New frontiers in nondiet counseling: Empowered clients make healthier choices

(used with permission from Healthy Weight Journal, January/February/95)

by Linda Omichinski, RD
The worldwide nondiet movement has given health professionals many new issues to consider in their interactions and interventions with clients. Society has begun to accept that diets don't work, yet weight preoccupation exists.

It takes courage to relinquish traditional medical models, yet considered risk taking is a hallmark of leadership. As we counsel clients to abandon diets and embrace healthy 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 language that diminishes self esteem and rekindles the defeatist chronic dieting syndrome. We can identify with the diet mentality both personally and professionally.

Clients are looking for answers and direction. We can best assist them with an empowerment approach to their health issues. We adapt these client concerns into our program language.

Health definitions

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 one's 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.

Challenge the comfort zone

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 dietitians, are we listening to the client, or staying in our own comfort zones by providing an individually-prescribed diet sheet?

Establish trust

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. Here are the types of questions that create this atmosphere of trust:

• Why do you want to lose weight?
• Why can't you accept yourself?
• How do you feel when society tells you to look a certain way?
• Do you have to feel this way?
• If you don't accept yourself, what will happen?

Alma

A recent counseling experience might further clarify this style. I saw Alma for initial assessment about diabetes. We worked through the nondiet nutrition concepts that would enable her to stabilize her blood sugar. A week later she called to tell me it wasn't working. She wanted to lose weight, and she needed a diet sheet.

Is it appropriate now to give the client what she wanted, that is, a diet sheet? The medical model says yes.

I analyzed what Alma told me. Why didn't it work for her? Maybe she wasn't a candidate for this approach? Was having a diet sheet an attempt to control one aspect of her life?

Then I probed further, and Alma opened up. She felt overwhelmed with the stressors in her life. 1) Her daughter was always unloading her problems in her life. 2) She was dependent on her husband for transportation. 3) She had lost interest in life and was bored frequently. 4) She took no time for herself. 5) 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.

Be a facilitator

Move into the facilitative role, working with the client by exploring, challenging assumptions and framing open ended questions. Explore the failure of diets with the client. The key here is to elicit acknowledgment from the client that diets don't work. Simply telling them does not allow the client to take ownership of the idea. Through their past dieting experiences, assist them in coming to the conclusion themselves.

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 client's history of chronic dieting.

Transfer power

Become an enabler of healthy living by transferring "power" for healthy decisions to the client.

With the empowerment model, we assist the client in identifying what steps they are making in the process of healthy 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, which yields 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 are:

How can you extract the most enjoyment from your food?

The answers you would want to draw from the client could be:

• by paying attention
• allowing myself to taste and savor food without guilt
• eating regularly so I don't come to the table starved
• tuning into the texture of foods

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

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.

Diet language & Nondiet language

DIET LANGUAGE	NONDIET LANGUAGE
Medical Model	Empowerment Model
preach	enable
compliance	examine
control	explore
adherence	identify
should	study
must	reflect
prescribe	enjoy
best for you	extract most enjoyment
approval	empower
limit	experience
regimen	delightful
willpower	choice

This comparative model sets out the medical (diet) and empowerment (nondiet) approaches 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. Notice how the actual counseling language sends desirable and undesirable messages. See how this works as you read how two clients, Sally and Hazel, move through the contrasting models.

ISSUES	MEDICAL MODEL (Diet)	EMPOWERMENT MODEL (Nondiet)
Expectation	Compliance	Self-awareness
Method	Behavior modification; control	Personal responsibility; informed choice
Result	Daily management	Quality of life
Setback	Failure	Self-discovery process
Effect	Immediacy	Gradual change
Responsibility	Health practitioners in control	Individual in charge
Information dissemination	Filtered by health professionals' judgment on need to know	Freely provided to facilitate choices
Success	External goals - weight loss	Internal goals - feeling better, improved well-being

Sally sets new goals for health

Sally went on a quick weight loss program and lost eighty pounds. She eventually stopped dieting and started to gain the weight back. Now she was at a decision point. She wanted two things - to follow a nondiet program emphasizing healthier living; and to avoid regaining any more weight.

Yet, the very consequences of dieting might interfere with her desire to stop weight gain. Change in body composition occurs with dieting as along with fat loss, there is loss of water and muscle mass. The effect is a lowered metabolism. So, Sally could choose to start the vicious diet cycle again with the predictable effect of weight gain, or she could choose a nondiet approach to health without any focus on weight issues.

When Sally is equipped with knowledge about how her body will react to either choice, she is empowered to take responsibility for her past actions and her own health. She can choose health goals over weight loss/gain goals. The key here for the health professional is the parameter of models for counseling.

In the medical (diet) model, the client and health professional view weight gain as failure, noncompliance and reason to quit. In the empowerment model, the health professional facilitator guides the client through self-discovery. The client concludes that diets don't work and is empowered to focus on improved well-being, not weight loss.

The facilitator's role as an enabler makes Sally aware of her options. Sally is empowered to be in charge of her own life. As an informed client, she can make her own life choices. Results are not immediate and external goals are no longer the endpoint. Sally studies the process of identifying the factors that will allow her to improve her quality of life. She discovers her own patterns for food and activity levels that keep her energized. She learns to let go of the constant preoccupation with food and weight. She begins to listen to her body for signals of hunger and fullness.

The facilitator recognizes that this process makes an impact on Sally's life that is more likely to be longterm. Sally no longer needs people to police her progress with daily management of her eating or her life. Sally accepts the consequences of past dieting as she sets new goals for her future health.

Contrast these positive results with the experiences most health professionals have with diet treatment. Perhaps we recommend exercise for 1/2 hour three times a week, using a prescribed exercise plan. Or we may prescribe a specific individualized regimen or meal plan for the individual, who attempts to follow it to seek our approval. We retain control with this method, doing what we feel is best for the individual. If they don't comply or adhere to the plan with its implied limitations, its should's and shouldn'ts, we feel we have failed, and that the client does not have enough willpower.

This new role for the facilitator is often uncomfortable. Traditionally, he or she may be more familiar with the didactic approach of telling Sally what she should do.

With practice though, the empowerment approach is reinforced through satisfying experiences.

Hazel untangles emotional needs

Hazel is starting to sort out lifestyle situations that were affecting her enjoyment of food.

She is a 43 year old woman with arthritis. Her doctor suggested that she decrease her weight to ease discomfort.

I asked Hazel about her weight history. She felt that genetically her body weight was high. Previous attempts to cut back on calories did not result in weight loss. Hazel was 114 to 120 pounds when she got married. Six children later, she was around 215 pounds.

I built an expanded profile on Hazel with further discussion using open ended questions:

• ate under stress
• craved sweets
• perfectionist tendencies
• all or nothing diet mentality
• ate for psychological hunger
• late automatically to suppress feelings
• felt guilty when eating sweets
• frequently did not taste food
• ate more since didn't taste food due to guilt feelings
• got too hungry before eating therefore ate quickly
• came to table too hungry
• habit of cleaning plate
• overate because she likes the food
• spent little time on self; resentment and frustration built up. Hours spent on renovating daughter's room created a lot of frustration for Hazel - her 18 year old leaves room messy.

Hazel had tangled her emotional with her physical hunger needs, and needed help to establish new patterns for energizing healthy routines. The client with this type of profile is well-suited to the empowerment approach to health.

If Hazel had been put through the traditional diet with the expectation of weight loss, only one type of result is measurable. If she didn't lose weight, the outcome of diet/lifestyle counseling would be failure.

Medical model vs the nondiet model

Medical Model The Diet	Empowerment, Facilitative Model HUGS non-diet approach
Expectation compliance Counseling Question "Are you watching the fats in foods?" Message Hazel needs to comply to a certain, generic regime, "Food is high in fat; cut back in this area."	Expectation self awareness Counseling Suggestion "Try to notice why you are eating. You've mentioned guilty feelings and cleaning your plate..." Message Hazel becomes more aware of why she is eating; feels the individualized, caring guidance from health professional
Method behavior modification, control Counseling questions What do you do when you're frustrated? Can you go for a walk to let off some steam? Message Here is a band-aid for your bad habit of eating when frustrated; just handle it by going for a walk to get control of your feelings.	Method personal responsibility, informed choice Counseling Suggestion What do you think is causing your frustrations; how can you prevent these situations? Message Hazel has choices and inner desires that can be expressed. Issues of confrontation, acceptance of things beyond personal control, and making time for self will be explored jointly.
Result daily management Counseling questions Are you measuring your pasta and weighing your meat to make sure you are eating your allotment? Message Each day is a controlled regime.	Result quality of life Counseling suggestions Are you continually listening to your body for your hunger signals and other needs? This technique is your key to nurturing yourself. Often our body is disconnected from our mind if we are not in touch with our feelings. New ways of doing things take time. Message The capacity to balance your life is within your realm of choice.
Setback Perspective failure (gaining weight) Counseling implication You are not following the diet. Message You are a failure in my eyes.	Setback Perspective self-discovery process Counseling suggestion You can learn from setbacks. What do you think caused the weight gain? What did you do differently? Message Hazel learns that setbacks are part of the growth process.
Effect Immediacy Counseling statement Let's weigh you and see how you're doing. Message A steady decline in weight is required.	Effect Gradual change Counseling Suggestion You ate regularly Thanksgiving Day, enabling you to enjoy the meal without overeating. Hazel, this is progress as you indicated that you used to starve and binge on holidays. Message small steps, possibilities
Responsibility Health practitioner in control Counseling Question Are you doing what I told you to do? Message I know best and will advise you accordingly.	Responsibility Individual in charge Counseling Suggestion What steps will you take as a result of our discussion? What will you be doing differently over the next month? Message As a health professional I trust you to do the best you can with the knowledge you've gained from our discussions.
Info dissemination filtered by health professionals judgment on need to know Counseling Implication You don't need to know all the facts. Message Too much knowledge might confuse you.	Info dissemination freely provided to facilitate choices Counseling Suggestion Options are always available. Consequences of different courses of action can be explored. Hazel could continue to suppress her feelings with food or she could address causes with action. Message You can be in charge. You do have a choice
Success Weight Loss Counseling Situation I'll let your doctor know that you didn't lose any weight after two months on the diet. Message You failed.	Success feeling better - improved well-being Counseling Suggestion You're doing more fun things and more for yourself this last while. You don't seem as frustrated as you used to be. Tell me about how you've handled something challenging since we last met. Message I care. You can continue to balance your life and improve your perspective and overall health.