought healthier lifestyle would get her there. Clients and health professionals are used to judging success by weight loss. Let's work through the process of moving the client from the goal of weight loss to other viable alternatives.

The first step would be to assess the client's present lifestyle patterns. In Lia's case, it was discovered that she ate once a day beginning at 10 p.m., smoked a pack of cigarettes a day and started smoking at 14 for weight loss. Her eating pattern consisted of lots of carbohydrates with little to no protein. She enjoyed high fat foods and craved sweets frequently and was very inactive.

Using the traditional medical model, Lia would be told to eat foods lower in fat and participate in more activity, the definition of changing one's lifestyle. Is this not a diet repackaged under the new banner "lifestyle"? This is not the approach that was used.

When Lia left my office on the first visit, she felt relieved that she wouldn't have to diet and confident that she would learn to eat and exercise for energy, not exhaustion. She realized that there were "no good and bad" foods and therefore allowed herself to extract the most enjoyment from the food. In this way she was satisfied with less. Lia was given some support materials (book, audiotapes, fitness video) and her progress assessed a few weeks later. She was shown how to regain confidence in her ability to focus on health and lifestyle and to take responsibility for her own health. Lia was beginning to understand that there was a new way of looking at food and her old approach. When introducing clients to this new way of thinking, it takes time to internalize and accept it as part of their new way of life.

On Lia's return visit, some interesting points were discovered. Lia was taking a diet approach to lifestyle. She ate properly according to her definition and memory of former attempts to lose weight for a few weeks, lost weight and then binged and regained the weight back. She didn't feel that she was making progress as it was still defined by weight lost.

She managed to hear some of the message, but returned to the familiarity of what she "should" be eating. She ate the "proper" foods for a couple of weeks, depriving herself of her favorite foods such as french fries and gravy. Then the onset of the binge was a failure to Lia, rather than a normal response to the dieting deprivation cycle.

She also participated in a fitness video that she enjoyed and felt energized; however, she started too intensely and only maintained activity level for a week. Lia had difficulty with letting go the goal of weight loss.

In this session Lia was enlightened to find out that in fact she was slipping back into her usual pattern of judging success (weight loss) and eating and exercising according to the entrenched methods that were so familiar to her (restrictive eating and daily exercise). She began to recognize this pattern as we discussed it and allowed herself to learn from it.

We needed to backtrack and assess any progress that she did have, giving her new ways of measuring success. Lia had made strides in the following areas:

• allowing herself to taste and savor foods and therefore is satisfied with less;
• eating more regularly
• smoking 1/2 pack of cigarettes instead of 1, recognizing that some cravings for cigarettes were the result of low blood sugar, physical hunger
• having more energy.

On this visit, Lia appeared more vibrant and was taking more care of herself. It was pointed out that these were parameters of gauging success in terms of health and self-acceptance. Lia hadn't failed because of lack of weight loss; she succeeded in breaking through the one goal that for so many years she was putting her life on hold until she attained it. She also recognized that by focusing on weight loss as a measure of success over the first couple of weeks and for many years previous to this day, it made her more preoccupied with the food she ate, her obsessiveness tendencies increased, and she judged her self-worth and progress by the number on the scale. So often we equate weight loss with improved health, yet these are not indicators of better health and improved quality of life, so why focus on weight loss at the expense of health?

Where does Lia go from here? Lia recognizes that she does feel better about herself when focusing off weight. She is allowing herself to fine-tune her lifestyle, tuning into texture in foods (trying french fries without gravy to experience texture), taking time to actually get hooked on activity, and learning to stop punishing herself for the way she looks. Lia is more gentle to with herself. Lia understands that healthy living is a process that takes time and is beginning to enjoy the process. Weight loss is no longer the motivator. Her new focus is energy and improved self-esteem. Lia is beginning to adopt a healthier attitude around food and activity and gradually "letting go" of the goal of weight loss.

We as health professionals need to look at these goals as viable alternatives. Are we giving our clients mixed messages? Reflect on these questions:

• Are you weighing clients as indicators of health, implying that an improved lifestyle will translate into weight loss?
• Are you using the words "slim," "trim" or implying weight loss in the title of your program?
• Are you using a diet approach to lifestyle, still focusing on quantities, meal plans, in other words, repackaging the traditional "diet"?
• Are you allowing the client the power of choice in her or his decision to make the change at a rate comfortable to the individual?
• Do your methods allow the client to regain confidence in his or her ability to accept responsibility for his or her own health?
• Do you expect the client to conform to rigorous routines that you can't conform to yourself?
• Do you understand that in situations where a permanent lifestyle change to improve one's health status such as diabetes is required, focusing on weight loss can worsen the client's condition as in most cases, weight is regained?

As clients move toward this refreshing new direction in health, health professionals in the old mindset can attempt to sabotage client's effort. We need to ask ourselves "Are we part of the problem or part of the solution?" and equip clients with appropriate responses to be effective educators of this health professional group.

Advise the client in telling physicians or other health educators of their accomplishments with regard to change in lifestyle, and ask the physician what more they would be expected to do. When the physician looks at the client's dieting history and assesses progress, he may begin to understand that the client, given her genetic predisposition and history of chronic dieting, has a definite improvement in overall health status.

Putting the client on another diet would be an irresponsible decision. On the other hand, if the physician ignores the obvious facts, the client always has the choice of finding another physician with a more open perspective on health. We need to realize that we have to be consistent with our message and help our clients to find other health professionals that can support them with these new goals.

HUGS/Obesity & Health 1993

Moving from diet to nondiet thinking

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% gain back weight and then some.

This scenario sets the stage for the client being responsive to a new approach.

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 end 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 finally 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, I can't imagine this 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 weight loss. You would actually be allowed and encouraged to feel god. what a freeing effect it would be! Client: How do we begin....

Client ends up reflecting on her own thinking pattern, being convinced that diets and weight loss is no longer what she desires.