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A Lifestyle Approach to Health & Fitness
6th edition • Reviewed and Recertified August 2010
by Linda Omichinski, rd
Accredited Continuing Professional Education Course
7950 Jones Branch Drive, 7th Floor, McLean, VA 22107
1-800-866-0919 • www.nutritiondimension.com
cation
Nondiet Weight
Management
Co
du
Quality
Nondiet Weight Management
5
Nondiet Weight Management
7950 Jones Branch Drive, 7th Floor, McLean, VA 22104
1-800-866-0919 (US & Canada) • 1-703-854-2531 (overseas)
FAX:1-703-854-2531 • e-mail: [email protected]
Nondiet
Weight Management
A Lifestyle Approach to Health & Fitness
6th Edition • Revised August 2010
by Linda Omichinski, rd
About the Author:
Linda Omichinski, RD is a pioneer of the nondiet “health at every size” approach to health. An internationally
known lecturer and promoter of self-empowerment techniques that de-emphasize weight as a measure of success,
she authored the best-selling You Count, Calories Don’t, as well as numerous articles in professional and popular
journals. Sine 1987, Linda is President of HUGS.com, which serves as a center for information and resources about
nondieting and receives thousands of internet visitors each week. Linda has developed a full line of programs/workshops and resources marketed through Hugs International Inc., including HUGS, The Alternative to Dieting, which
is available through a network of licensed facilitators in six countries. HUGS stands for “Health focused, centered
on Understanding lifestyle behaviors, Group supported, and Self-esteem building”.
Education: BSc, McGill University.
EXPIRATION DATE: Students of all professions must submit this course for credit no later
than July 31, 2016. Credit will not be awarded for this course after that date.
Course Code: RD97, CHES97, FIT97, AT97
This course approved for
RD, DTR............................7 CPEU
CDM......................7 Clock Hours
ACE....................................0.7 CEC
(NATA) BOC..................... 5 CEU
ABMP................................... 7 CEU
NSCA................................0.7 CEU
ACSM................................... 7 CEU
CFCS....................................7 PDU
CHES.................................7 CECH
Copyright © 1995-2010 by OnCourse Learning Corporation
No portion of this course may be duplicated without the written consent of the copyright holders.
Edited by: Dales Ames Kline, MS, RD, CNSD
Copyediting/proofreading: Rich Kline, Gwen Hulbert
Design/production by: Knotwork Graphics
Nondiet Weight Management
ii
How to Earn Continuing Education Credit
1.Read or watch the course material. Don’t forget to review the course objectives and take note of
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Nondiet Weight Management
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Contents
1 Introduction
3 Chapter One: The Need for a New Approach
Traditional approach • Financial implications • A new approach • New indicators of success
15 Chapter Two: The Health at Every Size Approach
Diet approach to weight management • Health at every size approach to weight management
21 Chapter Three: Nondiet Empowerment
Why health professionals should consider a nondiet approach • Lifestyle adjustment
Moving into the facilitative role • Enabling ownership •Transfer power
Match language to intentions
31 Chapter Four: Applying the Nondiet Approach
Chronic weight concerns • Diabetes and/or heart health concerns • Lifestyle issues
41 Chapter Five: Breaking the Failure Cycle
What does having a positive body image mean? • Body type • Breaking out of the diet mentality
49 Chapter Six: Nondiet Nutrition Concepts
How food affects the body/how the body uses energy • Eating regularly
Getting the most energy by balancing meals • Tuning in to body signals
Types and roles of fiber • Vegetarian eating
59 Chapter Seven: Moderating Dietary Fat
Learning to enjoy foods with less fat • Gradually decreasing fat in meals
Modifying recipes gradually • Using herbs and spices
71 Chapter Eight: Hunger and Fullness
Focus on sustained energy and satiety • Skills to deal with psychological hunger
Confrontation vs willpower Learning to meet your needs • Eating without guilt
79 Chapter Nine: Fluid Management
Misuse of fluids • Is it really hunger or is it thirst? • Acquiring a taste for water • Caffeine
85 Chapter Ten: The Role of Exercise
Becoming addicted to physical activity • Exercise facts and fiction
Making a lifestyle change • Nondiet benefits of being physically active
91 Chapter Eleven: Lifestyle Strategies
Eating out • Relaxation • Taking time for oneself • Dealing with stress positively
Redefining health • Assessing progress
99 Chapter Twelve: Freedom from Counting for People with Diabetes
Traditional method of treatment • Blood glucose levels and weight loss
Practical application of the nondiet approach
105 Chapter Thirteen: Five Healthcare Myths
109 Chapter Fourteen: The Journey to Building Momentum and Unity for Health at Every Size
119 References
122 Appendices: Medical and Empowerment Models
Hidden Sugars and Caffeine
Case Studies
Energy Expenditure for Various The Big Decision
Activities
Sample Recipe Modification
Relaxation Scripts
Fluids and Their Functions
Using Nondiet Approach in
Diabetes Treatment
133 Examination
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Learning Objectives
Upon successful completion of this course the student will be able to:
1. Explain why dieting may fail to produce long-term weight loss.
2. Define “diet mentality” and identify three consequences of this belief.
3. List four ways studies that link obesity to health problems may be flawed.
4. Explain why weight loss may not be an indicator of improved health.
5. Describe how repeated attempts at weight loss through dieting can increase risk of physical
and mental health problems.
6. List 10 alternative goals to weight loss as indicators of improved health.
7. Describe how the nondiet approach can be employed in therapeutic and lifestyle situations.
8. Identify five influences on body image and provide six suggestions for improving body image.
9. List five consequences of weight preoccupation.
10. Name and describe three basic body types.
11. Explain the role of carbohydrate and protein in appetite control.
12. Define the glycemic index and list six factors that affect glycemic response.
13. Explain how attempts to restrict high-fat foods may backfire.
14. List 10 possible indicators of rigid fat restriction.
15. List five indicators of an acquired taste for lower-fat foods.
16. Describe six methods of making gradual changes in food purchasing and preparation.
17. Contrast diet and nondiet approaches to portion control.
18. Explain how sensitivity to hunger, appetite and satiety signals can be enhanced.
19. Explain how dieting may influence cue sensitivity.
20. List 15 reasons — other than hunger — for eating.
21. Explain the role of fluids in the body, and list three ways fluids can be misused by dieters.
22. List five signs of dehydration.
23. Explain how clients can acquire a taste for less-sweet foods and fluids.
24. List six symptoms of exercise addiction.
25. Name and refute three myths about exercise.
26. List 11 indicators of lifestyle shift other than weight loss.
Nondiet Weight Management
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Introduction
The purpose of this course is to give practitioners a practical guide for working
with the nondiet approach to weight management, for it is in this approach, we believe,
that the greatest potential for overall health and wellness lies.
Traditionally, dieting or restrained eating — defined as the deliberate restriction or
alteration of food intake in order to lose weight or to prevent weight gain — has been
the pattern of eating employed by millions of people in order to reach a medically or
societally prescribed body weight (Polivy and Herman, 1983). This magic formula — X
pounds of body weight equals health, fitness and happiness — is not only unrealistic,
but also dangerous to many people's physical and mental health.
Although we define this course in terms of weight management, it will de-emphasize weight as a measure of success in lifestyle, health and fitness. This radical departure from orthodox health and fitness thinking recognizes one inescapable fact: for most
people, diets don’t work.
Despite high expenditures on diet programs and products and research efforts
directed toward obesity treatment, decades of research have shown that both selfinitiated and professionally-led diet programs are largely ineffective for producing
lasting amounts of weight loss. Repeated weight loss efforts may aggravate health risk
factors and lead to serious side effects (Garner and Wooley, 1991; Ernsberger and
Haskew, 1987).
While this indicts dieting per se, it also draws into question the methods we use to
measure success, and our effectiveness in diagnosing and prescribing weight management regimes. As health practitioners, we may feel we have failed when our clients
return, unable to maintain the weight that dieting has temporarily provided, and perhaps in worse health.
So, not only do we need a new approach for our clients to use, we also may need to
change our thinking about our relationship with our clients. In some ways, we need to
place the responsibility for our clients’ health back on the client — while giving them
the tools to manage their own treatment and care.
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There are two facets to this home study course. It will provide you with the opportunity to find answers to many questions you may have had regarding measures of
success and treatment for obesity, diet-sensitive diseases such as diabetes, and lifestylerelated conditions such as heart disease. And it will help you learn how to think differently about food and activity, and to move from using a diet approach to a true nondiet
approach. You will also move from your role as a teacher to that of a facilitator.
You will notice the phrase “true nondiet approach” in the last paragraph. This
means that we will focus on health parameters instead of weight loss as a measure of
success. For some, weight loss may be experienced as a side effect of this approach,
although it is not the focus nor the measure of success or progress.
Someone who is listening to body signals, being more active, and eating healthier
foods may ultimately have their body weight decrease to their natural, healthy weight
over time. However, those whose weight was not above their natural body weight, or
who have a genetic predisposition to obesity and/or a history of chronic dieting, may
develop healthier living patterns and still not experience weight loss. These individuals
are still successful under the new measures of success we will establish here.
Obesity treatment and prevention strategies must be thoughtfully designed and
implemented to avoid a worsening of the preoccupation with weight and dieting, an
overvaluation of thinness, and social prejudice toward the obese (ADA, 1989). The shift
from using the traditional medical model of weight loss to the health-promotion model
of healthier living is gaining acceptance.
However, many health professionals are in transition between the two approaches.
The result may be that our clients receive mixed messages. We talk about a “nondiet”
approach to eating but still provide exchange “eating plans.” We talk about healthy
lifestyles and improved wellness but continue to use thinness or weight loss as a goal.
Thus, we imply that the way to an improved lifestyle is through structured living which
will translate into weight loss.
Healthy eating has become the latest diet fad. Low-fat and high-fiber are the new
status icons for a health-conscious public. Instead of counting calories or exchanges,
people are now counting grams of fat and fiber. Since the focus is still on choosing kinds
and amounts of foods for the correct “numbers” rather than satiety and enjoyment of
taste and texture, this type of program is a diet repackaged as healthy eating. Counting
is counting; weight-loss programs are diets. The focus and the consciousness are identical — and so is the failure rate.
Health and well-being can be achieved without significant weight loss in individuals whose weight exceeds recommended levels (Foreyt and Goodrick, 1993). People with
weight concerns can be better helped by being encouraged to develop self-acceptance,
eat healthier foods, increase physical activity, and avoid weight cycling (Parham, 1991).
Nondiet Weight Management
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Chapter One:
The Need for a New Approach
I
n this chapter we discuss what we know about weight management and make a
case for a new approach (which we call lifestyle education, to de-emphasize weight as a
measure of success). Traditional weight management says: “A 3500 kcal energy deficit is
needed to lose 1 lb of body fat. Therefore, a deficit of 500 kcal per day means a loss of 1
lb of body weight each week.” (Snetselaar, 1989). Health, happiness and fitness, it is
assumed, naturally follow when enough of those weekly pounds are lost.
However, the experience of most clients and health care practitioners reveals a
much more complex interaction between mind, body and food. Indeed, the traditional
approach leaves unanswered a number of questions:
Unanswered Questions About Diet & Weight
• Why would someone attempt to lose weight in the first place?
• Are all pounds equal when it comes to improving physical health?
• Does a deficit of 500 kcal a day always lead to a loss of 1 lb a week?
• Are all calories equal when it comes to loss or gain of body fat?
• What effect does restricting caloric intake have on eating behavior?
• Is the weight loss resulting from this approach permanent?
• What effects do repeated attempts at caloric restriction have?
• Does this approach have ethical implications?
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This chapter will address these questions, and concurrently provide a justification
for a new approach to weight management.
Why would someone attempt to lose weight in the first place?
Typical answers are: to reduce health risks, and to improve body image.
• Health risks. Being overweight has been associated with a variety of health
problems, including cardiovascular disease, hypertension, diabetes, arthritis, gall
bladder disease, and some cancers.
Few would deny the health benefits of the population as a whole maintaining a
desirable weight. However, the findings linking overweight to poor health, though they
may be true for a specific group of people, may not be true for everyone. Careful screening and assessment must be used to determine whether any particular client would
benefit from weight loss. This is true because there are several common design flaws in
the studies that have associated being obese with having health problems.
First, the studies do not control for previous dieting by the obese subjects, despite
the evidence that dieting itself can lead to health risks (as discussed later in this chapter). This places all “overweight” people together — those who lose and gain or starve
themselves on weird fad diets, and those who maintain a stable weight and generally
meet their nutrient needs. Even though their weight may be higher than what is medically prescribed, stable obese people may be at a lower health risk than those who show
repeated patterns of weight loss and regain. Given the societal pressure to lose weight,
it is likely that many obese research subjects had dieted in the past or were dieting at the
time of the studies. Thus, the health risks that have in the past been attributed to obesity
may, in fact, be a result of attempts to lose weight. This lack of control is disturbing.
Second, studies generally do not control for socioeconomic status, despite the fact
that members of lower socioeconomic classes tend to weigh more than members of
higher socioeconomic classes (Goldblatt, et al., 1965). Affluent subjects are likely to be
better educated and to receive better medical care than less- affluent subjects, which
results in a serious confounding of variables. Also important to consider is that, given
the prevailing prejudice against large people in the health community (Marchessault,
1993), many large people delay seeking medical attention until their problems are more
advanced and less treatable.
Third, cigarette smoking, which is linked to many of the same diseases as obesity
and which many people use as an appetite suppressor, is rarely analyzed separately
from weight. It has been suggested that obesity and smoking are more likely to be
linked in the lower socioeconomic classes (Andres, 1980).
Fourth, there is an apparently natural trend to increase weight through the adult
years. Since the risk for most health problems also increases as we age, it is important to
consider whether a finding of increased health problems with increased weight may be
a result of increased age, not necessarily increased weight.
As well, it must be noted that not every study links weight with mortality or
disease. Experts such as Ancel Keys (1992) have asserted that the evidence is inconclu-
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5
sive or negative, especially as it relates to cardiovascular disease.
Even for those obese who are shown to be unhealthy, it does not necessarily follow
that their weight per se is responsible for their ill health. Obesity is often associated with
unhealthy practices; these associated factors may actually be responsible for health
problems, and may need to be treated. For example, elevated free fatty acid levels that are
characteristic of the obese have been found to correlate with chronic restrained eating in
both obese and average weight individuals (Hibscher and Herman, 1977). This suggests
that disordered eating rather than body weight may be responsible for the elevation.
It may be that a high-fat diet and a sedentary lifestyle may promote heart disease
while coincidentally promoting weight gain. Thus, adiposity and heart disease may be
associated because they share antecedents, not because one causes the other. Correlation
does not prove causation. Treating weight may not address the real problem. In fact,
many people try to lose weight at the expense of health.
Moderate weight loss (10 to 15 percent of body weight) has been found to decrease
health risks and medical problems in 90 percent of obese patients (Blackburn and
Kanders, 1987), resulting in improvements in heart function, blood pressure, glucose
tolerance, sleep disorders and lipid profiles, as well as decreased requirements for
medication, decreased incidence and duration of hospitalization, and decreased postoperative complications. Cardiovascular disease is reduced in women after moderate
weight loss, even when they remain obese (Trembly, et al., 1991). Therefore, one could
hypothesize that it was actually the behavior changes that resulted in improved eating
and activity habits that, while resulting in weight loss as a side effect, are the true cause
of improved health status. Thus to focus on “weight maintenance” rather than “behavior maintenance” misses the point.
Many obese/large people are healthy. There are risks associated with obesity, but
there is not any evidence that people cannot be or are not healthy at any weight.
• Body image. Over the past 10 years, a number of studies have shown a rise in
the prevalence of body image problems among both men and women. The most
fundamental reason for this dissatisfaction is an increasingly thin standard of beauty
(for women) and muscularity (for men). Role models on television and billboards and
in fashion magazines are virtually always thin. Our standards of beauty have become
increasingly unrealistic and distorted. Marilyn Monroe was 5'2" and weighed 140 lb —
was she unattractive?
Because of the belief that body size and shape are totally under a person’s own
control, men and women sometimes enter diet and exercise programs with unrealistic
expectations. Attempting to reconcile expectations and reality may have psychological
and physical costs. Feelings of shame, failure and deprivation, yo-yo dieting and, in
men, the use of male hormones and steroids are common. These issues will be discussed
further in a later chapter.
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Are all pounds equal when it comes to improving physical health?
Many obesity studies were done with all male subjects. It is difficult to say whether
these results can be generalized to women, particularly given the findings about the
importance of fat localization. Recent evidence suggests that the connection of obesity
to some disorders may be due not to the amount of fat but to its location in the body.
Kuhn and Rackley (1993) and Angel, et al. (1994) have reported that waist circumference, not weight or Body Mass Index (BMI), is the anthropometric measurement most
closely associated with cardiovascular risk factors.
Abdominally localized fat (sometimes referred to as the android pattern or apple
shape) appears to significantly increase the risk of cardiovascular disease, diabetes,
hypertension, and cancer. This pattern of fat localization is more common in men than
in women, who are more likely to have fat located in the thighs and buttocks (the
gynoid pattern or pear shape) (St. Jeor, 1993).
In fact, dieting may cause an unhealthy shift in fat deposits. Studies of animals and
humans who have been deprived of food (whether intentional or accidental) show that
surplus fat is accumulated when food supplies are restored, perhaps as a hedge against
future famines (Bennett and Gurin, 1982). The increase in obesity usually occurs in the
abdomen (Rodin, et al., 1990). This upper body adiposity poses many more deleterious
health effects than does the same degree of obesity located on the lower extremities
(Bjornthorp, 1985).
Simply weighing a person does not tell us anything about their body composition.
Thus, a muscular individual may have a higher weight without any greater chance of
developing health problems. Focusing on weight loss as an indicator of improved
health has a similar limitation — by developing healthier living patterns, one’s body
composition may change. This may result in a loss of body fat, a slight increase in
muscle mass and a smaller waistline with little or no change in body weight. So even if
weight remains stable, there may be reduced health risk for an individual.
The Body Mass Index BMI (weight in kilograms divided by height in meters,
squared) is becoming more commonly employed as a method for assessing an
individual’s health risk. Assessment based on relative weight-for-height has many of
the same limitations as body weight when used as an indicator of progress towards a
healthier lifestyle for several reasons.
First, a high BMI is not always related to “overfatness” since the BMI does not take
into account body composition or fat distribution. Many muscular or short, stocky
people have a high BMI but are not necessarily at increased health risk.
Second, the BMI is considered appropriate only for adults 20 to 65 years of age,
since it cannot account for patterns of growth for adolescents or the typical decrease in
height with advanced age. It is often inappropriately applied to adolescents.
Third, and perhaps most important, the focus is still on changing one’s weight to
produce a lower BMI (as there is little one can do to increase one’s height!). This continues to promote weight preoccupation by focusing on changes in weight towards an
ideal or goal weight.
Nondiet Weight Management
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Because we do not know how to define which sorts of overweight are medically
important, decisions to treat are based more on general assumptions than on actual risk.
This results in treating many individuals who are not even at medical risk due to their
weight.
Does a deficit of 500 kcal a day always lead to a loss of 1 lb a week?
Basal metabolism is the energy needed to maintain the body’s functions, exclusive
of digestion and activity. For example, the body must have energy for the beating of the
heart, for breathing, for the operation of vital glands, for blood circulation, for maintenance of body temperature — in short, for mere survival. Basal metabolic energy needs
vary somewhat from one individual to another — some people need more than others.
The speed at which the body operates and requires energy for survival is termed the
basal metabolic rate (BMR).
It has long been suspected that dieters may fail to keep off their weight because
their bodies become more efficient, in effect burning up calories sparingly, although
studies have not consistently shown changes in metabolic rate following diet cycling.
Most recently, Leibel et al. (1995) measured the energy expenditure of obese and
normal-weight subjects and found that the metabolic process of subjects in both groups
adapted to a lower body weight with a reduction in energy expenditure. However, the
obese subjects had an approximately 33 percent greater reduction in energy expenditure. Maintenance of a body weight about 10 percent below usual weight resulted in a
mean (± standard deviation) reduction in total energy expenditure of 6 ± 3 kcal/kg fatfree mass per day in non-obese subjects, vs 8 ± 5 kcal in obese subjects.
Leibel et al. attribute the frequently observed long-term ineffectiveness of obesity
treatments to the fact that “Maintenance of a reduced or elevated body weight is associated with compensatory changes in energy expenditure, which oppose the maintenance
of a body weight that is different from the usual weight.”
Thus, chronically reducing one’s caloric intake by 500 kcal per day may result in
reduction of the requirement of calories, leading to a much slower weight loss than
would be expected.
Are all calories equal when it comes to loss or gain of body fat?
Food can only provide energy for the body by undergoing considerable processing
after being eaten. In fact, the release of energy from food in itself requires energy to
facilitate the digestion, absorption, transport, metabolism and storage of the various
nutrient components of the food that is eaten.
In recent years, investigators have found evidence that the body may be able to
convert dietary fat into body fat with greater ease than it can convert carbohydrates
(starches and sugars) into body fat. In other words, it takes more energy to convert
carbohydrates into fat tissue than to convert fat calories into fat tissue. Thus, more
carbohydrate calories are expended and less stored as fat than are fat calories.
Experiments at the University of Massachusetts Medical School suggested that if
Nondiet Weight Management
8
one consumes 100 excess carbohydrate calories, 23 of those calories are used to process
the food and 77 kcal are stored as body fat (reserve energy). In contrast, if one consumes
100 excess fat calories, 3 kcal are used to process the foods and 97 kcal are stored as
body fat. Fat may be metabolically prone to storage since its profile is already very
similar to that of the fat found in one’s body. So it takes less calories, energy, or heat to
convert the fat in food to body fat (UC Berkeley, 1988).
Therefore, all calories are not equal when it comes to loss of body fat tissue. The
macronutrient (protein, carbohydrate, fat) composition of one’s eating pattern will affect
the degree of fat deposition or loss. This is illustrated by the example below.
If you took an individual who ate 2000 kcal in his or her diet in which 40 percent
came from fat and replaced half of the fat calories with calories from carbohydrates, you
would be exchanging 400 fat calories for 400 carbohydrate calories. The metabolic
savings would be only about 80 kcal/day, but due to the energy costs of storing carbohydrates as body fat, the exchange could account for a loss of about 2 lb in three
months.
In this instance, the total number of calories is not changed, it is the distribution of
the calories or the redistribution of the macronutrients that is being changed. Keeping
the calories constant minimizes the drop in metabolic rate, or may actually negate it
entirely. Also, 400 kcal of carbohydrates consists of a lot more food than 400 kcal of fat
(Omichinski, 1993a).
What effect does restricting caloric intake have on eating behavior?
To be a successful dieter, one must learn to ignore or distrust inner signals of
hunger, appetite and satiety and instead depend on external references, such as foods
allowed/not allowed, suggested frequency of eating, and weighed or measured portion
sizes. As a result, most chronic dieters have lost the ability to eat in response to physical
needs and may be more susceptible to overeating for environmental (“because it’s
there” or “because it’s lunch time”) and emotional reasons (Polivy and Herman, 1983).
Focus on the external goals of adherence to a diet plan and weight-loss indicators
can lead to perfectionist tendencies that often result in a loss of control. Dieters and
eating disorder patients develop similar thinking patterns in relation to food: foods are
either “good/diet” foods or “bad/bingeing” foods; as either “good/small/low energy”
amounts or “large/diet-breaking” amounts (Polivy and Herman, 1983). If dieters eat
“bad” foods or foods in “large” amounts they perceive that they have “blown” their diet
for today or this week — so they might as well keep eating and start over tomorrow.
The pattern of thinking and behaving described above is commonly called “the
diet mentality.” This mentality, or lifestyle perspective, is likely to result in weight
obsession, poor self-image, disordered eating patterns, and disordered lifestyles, often
marked by excessive or inadequate exercise.
Berg (1994b) has concluded that chronic restrained eating has been linked to overwhelming hunger, weakened control over food intake, heightened responsiveness to
external hunger cues, and possible risk of bulimia. Surveys indicate that at least 80
Nondiet Weight Management
9
percent of young women in treatment for bulimia were attempting to lose weight when
they experienced their first binge-purge episode (Wooley and Wooley, 1984).
Approximately 50 percent of individuals undergoing weight-loss treatments have
some degree of nonpurging bulimia (Goodrick and Foreyt, 1991). This phenomenon can
lead to more serious degrees of purging bulimia or anorexia. Both eating disorders are
extremely hazardous to an individual’s physical and emotional health and carry their
own high mortality rates.
Is the weight loss resulting from this approach permanent?
Successful weight loss is difficult, especially long term. While almost any treatment
causes some weight loss in the short run, research indicates that most weight loss is not
sustained (National Institutes of Health Technology Assessment Conference, 1992).
Brownell and Jeffery (1987) examined the results of controlled trials of behavior
therapy for weight loss. These data, published in selected journals, suggest that current
programs offered in research settings can deliver reasonable initial weight losses, but
that weight regain tends to occur after treatment ends. Follow-ups beyond 1 year
showed a trend toward consistent weight regain. The difficulty with maintaining
weight loss is also documented in a study by Kramer, et al. (1989), which followed 152
people for 4 or 5 years after a 15-week behavioral weight loss program: fewer than
three, on average, were at or below their posttreatment weight on all follow-up visits.
Weight regain following very-low-calorie diets is also common. Wadden, Stunkard
and Liebschutz (1988) found that people who received very-low-calorie diets alone
initially lost 14.09 kg (30.93 lb) on average, but had regained all but 3.76 kg (8.27 lb) of
this 3 years later, even though at least 53 percent of them (8 of 15) had received additional therapy. Hoevell, et al. (1988) concluded that only 10 percent of people who lose
25 lb (11.36 kg) or more will remain at their desired weight beyond 2 years.
Therefore, short-term weight loss is of questionable clinical value, since the health
benefits associated with weight loss are likely to be sustained only if this loss is maintained over time (Robison, et al., 1993).
What effects do repeated attempts at caloric restriction have?
There are physical and psychological effects of repeated caloric restriction.
• Physical effects. Repeated unsuccessful attempts at long-term weight loss can
increase health problems. It is well known that continued dieting can result in inadequate nutrition, fatigue, weakness, and sudden death from cardiac arrhythmia and
gallstones (Berg, 1994a).
It is generally believed that obese pre-menopausal women are at low risk for
osteoporosis. However, Bacon, et al. (2000) found that obese pre-menopausal women
who are restrained eaters (chronic dieters) can have reduced bone mass. The authors
attributed the finding of low spinal bone mineral content to the effect of dieting on a
skeletal site consisting primarily of trabecular bone. Calcium in trabecular bone is more
labile. It is possible that with chronic dieting, there may be selective mobility of calcium
Nondiet Weight Management
10
in the trabecular, non-weightbearing bone, especially if calcium intake is deficient. Thus,
chronic dieting can affect the long-term health of the spine.
Because virtually all weight-reduction methods are only temporarily effective,
they can be indirectly hazardous due to the adverse consequences of the regaining
phase. Ernsberger and Haskew, in an extensive alternative review of the health risks of
obesity, present a thought-provoking hypothesis that many of the hazards associated
with fatness may be mainly related to rapid regain of weight, not to obesity itself.
They report that when dogs, swine, rats or mice are repeatedly deprived until they
lose 20 percent or more of their body weight, then are allowed to regain the weight,
they develop high blood pressure, damaged blood vessels, and heart disease similar to
that seen in overweight humans.
As illustrated below (Omichinski, 1993a), recent data from the Framingham Heart
Study indicate that patients who have even relatively small weight fluctuations are at
greater risk of death from coronary heart disease (CHD) than those who have maintained a stable, although higher, weight (Lissner, et al., 1991). While a weight loss
seemed to produce a 20 percent decrease in risk for CHD, a similar weight gain resulted
in a 30 percent increase in risk for CHD.
Weight Loss/Gain & CHD Risk
Regaining
10% weight = 3
0% increase in risk
10% weight loss =
20% decrease
in risk
(Omichinski, 1993a)
Weight fluctuations are most strongly correlated with increased risk in the youngest age groups (30 to 44 years). This group was more frequently engaged in dieting
practices. Thus research has shown that even small repeated cycles of dieting and
weight regain may increase a patient’s mortality and morbidity, not decrease it as
commonly assumed.
We don’t know if weight loss actually improves medical conditions in the long
term because dropout and relapse rates are so high that few studies have been carried
out. As well, the high relapse rate of dieting has led many chronic dieters to weight-loss
techniques such as fasting and purging that are more dangerous than maintaining their
original weight. When this is added to the fact that many of those treated were not even
in jeopardy from their weight, it appears that we may be hurting these individuals. The
chart below summarizes the physical risks of repeated dieting.
Nondiet Weight Management
11
Physical Risks of Repeated Dieting
• Inadequate nutrition
• Fatigue
• Weakness
• Cardiac problems
• Gallstones
• Hypertension
• Reduced bone mass
• Alterations in metabolism
• Alterations in body fat deposition
• Increased cardiovascular risk
• Psychological effects. Repeated unsuccessful attempts at lasting weight loss can
also seriously affect the dieter’s psychological well-being. Psychological stress has a dual
origin: stress associated with societal pressures and discrimination, and stress associated
with failed dieting attempts. Thus the traditional treatment for obesity, dieting, may have
the same negative psychological impact as obesity itself (Brown and Jasper, 1993).
With each weight-loss attempt, clients often experience increasing failure (Wooley
and Wooley, 1984). Failed dieting attempts further diminish a client’s already low selfesteem, increase depression, and lower feelings of self-empowerment. Discrimination
and low self-esteem cause many clients to view weight- loss programs as infallible and
place the burden of failure upon themselves, as illustrated in the following example of a
case report.
Edna is 42 years old and weighs 240 lb — 20 lb below the top weight she reached
in her mid-30s. At that time she lost 60 lb through her participation in a proprietary weight loss program. During the following 7 years she repeatedly tried
to reverse her continued gaining, but with very little success. Now, driven by
disgust with her large size, Edna’s trying once again. She labels herself a failure, but she’s flinging herself again into the effort. She talks about being slender for her college reunion.
In spite of all our best research efforts over the recent decades, we have been
able to do very little to improve the prognosis for lasting slenderness for people
like Edna. Perhaps “thin forever” is not the most appropriate goal for her. I’d
like to suggest that many of the satisfactions she is seeking can be achieved
through alternative goals.
— Ellen Parham, 1991
Another psychological aspect often overlooked is the financial burden placed on
dieters. Every year numerous new weight-loss programs are marketed and more than
$33 billion spent on weight-reduction products (including diet foods and drinks) and
services (Committee to Develop Criteria..., 1995).
Nondiet Weight Management
12
Psychological Risks of Repeated Dieting
• Heightened responsiveness to external food cues
• Weight obsession
• Poor self-image
• Disordered eating patterns
• Disordered lifestyle (e.g. excessive or inadequate exercise)
• Increased incidence of eating disorders
• Increased sense of failure
• Financial burden
• Increased pressure to conform to society’s unrealistic standards
Does this approach have ethical implications? Perhaps the most serious consequence of defining success in terms of caloric restriction to produce weight loss involves
the reinforcement of our cultural obsession with slimness (especially for women) and
the strengthening of social prejudice against obesity (Tisdale, 1993). It is estimated that
50 percent of adolescents and young women are dieting at any one time even though at
least half of these individuals are already at or below normal weight (Rosen, et al., 1990).
It has been stated that “a clear case cannot be made for a positive proportion of
benefits to harms for overweight persons who enter a weight-loss program (excepting,
perhaps, the morbidly obese)” (Lustig, 1991).
In other words, if there is any question as to whether dieting may be harmful when
we cannot show that it has long-term benefits, there is no ethical reason to continue to
condone it as a healthy practice. Obesity is the result of a complex interaction of medical, psychological, behavioral, social, and cultural factors which vary greatly among
individuals. Focusing on weight can obscure or even exacerbate these factors (Wooley
and Wooley, 1984; NIH, 1992). The result is treatment that deals with symptoms rather
than causes, and is likely to create more problems than it alleviates. The risks seem to
far outweigh the possible benefits of short-term weight reduction (Ernsberger and
Haskew, 1987).
A NEW APPROACH
For all of these reasons, defining success in obesity treatment in terms of caloric
restriction to produce weight loss is no longer appropriate. Most weight-loss programs
measure success solely in terms of the number of pounds or kilograms lost per weightloss attempt. They do not take into account the quality of the process used to achieve
weight loss or the likelihood of sustained weight loss.
Because caloric restriction to produce weight loss without maintenance is not
beneficial and potentially harmful, weight-loss programs could be discontinued and
replaced by health-oriented, lifestyle change programs. Treatment must “focus on
Nondiet Weight Management
13
approaches that can reduce risks independently of weight loss” (NIH, 1992).
Some professionals may continue to justify dieting because they are not aware that
a true alternative exists — an alternative that is not a diet repackaged as healthy eating.
That alternative is the nondiet approach to healthier living.
This true nondiet approach helps clients take the focus off their weight and calorie
counting and by shifting their attention to other goals, such as healthier eating, enjoyable physical activity, and a positive self-image, as recommended by Health and Welfare
Canada (1988).
By providing clients with the tools that will enable them to be successful in developing healthier, more enjoyable eating and activity patterns, a healthier lifestyle will
develop regardless of their weight. By shifting the focus from weight to other goals,
such as healthier eating, enjoyable physical activity and a positive self-image, health
professionals can now help clients take steps toward health at any weight.
NEW INDICATORS OF SUCCESS
Success can be measured on a variety of levels. Long-term amelioration of medical
problems and health risks, and improved quality of life, with or without weight loss, are
the most important measures of success (Robison, et al., 1993). Short- and medium-term
changes also could be defined and measured regularly during treatment. These include
obvious changes in health-related behavior patterns such as decreased reliance on
medications, increased physical activity, reduced fat intake, and normalized eating.
Physical indicators of progress towards a healthier body fat distribution include
the waist circumference and the waist-hip ratio (WHR). Because abdominal or android
obesity has been demonstrated consistently to be associated with risk factors for diabetes and heart disease, any reduction in the waist circumference or in the WHR could be
used to indicate progress towards a healthier body fat distribution regardless of weight
loss (Angel, et al., 1994). Constant comparison with an “ideal” measurement can be
avoided since the value for the waist circumference or WHR at which risk of morbidity
and mortality increases significantly for both men and women of various age groups
remains to be determined.
While Bjornthorp (1985) has suggested specific WHR values of 1.0 for men and 0.8
for women where risk may begin to increase, and there is increasing risk with increased
values, at this time no scale of measurement or “continuum” showing increasing probability of developing health problems is available.
As well, new measures of success must account for improvements in psychological
functioning. Although conventional belief holds that underlying psychological problems don’t play an important role in obesity, evidence is accumulating to the contrary,
particularly with respect to eating disorders and severe obesity.
For many individuals, unhealthy lifestyle patterns can have powerful coping
benefits (Ciliska, 1990). For such individuals, confronting and overcoming these barriers
is a true measure of success, whereas weight-loss attempts may only lead to more
shame, continued cycling, and repeated failure.
Nondiet Weight Management
14
New Measures of Success
•
•
•
•
•
•
•
•
•
•
Improvement in health risk factors
Improvement in medical conditions
Improved quality of life
Improved psychological functioning
Decreased reliance on medications
Positive self-image
Enjoyable physical activity
Healthier, normalized eating
Reduction in waist measurement or waist-hip ratio
Reduced fat intake
As summarized in the chart above, there are many indicators of progress towards a
healthier lifestyle that can be used to replace weight loss.
The following chapters will provide practitioners with an alternative approach to
offer clients who seek caloric restriction to produce weight loss in the belief that this is
the approach to a healthier body and improved self-image. This new nondiet approach
to lifestyle education promotes independent self-reliance, where self-acceptance and the
ability to nourish one’s self for health and energy, rather than weight loss, are the new
goals.
Nondiet Weight Management
15
Chapter Two:
The Health at Every Size Approach:
Extreme Thinking and the Middle Path
The irony underlying the media-trumpeted “obesity epidemic” is that diets go
hand-in-hand with obesity. While people may believe that dieting is a health-oriented
response to the problem of obesity, we now understand that people on diets do not
have normal, healthy relationships with food, and are therefore destined to fail in their
quest to lose weight; and will in fact likely gain more in the long run. So the diet industry, while ostensibly responding to the “obesity epidemic,” is in fact feeding it; and the
only people who win in the end are those who pocket the substantial profits from the
latest diet book.
The Western medical establishment generally assumes that being large is a health
hazard. In their eagerness to help their patients conquer obesity, however, efforts by
medical and dietetic practitioners to help may actually mask what is essentially fat
prejudice. Zeal for improved health can become rigid belief that obesity is the enemy
that must be defeated at all costs, the costs of course being accrued by the patient in the
forms of lowered self-esteem, unhealthy adherence to unrealistic diet plans, exercise
addiction, disconnect with their own bodies. Irony again: these problems can be linked
to being large as well. Apparently dieting won’t fix them.
The Health At Every Size (HAES) movement is the response to the destructive
beliefs of the obesity/diet dyad. HAES reminds us that those costs accrued by the
patient may be too high, or just as harmful in the opposite direction. In recognizing the
correlations between obesity and dieting, and in reminding us that being thin does not
guarantee one is healthy any more than being large guarantees ill health, HAES offers
tremendous help. However, as with any social paradigm shift, the pendulum can swing
to both extremes before it comes to rest in the middle. In their fight against fat prejudice, HAES believers can be as zealous and rigid as obesity critics.
Nondiet Weight Management
16
Can you identify aspects of the purist, all-or-nothing mindset in yourself? What is
your enemy, obesity or fat prejudice? If you are a practitioner or educator, your clients
or the people you work with do not require nutritional or HAES purity from you; they
need you to recognize that each of them is on his/her own path, to accept the reality of
that person’s path, and to meet him/her on it, gently helping guide and shape their
journey to a healthier, happier place. The counsellor is not the judge of the client’s
shortcomings, but the pragmatic accepter of the client’s truth, even if you don’t initially
agree with it. Judging and condemning such people will not help you to help them. If
you do not take a pragmatic, accepting approach, whatever your personal philosophy,
you will lose the client, and will have failed in your goal to help.
Given what we now understand about the obesity/diet dyad, then ideally you are
helping your clients go through a process, as in the HUGS program, to convince them to
stop self-defeating dieting, learn to love and accept themselves as they are, and to learn
how to have a healthy relationship with food again, as well as to live a healthier, happier life. This process can help people gain improved physical and mental health, and
quality of life. Diet thinking means perfectionist, all-or-nothing negative mindsets and
beliefs, and one of the best ways to help your client is to replace those beliefs with
something realistic and positive for their lives. Chronic dieters who come to HUGS for
help are people used to living by rules arbitrarily assigned to them by the latest diet
plan. They do not know how to govern their own lives to make their own decisions
around issues of food and physical health. The facilitator seeks to get them off the false
rules and to learn to take responsibility for their own choices.
Practitioners and educators should ask themselves: what is your personal goal for
your clients or the people you work with? What do you think they need from you?
What do they HAVE to do to succeed? If they HAVE to do anything, then they are being
led into perfectionist, diet thinking again; and, by the way, how do you measure success? It may be difficult for dieticians in particular to avoid automatically talking about
numbers of daily servings, and serving sizes, and measuring salt, fat and sugar content
in everything the client eats. All of this is in aid of endorsing a healthy, balanced diet;
but of course, it’s still a DIET – this approach is putting the client right back on a “plan,”
and missing the point of HAES altogether.
Health behavior change cannot be achieved by imposing your own rigid set of
beliefs on others. You have to know what their beliefs and goals are, what their concerns
are within the realities of their own lives: you need to understand “where they are
coming from.” If you don’t, they likely will not take your message onboard themselves,
and you will fail to help them. This is true at the community health promotion level, as
well as for individuals.
For example, the perennially popular public health initiative: the stop-smoking
campaign. Everyone knows that smoking is bad for you, that it can cause cancer and
kill. In countries with universal healthcare, treating smoking-related cancer is a public
expense as well as a personal tragedy. A sensible solution, therefore, is to get people to
stop smoking. Demographic reality: rates of smoking are very high among the homeless
Nondiet Weight Management
17
population. Follow the logic, however, of designing a public health intervention to
encourage homeless people to stop smoking. Explaining to a panhandler who lives on a
sidewalk grate, and who may freeze to death tomorrow night if he doesn’t get assaulted
for his shoes, that his smoking is the real hazard, is entirely useless. Given the lifestyle
described, smoking is the least of his worries and probably the only pleasurable thing
he does all day. This person’s values and list of needs more likely begin with personal
safety and shelter; concern for negative health behaviors is right at the bottom of the
list, if it is there at all. There is no way an appeal to stop smoking will reach this individual until his other needs are met.
By the same token, as a practitioner or educator, approaching others with purist
enthusiasm for your personal philosophy and ignoring an individual’s list of needs will
also get you nowhere.
CASE STUDY
A recent reality television show — aimed at helping large individuals lose weight
and improve their health and lives by assigning a team of professionals to help them in
areas of food, exercise, and self esteem — featured a client who was an obese chronic
dieter and binger. Very unhappy with herself and her home life, she was addicted to
bingeing on convenience and prepared foods, and convinced that carbohydrates were
the enemy. This is, of course, anathema to a dietician. The nutritionist assigned to help,
rather than accepting the reality of the client’s situation and misguided beliefs, and
trying to gently guide her to a healthier “place,” took an inflexible, rule-bound approach,
imposing a great number of behavioral changes on the client all at once, requiring her to
eat according to new “healthy” rules, and to give up coffee, among other things.
The result after a couple of weeks was a slightly hysterical client suffering from
headaches, insomnia and constant hunger, as well as panic at being forced to eat more
carbohydrates than she was comfortable with, as she truly, deeply feared carbohydrates
as a food group. In fact, she stated her firm belief that carbohydrates were not necessary
at all, refusing even to eat carrots as they were “high in carbs.” The client was convinced
she could not follow the nutritionist’s plan, and worried she would fail. When she sat
down to discuss her fears and concerns with the nutritionist, the practitioner was
adamant that her plan be followed, that there was no room for flexibility based on the
client’s reality. What she said to the client was “I can’t work with you if you continue to
stand in your own way.” This touchy-feely New Age language is in fact passive-aggressive code for “I won’t work with you if you don’t follow my rules.” The nutritionist
then refused to continue with the client, got up and walked away, leaving the client
alone on camera in a flood of tears.
This case study clearly illustrates the problems of rigid, purist approaches, and the
futility of trying to effect health behavior change by imposition of beliefs and rules. The
client’s weight issue was caused to a great extent by being on diet plans, but the practitioner attempted to impose yet another plan (even if it was supposed to be healthier and
based on the food groups, etc.). The client learned nothing about herself from this;
Nondiet Weight Management
18
further, it was a plan the client could not comfortably follow. The practitioner did not
acknowledge or deal with the client’s personal issues and wants. Finally, the plan
imposed too many changes on the client at once, completely disrupting the life she was
comfortable with. This is the ultimate irony: the client has been repeatedly set up to fail
by years of false diet plans, and then is set up to fail by the person to whom she turned
as her last hope for help, and then is abandoned by this person when she inevitably
does fail. The client is left feeling like a complete failure again, and the practitioner has
failed to help her.
At the other end of the pendulum swing, HAES practitioners may have difficulty
in supporting clients who have beliefs that counter the HAES philosophy. Case example: a client who is clinically obese approaches a HAES-oriented practitioner for help
with self-acceptance, but is also seriously considering some form of diet, or, more
drastically, surgery to “fix” her weight problem more quickly. This person may be
honestly unhappy with her appearance as a large person; and, given the cultural issues
surrounding obesity and the social disadvantages that can attach to it, this unhappiness
has a legitimate basis. Unfortunately, surgical intervention is gaining wider acceptance
as a “solution” to weight issues. This is, of course, a social problem that the HAES
movement seeks to address; but taking a pure HAES stance with the client, refusing to
discuss the existence of surgery as an option, and ignoring her very real dissatisfaction
with herself, will not help you to help her. She will willingly move on to a practitioner
who will support her choice for a rigid diet or weight loss surgery.
Purists think you should tell people that weight loss isn’t important, but this is
how you lose people: they won’t listen and they are gone. In another example, while
being large does not mean one is not healthy, an individual may believe that some
measurable health problems, such as diabetes or hypertension, could be ameliorated by
weight loss. A counsellor who ignores these health concerns and adheres inflexibly to
HAES philosophy will not reach this client either, and is more likely to lose him to
someone (like his doctor) who will put him on a diet plan. The greatest help you can
give such clients is to take an accepting approach, which will allow you the time to
work with them and to gradually educate them on a healthier life-view and wean them
away from harmful beliefs and behaviors.
Change can only come successfully one step at a time, and small steps at that. (In
HUGS these are called “baby steps.”) You cannot simply order clients to stop being
influenced by false social values surrounding beauty and self-worth. You cannot tell
them to stop drinking coffee, start a new exercise program and completely change their
eating habits all at once. This sets them up to fail again.
As you lead people through their individual journeys, be open to what the process
also teaches you about your own beliefs, and about issues such as perfectionism, control
and acceptance.
Remember that pendulum swing? An effective approach rests in the middle.
Nondiet Weight Management
19
Diet Approach to Weight Management
Diet Program (restrictive eating)
i.e. Weight Watchers
Start:
"Wrong"
Weight
Plan
actually
goes
here:
End:
"Ideal"
Weight
Plan promises to go here:
Deprivation, will power, failure
food as the enemy
All-or-nothing
Control, perfection
Self rejection
End up
heavier
YO
YO
DIETS
Emotional
toll:
Health
risk:
Deprivation leads
to binging.
Lower self-esteem
through perceived
failure.
Greater risk for
diabetes, heart
disease, and high
blood pressure.
20
Nondiet Weight Management
Health at Every Size Approach to Weight Management
A HAES approach, such as HUGS, changes the perception of one's body weight to
what is naturally meant to be, exploring all the issues that influence body size.
Health
➔
➔
➔
Dieting History
Set Point
Body Size
➔
➔
Activity/
Joy of Movement
➔
Stress
Body Image
Dieting Client
• Desires weight loss
• Diet treadmill
• Frustration
• Disordered eating
• Low self-esteem
• Perceiving "ideal"
self
Results
• Off diet treadmill
• Accepting what you
can't change
• Reduced frustration
• Normalized eating
• Improved self-esteem
• Quality of life
• In some cases, weight
loss
HAES Approach
• Self-acceptance
• Non-dieting
• Perceiving self
realistically
The above diagram illustrates how a dieting client (in left column) and the HAES
approach (at right) combine together (in center) to help the client develop a
healthier lifestyle and improve quality of life. The results show what the client and
a HAES approach can build together.
Nondiet Weight Management
21
Chapter Three:
Nondiet Empowerment
The long-term success rates of dieting to achieve permanent weight loss cited in
the literature are very familiar to most practitioners. Outpatient clinics’ appointment
books feature a parade of past weight-loss clients. Those who we thought were successful come back for another weight-control diet, most of them heavier than when they
were first seen.
We had done everything our training had taught us to do. We developed meal
patterns that moderately restricted caloric intake and accommodated the client’s usual
eating patterns. We encouraged exercise and supported and coached clients during
weekly follow-up visits. Despite the educating, planning, hand-holding, and good
intentions, we realized that what we were doing was not working in the long run. Why
did we fail? Or did the clients fail?
More to the point, is the entire approach a failure? We argue for the last option.
WHY CONSIDER A NONDIET APPROACH
Some health professionals may argue that weight loss is necessary to reduce one’s
risk for disease. This assumption can be challenged by reflecting on these points:
• If there is no proven effective method of achieving weight loss, why do we
continue to prescribe it?
• Are health problems associated with obesity caused by repeated weight-loss
attempts ?
• Is it ethical to help clients attempt weight loss when they’re likely to fail?
• Are the 2 to 5% who maintain weight-loss preoccupied with food and weight?
Are they undereating and/or overexercising to maintain an artificial lower
weight?
• If losing and regaining is more harmful than stabilizing at a higher weight, why
do we continue to focus on weight loss as a measure of success?
Nondiet Weight Management
22
LIFESTYLE ADJUSTMENT
“I don’t want to change my lifestyle — I want to diet.”
This is what most people say when confronted with a new way of thinking about
lifestyle, weight and fitness. This is analogous to the “quick fix” school of medical care:
treat, don’t prevent. It’s easier for people to just follow a prescribed regimen than take
charge of themselves.
Change is always difficult at first, but once clients believe that they have the ability
to find a comfortable balance of food, activity, and life attitudes, they can break free
from diet sheets and meal plans forever. Clients make changes simply because it makes
them feel good and gives them more energy (Omichinski, 1995). Weight loss, if it occurs,
is incidental.
Changing a way of life and thinking is a step-by-step process of preference
changes. Once progress towards a healthier lifestyle has begun, it is maintained because
the clients are learning and improving, not because they are following a plan. They feel
a sense of accomplishment. They are not controlled by a diet. Rather, they are empowered to effect change and take charge. Empowerment comes from having a sense of
mastery or being in charge, which helps build self-esteem, which enhances empowerment, and so on . . .
Dieting is different. Weight loss from following a rigid diet is usually temporary.
The new diet is too drastic to be maintained; it is artificial and unpleasant; it is physically and emotionally stressful. So the client stops dieting and resumes old eating
patterns. The diet controls the client; the client is not in control. The client lives by the
diet sheet. He may lose weight, but has learned nothing about eating or himself. Realistically, a client can’t eat this way for the rest of his life — depriving himself, always
thinking of food.
An alternative approach promotes self-reliance to maximize potential for health
and wellness. The emphasis is on leaving behind disordered eating patterns (that often
result from chronic dieting) and optimizing nutrition, rather than achieving weight-loss.
The nondiet intervention focuses on self-esteem and self-acceptance issues, on how to
resist the cultural pressures to be thin, and on eating for health rather than weight loss.
The chart on the following page contrasts the traditional medical (diet) approach
with the empowerment (nondiet) approach in counseling issues. The goal of each model
is to assist the client to better health, but the diet model has built-in limitations because
of a single closed goal. (Appendix #1 gives details.)
A nondiet approach gives health professionals many new issues to consider in their
interactions and interventions with clients. It takes courage to relinquish traditional
medical models, and as we counsel clients to abandon diets and embrace healthier
living, we must also provide new signposts to guide them in their journey.
Clients have told us that health professionals often deliver counseling and education in a way that rekindles the defeatist chronic dieting syndrome.
Nondiet Weight Management
23
Diet vs Nondiet Thinking on Key Issues
Issue
Expectation
Medical Model (diet)
compliance
Empowerment Model (nondiet)
self-awareness
Method
behavior modification, control personal responsibility, choice
Information
filtered (“need to know”)
free
Progress
any weight loss
gradual lifestyle changes
Success
external goals: weight loss
internal goals: self-acceptance
Effect
immediacy
gradual change
Result
daily management
quality of life
Responsibility practitioners in charge
individual in charge
Self-esteem
only after weight loss
natural self-nurturing cycle
Setback
failure
self-discovery, process
Exercise
no pain, no gain
energetic daily living, fun
Food
enemy: deprivation, willpower
friend: enjoyment
Language
“Should I have it? ”
“Do I need it? Do I want it?”
Thinking
“I need it all or nothing at all.” “I can have it if I really want it.”
Attitude
perfectionist, rigid
flexible: goes with the flow
Choice
diet in control; no choice
person in charge, decides what
and when to eat
Hunger
out of touch with physical
hunger; eats in
response to stress
in tune with internal cues, physical
hunger; does not use
food to deal with stress
(Omichinski, 1993b; 1995)
Are we giving our clients mixed messages? Reflecton the messages posed in the
chart on the following page.
Nondiet Weight Management
24
Mixed Messages
• Weighing clients to assess health, implying that an improved lifestyle
will translate into weight loss
• Using “slim,” “trim,” or implying weight loss in title of your program
• Using a diet approach: focusing on quantities, meal plans
• Prescribing rate of change, not letting client change at comfortable rate
• Implying that clients don’t have to accept responsibility for their health
• Not allowing clients to gain confidence by taking responsibility
• Expecting the client to conform to rigorous, unrealistic routines
(Omichinski, 1993b)
Society has begun to accept that diets don’t work. Clients are looking for answers
and directions toward a healthier attitude around food and activity and gradually
“letting go” of the goal of weight loss. Health professionals in the old mind-set can
sabotage clients’ efforts to move away from the diet approach to life. We can best assist
them with an empowerment approach to their health issues.
REDEFINING HEALTH
A refocused definition of “health” is a starting point for this approach. A meaningful and tangible definition has been developed, which translates into the language of
both health professionals and clients.
For the professional, health is defined as an independent, nondieting lifestyle
characterized by nourishing eating and activity patterns, and self-acceptance.
For the client, health means putting aside the scale, calorie counting and fat gram
levels. It means listening to your body for signals that mean “enough” and “more,” and
discovering individual patterns for food and activity levels that keep you energized. It
means finding the strength to accept yourself just as you are and get on with life. Clients
can simultaneously be large, healthy and happy if they demonstrate the characteristics
of this definition.
These new parameters could replace weight standards and diet preoccupation in
your clinical approach (Omichinski, 1995).
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25
MOVING INTO THE FACILITATIVE ROLE
The first step to offering the client an empowerment approach is to understand
your new role as counselor. You are now a facilitator, adding a new dimension to the
traditional role of teacher. Expertise and education are not abandoned; rather, knowledge and objectivity are redirected.
It’s natural for clients to want diets from us because they want to lose weight. We
may think fulfilling this request is the best approach — but is it? Does the client really
want a diet, or merely the sense of security that comes from a piece of paper, telling
them what to do? As health professionals, are we listening to the client, or staying in our
own comfort zones by providing an individually prescribed diet sheet?
A facilitator explores the client’s understanding of and experience with dieting by
asking probing, open-ended questions that gently challenge personal myths and understanding.
The type of questions that create this atmosphere of trust are shown in the chart
below.
Establishing Trust
• What makes you think you need to lose weight?
• What makes you think there is something wrong with
the way you are now?
• How do you feel when society tells you to look a certain way?
• Do you have to feel this way?
• What will happen if you don’t accept yourself?
A recent counseling experience might further clarify this style.
“Alma” came for an initial assessment about diabetes. We worked through the
nondiet nutrition concepts that would enable her to stabilize her blood glucose levels. A
week later she called to tell me it wasn’t working. She wanted to lose weight, and she
needed a diet sheet.
Was it appropriate to give Alma what she wanted, a diet sheet? The medical model
says yes. I analyzed what Alma told me. What prevented the nondiet approach from
working for her? Maybe she wasn’t a candidate for this approach. Was having a diet
sheet an attempt to control at least one aspect of her life?
As I probed further, Alma opened up. She felt overwhelmed:
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26
• Her daughter was always unloading her problems in her own life;
• She was dependent on her husband for transportation;
• She had lost interest in life and was bored frequently;
• She took no time for herself;
• She ate to suppress these feelings (she ate for psychological hunger, not
just physical hunger).
Identifying these situations enabled us to explore possibilities to break this negative cycle. Alma became aware that she was eating for reasons other than physical
hunger. She could see that she needed to make her own decisions about more than just
what food to eat.
ENABLING OWNERSHIP
In order to make a nondiet approach work, practitioners must move into a facilitator role, working with the client by exploring, challenging assumptions and framing
open-ended questions. Part of this approach is to explore the failure of diets with the
client, by eliciting acknowledgment from the client that diets don’t work. Simply telling
them does not allow the client to take ownership of the idea, a vital breakthrough in
consciousness. Through examining their past dieting experiences, you can assist them in
coming to the conclusion themselves.
The following dialogues contrast the traditional method of providing information
with an explorative approach (Omichinski, 1993b).
Discussion issue: “I need a diet to feel in control.”
Often clients think they want a diet because this is what they are used to following.
For the same reason, they look at weight loss as a measure of success.
Here is a supplemental role-playing exercise that brings out the issues.
Dietitian: Have you ever been on a diet before?
Client: Yes, several times.
Dietitian: Did it work?
Client: Yes, while I was on it.
Dietitian: Can you follow a diet for the rest of your life?
Client: No, not for the rest of my life.
Dietitian: So it doesn't work. No one can realistically follow a diet for the
rest of their lives. It isn't because you don't have enough willpower or discipline. Diets don't work. Evidence suggests that 95 percent gain back weight
and then some within a five year period.
The next scenario sets the stage for the client being responsive to a new approach.
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27
Dietitian: When you focus on weight loss as a measure of success, how do
you feel when you don't lose weight?
Client: Like I failed.
Dietitian: Did you fail?
Client: Yes.
Dietitian: Actually you didn't. Because of our genetic predisposition and
history of chronic dieting, we may not always be able to lose weight.
Client: But I need to lose weight.
Dietitian: What has happened in the past by focusing on weight loss?
Client: I ended up being more preoccupied with food, maybe undereating
and overexercising until I lost the weight.
Dietitian: Did you enjoy the process?
Client: No, I felt deprived, almost punishing myself for the way I looked.
Dietitian: So you were happy to arrive at your goal weight and go off the
diet?
Client: Yes, I was happy it was over.
Dietitian: Would it be different if you enjoyed the process, actually got
hooked on your new lifestyle?
Client: Probably, but I can't imagine it happening.
Dietitian: Let's explore this further. Why do you start dieting?
Client: Because I look in the mirror and hate the way I look.
Dietitian: Does it motivate you?
Client: Yes, I'm really strict with myself and watch what I eat.
Dietitian: And then what happens?
Client: Well, I can't stand it any longer and I go off the diet.
Dietitian: What if you were shown how to feel good about yourself right
now?
Client: I couldn't do that.
Dietitian: But if you could?
Client: Well, I would probably have more energy and interest in taking care
of myself for a longer period of time.
Dietitian: In other words, "feeling good" would not be dependent on weightloss? You would actually be allowed and encouraged to feel good? What a
freeing effect it would be!
Client: How do we begin?
The client ends up reflecting on her own thinking pattern, being convinced that
diets and weight loss are no longer what she desires.
Additional case studies are presented in Appendix #2.
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Another important step is to jointly identify weight cycling and a history of chronic
dieting in the client’s health profile. This will impact the client’s ability to lose weight
with a healthier lifestyle. However, when we focus on healthier living per se and not
weight loss, improved lifestyle for the client is the desired result. The client’s weight
will stabilize, decrease, or slightly increase depending on the genetic profile and previous history of chronic dieting.
TRANSFER POWER
Become an enabler of healthier living by transferring “power” for decisions to the
client. With the empowerment model, we assist the client in identifying what steps they
are making in the process of healthier living, not what they are not doing. We, as facilitating agents in this process, desire changes to be permanent. We can assist clients in
reflecting on their true lifetime goals, thus yielding more emotional and physical health
benefits. For example, how can clients experience the enjoyment of increased activity?
Possibly by experimenting with different activities to find one they enjoy. We can suggest they model others who partake in activity for the fun of it.
In our new role as facilitators, we enable the client to explore the options, but the
final decision is up to the client. The type of questions we can ask include: “How can
you extract the most enjoyment from your food?” The answers you would want to draw
from the client could be those in the following chart (Omichinski, 1995).
Enjoying Food
• Pay attention to what you are eating
• Allow yourself to taste and savor food without guilt
• Eat regularly. Don’t come to the table starved
and then eat too fast
• Notice the texture of foods
• Expand the variety of foods eaten
Clients begin to appreciate the flavors, textures and subtle changes in making
slight shifts toward a lower fat eating pattern. The process takes time and is enjoyable,
resulting in preference changes.
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MATCH LANGUAGE TO INTENTIONS
Do you use words like “overweight”? Use the word “large” instead. Do you focus
on weight as a measure of success? Replace with the word “health.” Are you able to
present the educational information with a health focus? Focus on lifestyle changes, not
weight loss. Do you give clients the final choice? Extract lifestyle experiences from your
client. Using this information, you can identify and personalize the choices available to
the client.
Here is a helpful list to cue you further about the art of changing language and
using positive expressions of encouragement.
Using appropriate language
Medical model (diet)
preach
compliance
control
adherence
should
must
prescribe
best for you
approval
limit
regimen
will power
Empowerment model (nondiet)
enable
examine
explore
identify
study
reflect
enjoy
extract most enjoyment
empower
experience
delightful
choice
(Omichinski, 1995)
This nondiet health-enhancing paradigm focuses on wellness solutions and rejects
weight-loss dieting and food restraint. This approach offers a journey of self-discovery,
not tests of willpower. It celebrates self-esteem, diversity and accepting people as they
are, not judging and putting others in molds. It encourages people to get on with living
and stop putting their lives on hold while waiting to be thin (Berg, 1992).
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Notes
30
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31
Chapter Four:
Applying the
Nondiet Approach
It is very difficult for people who have spent years fighting their weight to suddenly accept that significant weight-loss is unrealistic and unnecessary. Parting with the
weight loss myth is painful but perhaps not as painful as a lifelong pursuit of false hope
and the delay of positive lifestyle changes that can improve health and well-being
(Lemaire, 1993; Kirkland and Anderson, 1993).
The clients who are candidates for a nondiet lifestyle approach are those who
identify that they need to do something (other than entering another weight-loss program) about their eating and activity patterns and self-acceptance.
People who are not appropriate candidates for this approach are those who may
have a strong belief that they need to, and can, lose weight in order to feel better about
themselves. These people are not yet ready for this approach. Let them go. They will
need to diet a few more times and hear the message several more times, perhaps from
different sources, to give up on the dieting.
Dieting to them is comfortable, it’s what they know, and it takes time to move
through the process to accept that what they have done all these years has not worked
and will do more harm than good. They may find it easier to live in the short term even
though the long term will mean even more weight gain. “Just one more time,” or “After
I lose the weight” are parts of the dieters’ philosophy that just don't want to let go.
In one particular instance, I remember someone calling me up after they heard me
on the radio and asking me if I had been on a certain program two years previously. She
indicated that she had heard me then, too, but was only listening with half an ear and
that now she was ready to hear my message. It takes time for people to move to the
state of readiness after years of dieting.
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The nondiet approach to weight management can be applied in many situations.
The principles and techniques presented in this course were originally developed to
assist people who were chronically concerned about their weight, and people with Type
II diabetes and/or heart-health concerns. This approach can also be applied to address a
variety of lifestyle concerns.
CHRONIC WEIGHT CONCERNS
For several years now, the authors have participated in a 10-week group-counseling intervention, employing the nondiet approach. This intervention was designed to
help chronic dieters, binge eaters, compulsive eaters and those preoccupied with
weight, overcome their dependence on external sources of control and learn to nourish
and accept themselves (Omichinski, 1993).
Most clients who came to the nondiet program had extensive histories of failed
dieting attempts, while others simply wanted to take steps toward achieving a healthier
lifestyle. Participants in the nondiet program were predominantly female (94 percent)
and between 36 and 50 years (47 percent); 25 percent were between 21 and 35 years; 20
percent between 51 and 65 years. Few participants were under 21 or over 65 years. Over
80 percent of participants attended eight or more of the 10 sessions — on average 8.3
sessions — much better attendance than the 20 to 50 percent dropout rate typical for
weight-loss programs.
To assess the frequency of thinking or behaving in a manner consistent with
chronic dieters before and after participation in the program, we had participants
complete self-administered quizzes at the first and last class of the intervention . A sixpoint response scale (1 = always; 2 = very often; 3 = often; 4 = sometimes; 5 = rarely; 6 =
never) was employed. A higher quiz score indicated a more independent, nondieting
lifestyle with nourishing eating and activity patterns and higher self-acceptance.
Data collected at the classes held in 10 cities across Canada in 1992 and 1993 — a
total of 26 classes — were subsequently published (Omichinski and Harrison, 1995).
Two hundred fifty-three participants completed the pre-quiz; 208 (196 female; 12 male),
average age 43, completed both the pre-and post-quiz. The direction and magnitude of
changes and effect of sex, age, initial score, and number of classes attended were measured. Participants made statistically significant changes in scores for each of the 16
statements, as well as for total scores.
Men reported a significantly lower frequency of dieting attitudes and behaviors
than women on the pre-quiz, but not on the post-quiz. Age and number of classes
attended were not associated with changes in quiz scores. Therefore, a lifestyle perspective consistent with dieting thoughts and behaviors and low self-acceptance can be
improved by participation in a nondiet lifestyle program.
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Lifestyle Quiz Scale Statement Scores
Statement
Self-Acceptance Scale
I’m unhappy with myself the way I am.
I am preoccupied with desire to be thinner.
I weigh myself several times a week.
I’m more concerned with the number
on the scale than my own overall
sense of well-being.
I think about burning kcals when I exercise.
I engage in all-or-nothing thinking.
I tend to feel that if I can't do it all
or do it well, what’s the point?
I try to be all things to all people.
I strive for perfection in my life.
I criticize myself for not achieving goals.
Total scale score
Mean score
Pre-quiz Post-quiz
Change*
2.8
2.7
4.2
3.6
4.0
4.2
5.5
5.2
+1.2
+1.5
+1.3
+1.6
3.2
3.2
4.5
4.7
+1.3
+1.5
3.0
2.9
2.6
28.2
4.1
4.0
4.0
40.2
+1.1
+1.1
+1.4
+12.0
2.4
4.1
+1.7
2.5
2.5
3.9
3.8
+1.4
+1.3
3.0
3.0
4.1
4.4
+1.1
+1.4
+1.5
+1.1
Self-Nourishment Scale
I’m out of tune with my body for
natural signals of hunger and fullness.
I eat for reasons other than physical hunger.
I eat too quickly, not taking time to
focus on my meal and taste, savor
and enjoy my food.
I fail to take time for activities for myself.
I fluctuate between periods of
sensible, nutritious eating and
out-of-control eating.
I give too much time and thought to food.
I tend to skip meals and eat early
in the day, so I can “save up”
my food for one big feast.
Total scale score
2.8
4.6
4.3
5.7
20.8
30.3
+ 9.5
Total quiz score:
49.0
70.5
+21.5
*The differences in means for each statement, two sub-scale scores and the total score were significant
at P<0.001 Omichinski & Harrison, 1995.
Widespread preoccupation with weight and dieting is an accepted, encouraged,
and rewarded aspect of social life (Brown and Jasper, 1995; Kalodner and DeLucia,
1992). It is not surprising that, on the pre-quiz, the “average” participant reports she
“often” finds herself thinking or behaving as a chronic dieter. Nor is it surprising that
men reported a lower frequency of dieting attitudes and behaviors on the pre-quiz,
since the social pressure on men to be thin is less severe than for women and men are
less likely to participate in formal weight-loss programs (Lavery and Loewy, 1993).
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34
Those participants not completing a post-quiz tended to have scored lower on the
pre-quiz and attended, on average, 6.5 classes (62.5 percent attended fewer than eight
sessions). The lower pre-quiz scores of participants not completing a post-quiz suggest
a lower level of self-acceptance in these participants, as well as more deeply entrenched dieting habits. These characteristics may have made it more difficult for them
to take time for themselves to attend a class where they were encouraged to accept
themselves as they were and were not encouraged to attempt weight loss. It may also
be suggested that there is a minimum level of self-acceptance required to enable a
change in perspective.
An appreciation of health benefits independent of weight loss may be the best
way to improve the physical and psychological health of persons seeking to lose
weight (NIH). Participants’ responses to the statements on the post-quiz indicate that
there is a shift in focus away from weight and calorie counting towards concern with
overall well-being.
This shift in thinking is concurrent with participants’ reports of eating more
regularly, eating in response to physical hunger signals, and being less preoccupied
with food. These eating patterns have been identified in recent literature as characteristic of persons more successful at changing to a low-fat eating pattern and maintaining a stable weight (Hawkins, et al., 1992; Ferguson, et al., 1992; Bowen, et al., 1993;
Jeffery, et al., 1984; Shatenstein and Gagnon, 1992).
Increased self-acceptance enables people to take ownership of their body and
their lifestyle. Balance in living replaces perfectionist tendencies and compulsive
behavior. Self-nourishment involves a consciousness of what we eat, of our need for
exercise, and a sense of responsibility to do what we need to do for ourselves. It does
not involve doing it all perfectly (Smith, 1990). Therefore, the significant improvement
in self-acceptance and self-nourishment reported by the participants is important.
Other nondiet programs have reported similar findings (Ciliska, 1990; Armstrong and
King, 1993).
Carrier, et al. (1994) evaluated the effectiveness of a nondiet approach designed
to reduce restrained eating behaviors and improve self-acceptance and self-esteem.
This approach also encouraged participants to address eating and exercise behavior
separately.
Subjects were employees who participated in a worksite wellness program and
completed pre-participation and 3-year follow-up questionnaires (n=79). Pre-and postsurvey data were used to assess participants’ eating behavior, dieting behavior, selfacceptance, self-esteem, level of physical activity, and demographic information.
Mastery of the internally directed eating style was assessed during the program at 3
months, at the conclusion of the 6-month program, and at the 3-year follow-up.
Analysis of variance indicated that participants were able to significantly decrease
their restrained eating behavior and increase self-acceptance, self-esteem, and level of
physical activity. Participants also were able to adopt many aspects of the
nonrestrained, internally directed eating style and decrease their frequency of weighing-
Nondiet Weight Management
35
in behavior. These results indicate that strategies fostering internally directed eating
behaviors may be more centrally related to an individual’s well-being than programs
supporting externally directed eating behaviors (Carrier, et al., 1994).
DIABETES AND/OR HEART HEALTH CONCERNS
Many clients who have diabetes, or heart health concerns such as hypertension or
hyperlipidemias, can be well served by the use of the nondiet approach. The nondiet
nutrition concepts discussed in Chapters Five through Eight are consistent with current
recommendations for managing blood glucose and lipid levels and are therefore appropriate for assisting people with Type II diabetes and elevated serum cholesterol levels.
For example, the principle of balancing carbohydrate and protein to slow down the
release of glucose into the bloodstream will assist in the management of blood glucose
levels for people with diabetes, as will learning to acquire a taste for less sweet foods.
Because people with diabetes are unable to produce the amount of insulin they need to
help the glucose in the blood stream move into the body’s cells, these people have
traditionally been advised to restrict carbohydrates and sugar-containing foods, which
break down into sugars and enter the blood stream as glucose.
Yet it is possible for people with diabetes to include more carbohydrates in their
eating pattern. Including a source of protein at meals will slow down the release of
sugar from carbohydrates into the bloodstream. Eating this type of balanced meal will
stabilize the blood glucose level. In some cases, the person with diabetes will find it
helpful to also include a source of protein at snacks between meals, as eating carbohydrate foods alone, especially fruit, may increase the blood glucose level substantially.
This way of eating will keep the individual satisfied for a longer period of time, resulting in less snacking as well as improve blood glucose control.
A person with diabetes following an exchange list or menu that restricts carbohydrates is like a long-term dieter... the difference is that this individual is not supposed to
go off the diet. If they are on a diet, they may still want sweets but they try to say “no”
and they feel deprived. By learning to acquire a taste for less sweet foods, the power of
choice rather than the diet sheet is the controlling mechanism. Blood glucose management will be achieved.
We have observed in the diabetic clinic over the past eight years that those who
adopt a more positive attitude are more relaxed with diabetes. They handle stress more
positively and stabilize their blood glucose better than those who are worried and
preoccupied with food and weight, portion control, and the “magic” diet that they
believe is the perfect way of eating (Omichinski, 1993a).
These same principles of improved carbohydrate/protein balance and acquiring a
taste for less sweet foods will help people with cholesterol concerns to reduce their total
fat intake, since much of our fat is found along with protein or in sweet baked goods.
Learning to acquire a taste for foods with less fat will assist in the reduction of serum
cholesterol levels.
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36
The do and don’t lists or foods allowed/foods not allowed lists generally provided
to clients often get followed for a short term. If tastes don’t change to enjoy foods lower
in fat, the lists become very restrictive. Eventually, once the cholesterol level has gone
down or the client’s health has improved, former eating habits resume. Why? Because
the individual still likes the high-fat foods.
Learning to eat in response to physical hunger and appetite will result in a gradual
consumption of less food, which, for many people, will lead to a return to a natural,
healthy weight and an improvement in serum glucose and cholesterol levels.
Dieting for anyone is usually viewed as a stressful sacrifice. For people with diabetes or heart health concerns, dieting is more stressful because of the consequences if
they go off the diet. One of the ingredients of quality of life is to be in control of your
life. The ability to direct the course of events in your life and being able to do what you
want to do is challenged by having diabetes or heart concerns. The nondiet approach to
diabetes and heart health, leading to permanent adjustments in lifestyle through progressive gradual change, now offers the person with health concerns hope for less
stressful and more lasting control over their health. It provides individuals with confidence to adopt a new lifestyle rather than continue with the perception that food controls them.
Armstrong and King (1993) report people who make the change to nondiet eating
experience a significant modification of compulsive and restrained eating, an improvement in self-esteem and feelings of control, a reduction of guilt, improved control of
diabetes, and gradual weight loss that is maintained. These results are consistent with
the goals of diabetes therapy without the rigid control of the content and time of meals
that has traditionally been the cornerstone of diabetes treatment and which may, in fact,
have contributed to compulsive eating.
Ciliska (1990, 1993) has reported that self-esteem and restrained eating patterns
were significantly improved by a nondiet psychoeducational program. Weight, blood
pressure, and serum measures of fasting glucose, cholesterol, and lipids were unchanged after this intervention. Thus, the use of a nondiet approach did not result in a
worsening of biochemical indicators: it may, in the long run, prove to be more effective
than traditional diet therapy for lifestyle-related conditions.
LIFESTYLE ISSUES
Vitality (Health and Welfare Canada, 1991) is an innovative Canada-wide public
awareness initiative that promotes healthier lifestyles and attitudes by encouraging
people to take charge of the three elements, or choices, of feeling good about oneself,
eating well, and being active. The initiative is based on the belief that these three choices
work together to make you feel healthy and energetic. Vitality de-emphasizes body
weight and fosters self-empowerment within the social environment.
The nondiet principles and techniques presented in this manual are consistent with
the Vitality initiative.
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37
Guidelines for Vitality Leaders
• De-emphasize body weight; focus on three positive choices.
• Emphasize the positive, enjoyable aspects of the three choices.
• Emphasize the interrelationships among the three choices.
• Encourage client development of approach, activity, and details, rather than
providing generic information or prescriptive instructions to all.
• Foster self-empowerment and personal control, recognizing the interdependence between the individual and social environment. Encourage people to
take charge of how they eat, how they stay active, how they think about
themselves.
• Foster physical environments, personal and broad social milieus that
support people taking control of their lives.
• Foster changes in behavior through building awareness, creating opportunity, supporting and reinforcing behavior.
SMOKING
Do any of these statements sound familiar to you?
“I’m afraid to stop smoking because I’ll get fat.”
“Smoking helps me keep slim.”
“I need cigarettes to curb my appetite.”
“I’ll quit smoking when I’ve lost 30 pounds.”
Smoking is widely used as a technique to control weight by women; many women
also resume smoking to curb weight gain and decrease appetite.
Unfortunately, the statements above are largely true. Nicotine increases metabolism (the number of calories burned at rest) by about 10 percent for heavy smokers.
However, to use smoking as a method of weight control is clearly an inappropriate
choice. A man who smokes has almost twice the chance of dying before age 70 as a
nonsmoker — far greater risk than overweight. As well, smokers tend to accumulate fat
around the waist, and this is associated with a greater risk of health problems.
New nonsmokers present problems for practitioners. Dieting after quitting smoking is not the answer to anticipated weight gain. First, not everyone gains weight once
they stop smoking. Second, a lifestyle change that includes healthier eating and regular
activity can offset the deprivation that may result from smoking cessation. A diet at this
time will likely increase the sense of deprivation.
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New nonsmokers will get hungry more often because their stomach empties more
quickly. Smoking keeps food in the stomach longer so people can go without food and
not feel hungry. People who stop smoking may turn to water and diet drinks to fill up.
They may feel bloated and temporarily full, but this is not satisfying. Clients need to
learn how to eat in a way that keeps them satisfied longer by naturally allowing food to
stay in the stomach longer.
Some scientists believe that nicotine affects the level of blood glucose in the body
by inhibiting insulin secretion, causing blood glucose levels to remain higher. This
suppresses appetite. This may be the reason many smokers reach for a cigarette when
they are actually physically hungry. After quitting smoking, clients may experience
lower blood glucose levels. When blood glucose levels are low, hunger is felt, especially
cravings for something sweet. A balanced lifestyle including regular, balanced meals
can reduce sugar and fat cravings and the urge to smoke (Omichinski, 1993a).
PREMENSTRUAL SYNDROME (PMS)
It is thought that PMS is brought on by high progesterone levels in the body during
the second half of the menstrual cycle. High progesterone levels can cause the body’s
cells to be resistant to insulin. This means that even though there are normal to high
levels of glucose in the blood, the glucose is not able to enter the body’s cells. This may
cause cravings for sweets and increased appetite.
Well-balanced, regular eating helps to avoid premenstrual binge eating. Clients
may be hungry more frequently during this time because the hormone progesterone
reduces the amount of glucose the body’s cells receive. Bingeing can produce higher
levels of insulin which may increase the cells’ resistance to insulin. Then a roller coaster
effect may occur where bingeing can result in increased hunger.
Blood sugar swings can be stabilized and symptoms of irritability can be reduced
by balanced eating. Physical activity can increase the sense of well-being, decrease fluid
retention, and help relieve depression. This lessening of symptoms may be linked to the
rise in endorphins, which have a relaxing effect, during physical activity.
THE NEXT GENERATION
A parent’s constant dieting and discontent with his or her body often sends messages to a child that he or she is not okay and needs to go on a diet. Our society’s preoccupation with perfection, whether it’s the “perfect body,” or being the best in school or
in sports, can lead a child into a constant struggle of trying to keep up.
Studies indicate that an important factor in adolescent depression and low selfesteem is poor body image. Up to two-thirds of young women between the ages of 12
and 23 are unhappy with their weight. The astonishing fact is that most of those who
wanted to lose weight were not even large! Both boys and girls desire flat abdomens
and hard bodies more than they desire health (Ciliska, 1990).
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39
As parents go through the process of self-discovery by tuning in to their bodies for
signals of hunger, appropriate levels of activity, time for themselves, and basic needs for
happiness, they will notice how these positive attitudes transfer to their children. The
bonus gained in living a healthier lifestyle is that there is a sense of inner satisfaction
when people take responsibility for their own health, which will positively affect their
family.
Sending Nondiet Messages to Children
• Don’t make children clean their plate to earn dessert or “be good.”
• Don’t use food as a reward or comfort.
• Establish family mealtimes instead of letting everyone fend for himself.
• Teach children to heed internal signals for hunger or satiety, rather than
trying to control their appetites.
• Accept child as he/she is. Don’t instill a feeling of not being good enough.
• Don’t introduce diets as a form of control; rather, adopt positive lifestyle
habits that become a family way of life.
• Avoid centering holidays on food; rather emphasize the meaning of the
occasion itself, friendship, conversation, and activities.
• Don’t rely on diet products (i.e. diet drinks) that do not allow children to
acquire a taste for low-sugar foods.
(Omichinski, 1993a).
Nondiet Weight Management
Notes
40
Nondiet Weight Management
41
Chapter Five:
Breaking the Failure Cycle
Male or female, we come in many shapes and sizes. Our individuality is what
makes us feel special and unique. Messages we receive from our families and friends
about our bodies can stay with us throughout our lives. Society communicates messages
to us through magazines, television, movies, music, and the “image industries” — the
advertising, fashion, fitness and diet industries — telling us that there is one “perfect”
look to which we must aspire.
Our body image is strongly influenced by these messages. Body image is the
mental representation or internal picture we have of our physical body; an inner view of
our outer selves. As the product of our imagination it can be easily distorted. Our body
image is vulnerable to outside feedback and can change with a few cookies, the wrong
number on the scale or a critical comment about what we are wearing. It is also influenced by the messages we received as children from those whose opinions mattered to
us (family and friends). For example, if a person was often called chubby as a child, he
will most likely see a chubby body when he looks in the mirror, regardless of his body
size as an adult.
We are told to enhance body image and self-esteem through exercise and dieting.
Both are promoted as healthy lifestyle choices, and they can be; however, the prevailing
message is that being healthy means being thin. This pressure to be thin often results in
a pattern of compulsive exercising and dieting, focusing on appearance rather than
health and fitness.
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Consequences of Weight Preoccupation
• Takes time, energy from personal growth and development
• Makes us believe our body is “the enemy”
• Breeds self-hatred
• Puts us into competition with others
• Takes away life’s spontaneity
Preoccupation with body shape, weight and food creates a lifestyle of emotional
and physical deprivation. Manipulation of body shape and weight is a full-time job —
robbing us of life’s meaningful experiences. Little, if any, free time or energy is left for
personal growth and development.
Diets take control of our body away from us. We are told what, when and how
much to eat. The fitness industry popularized such phrases as “no pain, no gain,”
“whip it into shape,” “burn that fat.” These encourage disrespect for, alienation from
and abuse of the body — as if it was something to be disciplined and punished.
Preoccupation with changing our body shape or size can lead to a mind/body split
where the latter is treated as a separate entity, an object, something that cannot be
trusted to know what it wants. Body signals about hunger, thirst, fatigue, sadness, joy
and anger are not responded to. The mind determines what the body will experience.
We are told diets are healthy and bring positive lifelong results. However, diets
often result in binge eating due to calorie restriction. The inevitable weight gain leads to
guilt that can begin a cycle of starving, bingeing and purging through vomiting and/or
compulsive exercising. Unable to lose weight, or maintain our weight loss, we tend to
believe we are the problem — when the truth is only 5 percent of diets result in longterm weight loss, and that diets can actually cause weight gain! Rather than making us
feel better about ourselves, diets set up a failure complex, and destroy our self-esteem
and body image.
This is particularly true for women. In striving to attain the idealized, “perfect”
shape, women are socialized to see other women as rivals. How many of us have said:
“I hate her. She’s so thin!” when referring to a woman we know, or when watching
television, a movie or flipping through a magazine?
Ironically, while so many women engage in dieting and compulsive exercising,
these are not “shared” activities. On the contrary, they serve to isolate women. They
make other persons the enemy, rather than potential sources of support at a particularly
vulnerable time.
Everything is planned, weighed and measured. A piece of chocolate cake is sinful.
An ice-cream cone makes one a bad person. A missed aerobics class means skipping
dinner and doing 500 sit-ups. Planning a dinner engagement requires a skipped break-
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43
fast and a salad for lunch. Spur of the moment invitations must be refused for fear of
being tempted with food not “earned” or calories not “saved.”
Many individuals — especially women — wage a day-to-day physical and emotional war to attain an unrealistic, elusive standard of body appearance. By continuously striving to achieve a societally-imposed ideal, they will never be free of their
insecurities or self-consciousness.
The pursuit of the “perfect” body never leads to ultimate, lasting happiness. Nevertheless, it is estimated that almost half of adult women and 25 percent of adult men
are attempting to lose weight at any one time. Approximately 44 percent of adolescents
in grades 9 to 12 reported that they were trying to lose weight; and 63 percent of highschool girls were dieting on the day of a survey, in spite of the fact that the majority of
the girls were already at or below normal weight (Robison, et al., 1993).
Having a positive relationship with the body is even more difficult for women and
men raised in dysfunctional families where personal boundaries may have been violated. The experience of “being in the body” as a child may have been too emotionally
or physically painful.
Children who are abused learn that their body is not a safe place to be — that to be
in touch with their body hurts too much. If their body is being physically or sexually
assaulted they may feel shame and hatred toward it. They learn to ignore messages and
feelings from the body.
Many years later as an adult they still may not be present in their body, that is,
aware enough to know what is going on inside. Disconnection from the body is most
common in victims of childhood physical and sexual abuse. “Splitting” from the body
may be the best survival tactic for a child; however, later in adulthood the numbness
can be frightening, alienating and debilitating.
It is not uncommon for these individuals to develop an addiction or an eating
disorder. Being high or drunk may be the only time they can enjoy their body. An eating
disorder can be a way to continue to punish the body that was punished in childhood,
or it may be a way to starve or stuff an emotional life.
Not surprisingly, the body image of an abuse survivor is often extremely negative.
They often feel dirty, ashamed, disgusted, and they often continue to abuse their bodies
through self-mutilation, neglect and negative self-talk (McFarland and Baker-Bauman,
1990; Latimer, 1993).
WHAT DOES HAVING A POSITIVE BODY IMAGE MEAN?
Having a positive body image means that your feelings about your body are not
negatively influenced because of other events in your life. Your body does not become
the emotional “dumping ground.” For many people, life’s problems are projected onto
the body. “If only I were thinner I might have been more successful in that relationship,” “ If only I were younger. . .,” “If only I were pretty. . .,” The body can become an
easy target for all that is wrong in one’s life. When body image is positive, the body is
respected and valued.
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People with a positive body image generally have a relaxed posture and open,
calm body language.
BODY TYPE
Bodies are more likely to reflect genes rather than wishes. There is such a thing as
body type. There are three basic body types: the ectomorph, slender and linear; the
mesomorph, muscular and blocky; and the endomorph, broad and soft.
Slender and linear is popular right now — for women and, somewhat, for men.
Mia Farrow is an ectomorph, as is Anthony Perkins. Pete Rose is a mesomorph, and so
is Mary Lou Retton. Michael Caine is an endomorph, and so is Bette Midler.
Three Main Body Types
Endomorph
Build
Body fat
Features
Examples
Mesomorph
Build
Body Fat
Features
Examples
Ectomorph
Build
Body fat
Features
Examples
heavy, rounded, shoulders often narrower than hips;
prominent abdominal viscera, large trunk and thighs,
tapering extremities
higher percentage, often carried on hips, waist, thighs,
and buttocks
rounded
John Goodman, Bill Clinton, Roseanne Barr
broad shoulders, narrowness in the rib cage, waist, and
hips; weight concentrated in upper body; compact and
muscular
medium, often carried around waist
angular, “chiseled,” prominent cheekbones
Arnold Schwarzenegger, Darryl Hannah, Kevin Costner
tall, slim, small-framed; narrow shoulders and hips
very little; tends to be dispersed evenly
thin, long jaw
Mia Farrow, Anthony Perkins, Fred Astaire
The endomorph might or might not be heavier than average. Fat is fluffier than
lean; it may look bulkier but doesn’t weigh as much. Endomorphs have pear-shaped
bodies — relatively narrow shoulders and broad hips. The mesomorph may weigh in
the obese range on the height-for-weight tables, even with very little fat on his body.
Hardly anyone is a “pure” body type, but we all have our tendencies. Children
inherit their body types from their parents. Those who got the luck of the draw got a
body type that is currently fashionable and one that lets them do what they want to do.
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The rest have had to learn to live with it. However, some people try to change their
body types by dieting or working out with weights or having plastic surgery. The
sacrifice of time and emotional and physical energy can sometimes be so great that it
impairs their ability to live their lives.
We are not all meant to be fashion-model size even though slim females and lean
muscular males are paraded before us as ideals. If a person understands and appreciates his body, he will be able to work with it, not against it. He cannot become another
type. No matter how he starves himself, his basic body shape will remain.
Learning to like one’s body takes practice. Here are some tips.
Changing Body Image
• Change your self-talk. Follow your thoughts for 1 or 2 days. Be vigilant in
hearing the types of messages that you repeat about your inner and outer
self. Increase positive self-messages and decrease the negative ones.
• Develop affirmations that focus on a new attitude about your body. “I like
my body when I eat the way it wants me to. I have attractive legs. I have nice
arms.”
• If you are weighing yourself, throw out the scale! This metal object has
been given too much power to determine how you feel on any given day.
• Ask yourself if you exercise for appearance or for fitness. If it is for
appearance, you may want to assess how helpful this is to achieving a
positive body image.
• Try not to compare yourself to models, actors, magazine photos. They
search the world over for these faces and bodies and none of them are as
they appear! Television makeup takes hours to apply, photography tricks
and photo airbrushing eliminate lines, blemishes and pores. These people
don’t even look this way in real life.
• Talk to a professional if negative body image is hurting you in your personal
life, relationships or the workplace.
McFarland and Baker-Bauman; Latimer
BREAKING OUT OF THE DIET MENTALITY
Unfortunately, the attitudes and practices acquired through years of dieting can
prevent people from achieving a healthier lifestyle (Pace, et al., 1991; Bennett and
Gurin, 1982).
To be a successful dieter, one must learn to ignore or distrust inner signals of
hunger, appetite and satiety and instead depend on external references, such as foods
allowed/not allowed, suggested frequency of eating, and weighed or measured portion
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sizes. As a result, most chronic dieters have lost the ability to eat in response to physical
needs and may be more susceptible to overeating for environmental (because it’s there)
and emotional reasons (Polivy and Herman, 1983; Goodrick and Foreyt, 1991; Garner
and Wooley, 1991).
Focusing on the external goals (adherence to a diet plan and weight-loss indicators)
can lead to perfectionist tendencies that often result in a loss of control. Dieters share
with eating disorder patients similar dichotomous thinking in relation to food: the
perception of foods as either “good/diet” foods or “bad/bingeing” foods; as either
“good/small/low energy” amounts or “large/diet-breaking” amounts. If dieters eat
“bad” foods or foods in “large” amounts they perceive that they have “blown” their diet
for today or for this week — so they might as well keep eating.
The pattern of thinking and behaving described above is commonly called “the
diet mentality” (Omichinski, 1993a). This mentality, or lifestyle perspective, is likely to
result in weight obsession, poor self-image, disordered eating patterns, poor nutrition,
and disordered lifestyles, often marked by excessive or inadequate exercise.
Diet/Binge Cycle
low selfacceptance
structured diet/living
low selfacceptance
structured
diet/living
deprived feelings
TARGET
WEIGHT
weight gain
binge eating
give up
guilt
The illustration above shows how people can get caught in the “yo-yo” dieting
cycle that begins with low self-acceptance, which results in structured eating and living
because people lack the trust to listen to their body signals and live spontaneously. This
results in feelings of deprivation leading to the inevitable binge. This in turn leads to
guilt, defeat, weight gain, and feeling even worse about themselves. Thus the cycle
begins again.
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Nondiet Weight Management
Methods of overcoming dieting habits to enable the adoption of a healthier lifestyle
are required. Interventions that help people take the focus off their weight and calorie or
fat counting are being suggested (Robison et al, 1993; Garner, 1993; Parham, 1991).
As discussed in Chapter Three, a lifestyle perspective consistent with dieting
thoughts and behaviors and low self-acceptance can be improved by participation in a
nondiet lifestyle program. Being unhappy with the way one looks provides only temporary external motivation which usually results in a diet and eventually weight gain. The
nondiet approach begins with the assumption that people are okay just as they are right
now. They don’t have to lose weight, look, or behave differently to be acceptable. Instead of having to be thin to feel good about themselves, the process is reversed.
Clients are taught to accept themselves and feel good about themselves first in
order for them to want to nurture themselves and take care of their body and mind.
Accepting oneself does not mean that a person is absolutely okay and needs to do
nothing. Rather, it implies that he/she has the energy to feel good about his/herself,
cares about oneself, and wants to do what is best for body and mind to be the best that
he/she can be!
Healthier Living Cycle
feeling better
about
yourself
active living
self-acceptance
enjoyable eating
self-confidence
self-nurturing
As illustrated in the healthier living cycle above (Omichinski, 1993a), a positive
cycle begins with self-acceptance, which allows people to feel confident in themselves
and their bodies: they then trust and feel they deserve to follow the natural signals of
hunger, satiety, and appetite that the body sends them. This results in a lifestyle shift
where enjoyment of eating and active living promotes even more positive feelings and a
continuation of the positive cycle.
The nondiet approach to lifestyle changes, as outlined in the chart on the next
page, will allow clients to work with their body and develop their full potential. It will
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48
show them a new way of thinking about themselves. Clients are encouraged to recognize “diet thinking” and to consider an alternative perspective. For example, for those
trapped in the diet mentality, exercise routines are embarked upon solely for their
contribution towards losing weight, and are often abandoned if not rigidly followed.
The nondiet approach discusses and demonstrates revamping these goals to result in
enjoying fitness for its contributions towards increased energy and well-being.
Making Lifestyle Changes
• Accept yourself as you are
• Believe that diets do not work
• Give up past failures; focus on the present
• Give up judging your self-worth by the number on a scale
• Relax; allow changes to happen naturally
• Care about yourself
• Let physical and psychological needs guide you
• Listen to your body
• Schedule special time for yourself
Omichinski, 1993a
Acknowledging two basic premises is crucial to allowing clients to move forward
in this approach. They must accept themselves as they are and develop their potential,
and they must be convinced that diets don’t work. Then they can forget past failures
and move into a positive future.
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Chapter Six:
Nondiet Nutrition Concepts
At this point, you’re probably thinking “All well and good — let’s deal with
psychological issues. But what about nutrition? Is everything we’ve learned about diet,
weight management and nutrients worthless?”
Not at all. The nondiet lifestyle approach to health and fitness has as its overall
goal to free clients from the “diet mentality” and promote an independent, nondieting
lifestyle characterized by nourishing eating, sound activity patterns and self-acceptance.
The counseling sessions are designed to foster self-reliance in the development of a
nondieting lifestyle and to provide practical, hands-on skill development as clients
make gradual lifestyle adjustments. Good nutrition is part of good self-nurturing.
Nondiet nutrition concepts, instead of food guides, are provided so clients can
understand the body’s physiological need for different kinds of foods and fluids and
relate nutrition to lifestyle issues. For example, the consumption of carbohydrates along
with a protein source (to slow the release of glucose into the bloodstream) at each meal
enables the individual to recognize signals of physical hunger (Omichinski, 1993a). It
provides a framework for learning to tune in to physical hunger — an internal cue
consistent with the nondiet approach.
Asking individuals to question how they feel 3 to 6 hours after eating a balanced
meal of this nature will assist dieters, who may be out of tune with their hunger signals,
to identify the signs of hunger. As well, this mode of eating will provide more sustained
energy throughout the day with less tendency for the evening meal to be overloaded
with protein. Portion control is replaced with the internal signal of fullness by experimenting to find a quantity of food that enables individuals to feel satisfied and not
overfilled.
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All food is “legal” in the nondiet approach. Sudden decreases in fat content are
recognized as being part of the dieting process — attempts to restrict higher-fat foods
while people still have a preference for foods higher in fat result in feelings of deprivation. That may cause a higher intake of fat than would normally be consumed. With this
approach, clients develop skills to tailor their tastebuds to appreciate new flavors and
textures. Application of these skills is integral to this approach.
HOW THE BODY USES FOOD ENERGY
It is important to balance meals and snacks with carbohydrate and protein foods.
Since many popular “food combining” or “meal balancing” concepts have been promulgated in recent decades, we need to establish a sound scientific basis for recommending
a particular formula. (Otherwise, the client may counter your recommendations by
citing a more complex “pop” food combining plan.)
A meal with carbohydrates alone results in being hungry sooner, with blood
glucose levels jumping up very quickly and dipping very low afterwards. This leaves a
person feeling tired, hungry, and weak. If a small amount of protein food is included,
one stays full longer, blood glucose levels stay more consistent, and one feels energized
for a longer period of time (Rolls, et al., 1988).
In order to understand why this is important, we need to consider how carbohydrate and protein foods are used by our bodies and how they interact with each other.
You could think of any meal as a time-release capsule. Different foods are broken down
by digestion at different times: carbohydrates are digested in about 2 hours; protein
takes longer to digest and slows down the digestion of carbohydrates, so the energy
from carbohydrates is released more slowly. The balanced combination of carbohydrate
and protein helps to keep us feeling energetic and satisfied until the next meal.
This principle allows these concepts to be used by people with diabetes to assist in
blood glucose management, instead of following a rigid eating plan. In adapting this
concept of eating more carbohydrates and some protein at each meal, we need to pay
attention to those foods like fruits and fruit juices that have a pronounced effect on the
blood glucose levels of a person with diabetes.
In fact, for some people, at breakfast in particular, it is helpful if they eat their
protein source first so that they have something in their stomach before eating the fruit.
An example would be to have toast with peanut butter before eating an orange. Eating
higher-sugar sources like fruit or a piece of cake has less of an effect on the blood glucose level if eaten after a meal.
Keep in mind that both fruit and a piece of cake contain sugar, just a different type
of sugar. Both have an effect on increasing blood glucose levels. Eating these foods after
a meal will have less of an effect on blood glucose levels. In Chapter Eight, we will
elaborate on how acquiring a taste for liquids and foods lower in sugar can also have a
long-term effect in changing tastes to appreciate lower-sugar foods. Combined with the
above concept, people with diabetes especially appreciate their new-found freedom in
this approach.
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Nondiet Weight Management
Several carbohydrate and protein foods are categorized below.
Carbohydrates & Proteins
Carbohydrates
Proteins
Grains: cereals, breads, buns,
crackers, bagels
Pasta: noodles, spaghetti
Rice
Fruit: fresh, canned, frozen,
dried, juice
Vegetables: potatoes, corn, carrots,
peas, turnip, squash,
pumpkin, parsnips,
tomatoes, beets, juices
Dairy: milk, yogurt
Meats: beef, pork, lamb, veal, game
Poultry: chicken, duck, turkey
Eggs
Fish and Seafood
Bean curd (tofu)
Dairy: cheese (except cream cheese),
peanut butter
Dried beans, peas and lentils
Those vegetables that you pull from the ground, such as potatoes, carrots, parsnips, beets, and turnips as well as corn, squash, and peas, are more starchy and therefore a better source of carbohydrate. Salad vegetables, such as lettuce, celery, peppers,
and vegetables such as broccoli and cauliflower, have vitamins and minerals, but they
are not good sources of carbohydrate due to their high water content. Therefore, clients
should be told that these vegetables cannot be depended on to provide carbohydrate at
a meal. These vegetables are best used as part of a meal containing other carbohydrates,
to provide variety in color and texture at the meal.
Milk is included on the carbohydrate list because, even though it contains some
protein, it is also very high in carbohydrate (lactose). Due to its liquid form and the fact
that it is a less concentrated source of protein than foods on the protein list, it is not
satisfying enough to be used as “holdover” power.
There is one type of food that crosses both the carbohydrate and protein categories
— legumes (dried beans, peas, and lentils). Many legumes are not only high in carbohydrate, but also high in protein.
Just as a car needs gas, the body needs carbohydrates to break down into glucose
to provide energy. Often people mistakenly believe that vitamins give them energy.
Excess vitamins will not push the pace of biological reactions faster, just as having a full
tank of gas will not make a car go faster. Vitamins help extract energy from carbohydrates, but carbohydrates provide energy. Eating in a healthy manner provides sufficient amounts of vitamins and carbohydrates.
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Protein is used by the body to build and repair tissues, hormones, and enzymes.
With regard to energy level, protein foods help to sustain the energy provided by
carbohydrates.
Foods such as meats, fish, poultry, peanut butter, eggs, and cheese give sustained
energy. Protein foods allow the body to extract energy from carbohydrates at a slower
pace.
As illustrated in the diagrams on the following page (Omichinski, 1993a), eating
protein foods along with carbohydrates allows the carbohydrates to break down into
glucose at a slower rate, resulting in more sustained energy (Rolls, et al., 1988). Protein
foods slow down the release of glucose from the carbohydrates into the bloodstream. In
this way, eating some protein along with carbohydrates stabilizes the blood glucose
swings that could otherwise lead to binges or feelings of hunger and irritability
(Omichinski, 1993a). For example, a carbohydrate only lunch of soup and salad would
result in a period of hunger. A balanced lunch which includes a protein source, such as
soup and meat sandwich, provides more sustained energy.
Balancing Carbohydrate & Protein
Eating Carbohydrate & Protein
Blood Glucose Levels Optimum Curve
Supper
Lunch
Eating Carbohydrate Only
Blood Glucose Levels Undesirable Curve
Too quick
rise and
rapid fall
Lunch
Stored as fat because
not burned for energy
Periods of hunger that
slow metabolic rate
Supper
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Because protein foods commonly contain fat, reducing the amount of protein to
that amount required to sustain the energy provided by carbohydrates will generally
result in a lower intake of fat, thus assisting in lowering serum cholesterol levels.
EATING REGULARLY
Clients who have been dieting are likely to be out of tune with their body and its
signals of hunger and fullness. They must begin by eating regularly, starting with a
breakfast, to tune back in. Provide clients with the following guidelines:
• Eat regularly — at least every 3 to 6 hours. Include a breakfast, lunch and supper.
Put a snack in at a convenient time to dampen your hunger. If you are really physically
hungry, do not fill up on water or coffee — eat something. Ignoring your natural hunger
signals will only lead to uncontrolled eating or bingeing later on.
One of my clients felt that when she started to eat breakfast, it made her more
hungry by lunch time; she began to eat more frequently, whereas formerly she did not
eat until supper. It takes 3 to 6 hours to digest a balanced breakfast, so you will be
hungry by lunch time. If clients eat these meals and stop eating when they are full they
will ultimately eat less at supper time and throughout the evening. Once clients get
“hooked” on eating breakfast, their body will find it difficult to do without it.
Undereating early in the day inevitably leads to overeating later on. People who
snack in the evening tend to cut back the next day to make up for it. They’re not hungry
until they start to eat, then their appetite goes up. If they eat breakfast, they are hungry
at lunch because this is part of the normal body function that has been ignored due to
dieting.
Eating regularly involves resetting our internal clock to a regular pattern of meals.
Once people begin to eat breakfast in the morning, within an hour of getting up, they
will start to wake up hungry for the morning meal.
• Balancing meals. Dieters have a different attitude toward foods labeled “carbohydrates” and “protein.” For dieters these are divided into “legal” (those foods that are
okay to eat when on a diet) versus “illegal” (those foods that are forbidden). Meats and
fruits are “legal;” breads, cereals, potatoes, and pastas are “illegal” foods that should be
eliminated or restricted, according to the diet mentality.
Dieters are not accustomed to eating carbohydrates. They are not aware that by
taking in more protein sources and cutting back on carbohydrates such as bread and
pasta they are actually setting themselves up to crave carbohydrates from other sources,
such as cakes and cookies. Restricting carbohydrates causes the body’s natural defense
mechanism to kick in to cause one to crave sweets as a quick source of fuel for the body.
This is a result of both physical and psychological deprivation.
Eating more carbohydrates that break down into natural sugar will allow clients to
receive the carbohydrates they need from less sweet foods and will result in fewer
cravings for sweets. Provide clients with the following guideline:
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• Choose meals and snacks that satisfy. Eat what you want, balancing carbohydrate foods for energy with enough protein to keep you satisfied until the next meal. If
you eat what you like to eat more often, you will eat less in total. If your choice of food
is based on “shoulds” rather than on personal preference, you will binge on the foods
you love.
A simple way to help clients balance their meal is to have them consider their plate
or meal (regardless of size) and divide it up to look like this:
Balanced Meal
2/3 to 3/4 CHO
(i.e. vegetable, bread,
potato, pasta)
1/3 to 1/4 protein content
(i.e. meat, seafood, poultry, eggs,
cheese, peanut butter, legumes)
If the meal consists of more than the main plate, this concept can be applied to the
whole meal. This simple tool allows clients to quickly check what kind of balance they
have in their meal and judge whether it is the balance that will leave them feeling
energized and satisfied.
Effective eating takes time. Clients need to find out how good it feels to sit down to
a meal pleasantly hungry and to have good food and to take their time with it. They
will end up truly satisfied and able to forget about eating between meal times. Slowly
and attentively is the way to eat.
To make eating worthwhile, clients need to come to the table pleasantly hungry,
not starved, allowing them to eat slowly until they are satisfied. They need to eat
enough food to fill up. It should be food that they like, that feels good in their stomach,
and provides enough energy so it will satisfy them and keep them comfortable until it is
time to eat again.
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TUNING IN TO BODY SIGNALS
Rather than prescribing exact amounts, it is more important for clients to become
aware of their own hunger signals, food needs, and what will satisfy them (Glanville,
1989). This may take a while, but the benefits are endless.
As a guide to knowing what hunger feels like, clients can check how they feel 3 to
4 hours after eating a balanced meal. This should provide them with an idea of what
appropriate physical hunger feels like.
To assist clients in determining what appropriate fullness feels like, clients can be
provided with the following guideline:
• Listen to your body. Tune in to your natural internal cues to hunger, not external
cues such as seeing or smelling food or eating the amount you think you should. You
can eat whatever amount you need to feel satisfied. You can learn to stop when you are
comfortably full, not stuffed.
Many people have lost the skill of knowing how much they need to eat to feel
energized and satisfied because they have spent so much of their life following regimented eating programs. Clients must be aware of their own signals of hunger and
fullness. Their own body is the best guide for how much they need to eat. They must
learn again how it feels to be hungry, full, or uncomfortably full. They can change their
eating patterns to start to eat when their body is telling them it is hungry and produce a
satisfied energized feeling after eating.
TYPES AND ROLE OF FIBER
As clients discover the different textures and flavors of foods they will experience
and enjoy the more chewy, crunchy texture of high-fiber foods rather than equating
enjoyment of foods with the greasy taste and mushy texture of high-fat processed foods.
High-fiber foods are those that add bulk to the diet and are not digested or are only
partially digested by the body. Fruits, cereals, seeds, nuts, grains, and vegetables are
examples of foods that are higher in fiber content.
Two Kinds of Fiber
Soluble Fiber
pectins, gums
Insoluble Fiber
cellulose, hemicellulose, lignin
Sources: seeds, legumes, oat bran,
nuts, raw & dried fruits, raw &
cooked vegetables
Sources: wheat germ, whole
grains, cracked wheat, bran,
bulgur, brown rice
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Both kinds of fiber are important. The difference is where they come from and their
effect on the body. Foods containing water-insoluble fiber are not digested and add bulk
to the diet. They are thought to improve bowel regularity. Foods containing watersoluble fiber become a gel-like substance during digestion. They seem to keep blood
glucose and cholesterol levels in line. As well, eating patterns rich in fiber-containing
foods are also thought to play a part in preventing serious bowel disorders and decreasing the risk of colorectal cancers.
How food is prepared can make a difference. Processing will change the size of the
individual fibers and their effects on the body although the total amount of fiber will be
unaffected. For example, finely ground wheat bran does not have the same anti-constipating effect as coarse wheat bran. For this reason, choosing a variety of high-fiber
foods that aren’t highly processed is important.
Glycemic Index
baked potato (russet)
honey
corn flakes
instant potatoes
millet
white/whole wheat bread
corn
candy bar
white rice
brown rice
raisins
wheat crackers
sucrose (table sugar)
frozen peas
porridge-style oatmeal
banana
buckwheat
sweet potato
pasta
oranges
orange juice
whole grain rye bread
apples
dairy products
beans/legumes
plums
cherries
fructose (fruit sugar)
peanuts
Slower
Faster
Rated from quickest glucose release to slowest
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Tests have been done using different carbohydrate foods to discover how these
foods affect blood glucose levels. Normal individuals ingested 1 oz (28 gm) portions of
carbohydrate foods and were tested to see the effect this had on blood glucose levels. A
glycemic index table was the result.
The table on the preceding page provides a method of rating selected carbohydraterich foods according to how quickly they elevate blood glucose levels. The higher the
glycemic index, the faster the food is digested and released into the blood stream,
thereby elevating blood glucose levels more quickly (Jenkins et al., 1981).
The glycemic index indicates that blood glucose levels will rise faster following a
snack of potatoes, carrots, or bread, than after a snack of fruit, legumes, nuts, or pasta.
Some high-fiber foods can keep blood glucose from soaring after a meal by releasing glucose in small doses. This prevents blood glucose from going on a roller coaster
ride that will cause energy levels to dip. High-fiber foods achieve this by delaying food
release from the stomach, and slowing the digestion of starch and sugars in the intestine. With a slower release of glucose into the bloodstream (a flatter glucose response
curve), you have a more sustained energy level. Other factors that affect glycemic
response are:
• The amount and type of fiber. In general, water-soluble fibers become gel-like
during digestion and take much longer to be absorbed into the blood stream. Fructose,
the major carbohydrate in fruits, takes longer to release glucose into the system than
table sugar (sucrose) because the body must first convert it to glucose. Pectin, a gel-like
substance found in some fruits and vegetables such as apples, cauliflower, citrus fruits,
green beans, cabbage, carrots, strawberries, potatoes and dried peas, delays emptying of
the stomach.
• The form the food is in. In general, the smoother the texture, the higher the
glycemic response. Insoluble fiber such as that found in whole grain products adds
texture to food. Since it needs to be chewed more and takes longer to eat, it helps to
extend the meal. The compact nature of the starch in pasta reduces accessibility of the
starch to digestive enzymes that are involved in breaking down the starch molecule. It
takes longer for the starch molecule to break down into glucose and this causes the
slower release of the glucose into the bloodstream. Grinding or cooking a starchy food,
as in mashed potatoes, speeds up the food’s absorption in the intestine, causing blood
glucose to rise more rapidly.
• The degree to which the food is cooked. When foods are raw, the cellulose cell
walls are not completely disrupted by chewing. These prevent access of digestive
enzymes to the starch within the cell. Cooking swells the starch within the cell, bursting
the cell wall and potentially making the starch more available for digestion.
• The speed of eating. Eating slowly maximizes the enjoyment of food and provides an earlier feeling of satiety for a given quantity of food consumed. Slow eating
will slow down the release of glucose into the bloodstream.
• Timing the consumption of liquids. Liquids ingested with solid foods empty
more rapidly from the stomach into the small intestine. So if you are consuming liquids
containing sugar, drink these fluids after a meal.
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By focusing on increasing the carbohydrate content of meals, clients will get the
benefits of regularity, satiety, and a sustained energy source.
VEGETARIAN EATING
Vegetarian eating is becoming more popular. With the emphasis on increasing
carbohydrates and fiber and gradually decreasing protein content, vegetable proteins
such as legumes offer an advantage. For vegetarians, the quality as well as the quantity
of protein is a concern.
As mentioned previously, protein provides the body with building blocks. The
adult body needs over 20 amino acids (protein building blocks) to maintain health. Nine
of these cannot be made by the body, so they must be obtained from food. Animal
protein has these amino acids in the proportions that the body needs — they are complete proteins. Most vegetable protein sources are missing at least one of these amino
acids. Therefore they are called incomplete proteins.
In order to complete the amino acids it is important to include a variety of foods
with vegetable protein. They don’t need to be at the same meal, just in the same day.
These add-on foods include nuts, seeds, grains, fish, eggs or dairy products. Adding
some of these foods to your daily intake when you are using vegetable sources of
protein will give you the nine essential amino acids and help to round out the vegetable
proteins into complete proteins.
Because many of the vegetable sources of protein are bulkier and lower in fat than
animal protein sources, the meals are often lower in energy and are digested more
quickly than a mixed meal of animal protein and carbohydrate. Therefore, persons
eating primarily vegetable sources of protein may find they need to eat more often.
As clients begin to include more vegetable protein (either by replacing animal
proteins with vegetable proteins in some of their meals or supplementing animal proteins with the vegetable proteins) it may be difficult for them to meet total daily protein
needs in three main meals. They may need to include more snacks. Including a carbohydrate and protein combination for snacks can help them to meet their daily protein
requirements. This will also help them to stay full between meals and help to regulate
the release of glucose into their bloodstream so that they will have a more constant
supply of energy. Eating smaller, balanced meals throughout the day gives the optimal
amount of energy for daily living.
By focusing on increasing the carbohydrate content and decreasing the protein
content of meals, clients already have decreased the overall fat content of meals. The
next step will be to learn to appreciate the tastes and textures of foods lower in fat.
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Chapter Seven:
Moderating Dietary Fat
If dietary fat were easy to control, most diet plans would probably succeed. Even
with the recent explosion of lower-fat foods, most people still eat too much fat. The
reasons are well-known: we’re accustomed to the taste of fat and “reward” foods are
almost always high in fat. We eat fat because we like it.
Attempts to restrict higher-fat foods while people still have a preference for them
causes feelings of deprivation and may cause a higher intake of fat than normal. Unfortunately, many people have moved from counting grams of carbohydrate, calories or
exchanges to counting grams of fat. This is simply a repackaging of the same old diet
message — the focus is still on numbers rather than satiety and enjoyment of taste and
texture. This is not a new, healthier, lifestyle. If tastes don’t change to enjoy foods lower
in fat, this quickly becomes very restrictive. Eventually, once the weight or cholesterol
level has gone down, the usual eating habits resume.
Clients with immediate cholesterol or heart concerns need to be cautioned about
making too many changes too quickly. It is important that clients move gradually from
a higher-fat way of eating through an enjoyable process of learning to acquire a taste for
foods lower in fat. Otherwise, they experience only short-term improvement in symptoms. Application of the nondiet nutrition principles with a focus on learning to acquire
a taste in foods lower in fat will produce a change in eating patterns that is more likely
to be long-term than a rigid, drastic restriction of fat.
Rigidly restricting fat in one’s way of eating, or replacing an obsession with body
fat with counting the amount of fat grams in one’s food, adds to one’s health problems.
Focusing on denying certain foods may lead to bingeing on fatty foods.
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By asking the following questions, you can determine whether clients may have an
unhealthy fear of fat. If they answer yes to one or more of these questions, then they
need to recognize that they can decide whether to buy into this way of thinking or make
some changes.
Questions to Identify Rigid Fat Restriction
• Are you counting number of grams of fat in foods you eat?
• Do you decide what foods to eat by the amount of fat in them?
• Are you attempting to cut out all fat in your food?
• Are you afraid of fat on your body and fat in food?
• Do you consider this behavior normal and healthy?
• Does your conversation revolve around food, fat and fiber?
• Are you preoccupied with numbers (calories, fat grams, etc.)?
• Do you feel bad about yourself for eating too much fat?
• Do you experience sudden hunger, cravings and feelings of deprivation?
• Do you binge on high-fat foods when you get the chance?
• Do you think fat is unnecessary for physical health and enjoyment of food?
The following example illustrates what can happen when clients attempt to restrict
fat by making drastic changes in food habits.
Ann would not eat pork and beef because she thought they were too high in fat,
but her lunches would often consist of deep-fried chicken or fish burgers, garlic toast,
and fries with gravy. All of these items are high in fat and Ann added even more fat by
topping them with greasy gravy. Was she compensating for the fact that she liked fat
and was cutting it out too quickly by eliminating pork and beef? Adding gravy to fries
did not allow her to tune in to their crisp texture. The idea is not to eat one way at home
(“being good all week”) only to binge on high-fat foods when eating out or on weekends (“the reward”).
In another situation, Donna decided to use margarine instead of butter, as she
enjoyed the taste of butter but did not care for margarine. Her thinking was that if she
didn’t like margarine she would not eat as much of it and therefore would decrease the
amount of fat she was taking in. This is, in fact, what happened in the short term — she
ate less margarine and therefore less total fat. However, a few months later her craving
for butter became so strong that she binged on it.
Sudden decreases in dietary fat content are part of the diet process, which ultimately is proven to fail. It is important for people to eat what they enjoy and make
gradual changes. Drastic changes end up backfiring.
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When people base their food choices on the number of calories, exchanges or
“foods allowed/foods not allowed” list, the focus is on numbers rather than satiety and
enjoyment of taste and texture, and people tend to make other changes in their food
habits. This often negates any positive effect the original focus on choosing foods lower
in fat may have had.
This phenomenon has been investigated by Caputo and Mattes (1993), who examined the influence of knowledge of the fat content of foods on dietary habits and demonstrated a marked cognitive influence on food intake in free-living adults. These
observations are based on diet records kept by subjects over 12-day periods. Subjects
were told that their lunch was either higher, lower, or of the same fat content as usual —
when, in fact, all subjects were given the same low-fat meal.
Total energy intake and energy derived specifically from fat significantly increased
when subjects were told that they were ingesting low-fat midday meals. People ate
more when they thought they were eating lower-fat foods!
Caputo and Mattes offer several possible explanations for the observed increase in
fat intake following what was perceived as a lunch with less fat than normal. Knowledge of fat content of meal may affect dietary habits because of:
•An effect on meal palatability. The meal identified as low in fat could have been
regarded as less pleasant by subjects. Having been required to ingest the meal,
they may have increased intake of preferred foods at a later time point as a
compensatory meal.
• An effect on hunger. Fat is often viewed as especially satiating, suggesting that
belief about the energy value of a meal may be a better predictor of hunger
following ingestion of the meal than its true energy content.
• An effect on health practices. If participants believed they had achieved some
desirable savings with the purportedly low-fat meal, they could afford to be
more liberal in their intake of energy and fat at other times without adverse
consequences.
Another example of what can happen when clients attempt to cut back on fat too
drastically is the following situation. Jane, who is a longtime dieter, ate cottage cheese
and fruit every time she was on a diet.
The problem was that she did not like the taste or texture of cottage cheese, so her
new way of eating did not become a lifestyle change — it was only something temporary that she did in order to lose weight. Resuming old habits of eating once the weight
is lost results in weight gain. And then the cycle brings you right back to the same
ineffective and unappetizing eating habits in order to lose weight.
Consumers are hearing very confusing messages about fat. People are more conscious of their fat intake and are consuming less butter and meat. Data from the
Framingham Study (Millen-Posner, et al., 1995) revealed that, while dietary cholesterol
levels fell substantially in both men and women, total fat intakes fell only slightly from
1957 to 1988, with mean levels still well above published recommendations. Total
carbohydrate and protein intakes changed little.
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‘Cottage Cheese’ Syndrome
depressed
about weight
don’t feel good
about yourself
eat more to
compensate
avoid fat
fed up
not enjoying food;
not tasty enough;
bored w/food
Omichinski, 1993a
Therefore, even though people are eating less meat, trimming fat off the meats they
do eat, and consuming less butter, their fat intake often remains high. This is possibly
because there has been an increase in the purchase of specialty and convenience foods
such as premium ice cream, gourmet soups, and luncheon meats which are high in fat.
Frequent consumption of these foods indicates that clients have not learned to enjoy the
taste and texture of lower-fat foods; they have simply shifted the source of their fat
consumption. The visible, politically incorrect fat is being traded for the hidden — but
trendy — fat.
Eating Ben & Jerry’s Rain Forest Crunch™ ice cream instead of a shake at Burger
King may make some people feel self-righteously good, but it is not progress from a
nutritional and lifestyle standpoint.
In recent years investigators have found evidence that the body may be able to
convert dietary fat into body fat with greater ease than it can convert carbohydrates
(starches and sugars) into body fat. In other words, it takes more energy to convert carbohydrates into body fat than to convert fat calories into fat tissue (UC Berkeley, 1988).
When dieters hear this, many feel they have to cut back fat intake even more. Yet
many are already cutting back their fat consumption too greatly. Remember the days when
people used to restrict carbohydrates, those foods that contain natural sugar, like breads,
potatoes and pasta, only to crave those foods later on? The same process may be occurring
with fat: the starve/binge cycle that occurred with sweets now also occurs with fats.
Part of the reason for this is making changes in one’s eating patterns — in this case
fat intake — too quickly (Omichinski and Wiebe Hildebrand, 1995). Making sudden
changes in one’s eating pattern, as illustrated in Appendix #3, may only lead to temporary changes. Gradual changes are more likely to last.
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Note the difference between the Big Jump and the Smooth Slide, the nondiet
approach this family takes toward healthier eating. This scenario also provides a wonderful role-playing opportunity for clients to really understand the difference between
the Big Jump and the Smooth Slide approach.
As illustrated in Appendix #3, making the Big Jump into healthier eating is likely
to result in feelings of deprivation, bingeing and, ultimately, a return to the old ways of
eating and cooking. Taking the gradual or Smooth Slide into healthier eating patterns is
encouraging, exciting, enjoyable, educational, energizing and enduring.
The best plan is to fine-tune present eating habits. Start from where clients are right
now and implement gradual changes to allow the entire family to acquire a taste for a
healthier way of eating. Begin by ensuring that clients have a balanced menu and then
gradually make changes to bring out new flavors and textures.
ENJOYING LOWER-FAT FOODS
Part of the philosophy of listening to one’s body and tuning in to taste and texture
involves making gradual changes, one step at a time. Body consciousness is important.
Many people know that higher-fat meals make their mind and body sluggish by slowing circulation and reducing the oxygen-carrying capacity of red blood cells.
However, meals too low in fat will leave them feeling hungry and thinking about
food. If clients crave foods high in fat, it may be a sign that they are not eating frequently enough or that they are restricting their fat intake too much. They can gradually
acquire a taste for new foods that are lower in fat content.
You can assess the progress clients are making in learning to tune in to their bodies
by asking them to reflect on the indicators shown in the chart on the following page.
If they answer no to some of the above questions, reassess if they are eating too lowfat and, therefore need to readjust to a more normal and natural way of eating. Recognize that any change is progress and that the point is to focus more on the satisfaction,
taste and holdover power of foods and meals rather than the content of fat and calories.
Body Consciousness Questions
Are you . .
• Tuning in to the texture, taste and satiety value of your meal?
• Enjoying the energizing feeling of balanced meals?
• Accommodating taste preferences by making slight changes?
• Eating balanced meals regularly?
• Free from cravings for high-fat foods?
• Paying attention to the experience of eating?
• Allowing yourself to taste, savor, and enjoy your meal?
64
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HOW TO GRADUALLY DECREASE FAT IN MEALS
Changing to a lower-fat way of eating can be a simple matter of adapting the foods
clients normally enjoy. Striving for a particular end point is falling back into the diet
thinking. Help your clients tailor their tastes to appreciate the slight subtle differences
in taste, texture, and mouthfeel of healthier foods. If clients eat lower-fat foods because
they prefer and enjoy them, fine; if not, then they are returning to the diet mentality.
In order to acquire a taste for foods and meals lower in fat, clients have to learn
how to make gradual changes to food preparation techniques so that they will enjoy the
end product. For example, the traditional way of frying with fat and no lid leads to
moisture evaporation and food sticking to the bottom of the pan. Adding more fat
results in a meal loaded with fat and grease, which is heavy on the stomach and difficult
to digest. Instead of feeling energized, one feels drowsy.
The chart below illustrates how the tastes and textures of traditional foods can
slowly be replaced by an appreciation of foods and meals with more refreshing and
energizing qualities. It isn’t important to know the exact calorie or fat content of food.
What is important is that clients enjoy what they eat.
Tailoring Your Tastes
New Experience
Traditional
Appearance
Refreshing, clean looking. Sauces,
Grease may be seen or is floating on
dressings, garnishes provide colorful
top of sauces, salads, soups.
accent w/out overwhelming food.
Washed-out colors of vegetables.
Thick beverages. Grease leaves mark Exciting colors, textures.
on napkins.
Taste
Natural flavor can be tasted. Less salt
& seasonings needed. The more you
taste it, the better it gets; taste is
subtle & builds gradually. Sauces,
dressings & garnishes enhance flavor
w/out overwhelming.
Texture
Subtle flavors not noticeable. Flavors
masked by fat taste.
Sauce, dressing, garnish overwhelms
food. Needs more salt or sugar to
bring out flavors masked by fat.
Crunchy, crisp, chewy, cleaner.
Mushy, gooey, soft, dense, greasy.
Mouthfeel
Coats mouth, greasy; beverages leave Experience variety of textures,
mouth more dry, coated w/fullness of consistencies. Beverages feel refreshing, go down easily.
beverage.
Body response
Heavy feeling as it goes down. Feel
tired, bloated when finished. Beverages leave you feeling still thirsty.
Refreshing, satisfying feeling as it
goes down. Not over-filling. Energized. Beverages quench thirst.
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Tailoring one’s tastes to enjoy new flavors and textures is a slow, pleasurable
process. Over time, the new choices will become preferences. Clients will choose cooking techniques and foods that are lower in fat, sugar, and salt and higher in fiber because they prefer them, not because they think they should eat them. When clients
prefer something, they repeat it. Repeating healthier lifestyle practices leads to healthier
living.
FAST FOOD
Modern life depends on convenience. Fast food isn’t popular because it’s healthful
or delicious — rather, because it’s predictable and available. Railing against fast food is
futile; your clients won’t admit it, but they like it. The challenge is to incorporate the
fast-food benefits into more healthful fare.
As illustrated in the chart below, a typical fast-food fried chicken dinner can have
over four times as much fat as a well-balanced 20 minute homemade chicken dinner.
Those of you familiar with fast-food fried chicken will remember the grease marks
on plates and napkins, the greasy fingers and lips that require a soap and water wash
after eating, the thirst produced by the extra salt needed to cut through the fat flavor,
and the full and bloated feeling after eating. In contrast, the home-cooked chicken meal
has a variety of colors, tastes and textures and leaves a refreshing, satisfying feeling.
Fast Food at Home
20 Minute Home-cooked Chicken Dinner for Four
Baked breaded chicken, rice,
Peas w/green onions,
sliced tomato and milk (2%)
Compare this with:
Fast-food Fried Chicken Dinner
1 piece side breast, french fries, coleslaw, and milk (2%)
To help clients make small changes in food purchases and cooking techniques, you
can provide them with the following guidelines.
• Choose meat with less marbling (streaks of fat seen in a cut of meat).
• Trimming all visible fat off meat before cooking can sometimes result in a drier,
less tender product, so try cooking it in a non-stick frying pan with a lid to retain the
moisture. Trim the fat from the meats, sear the meat in a non-stick frying pan with a
light coating of oil or non-stick cooking spray, turn the meat over, brown, and add the
lid to cook meat. Add onions, garlic, and fresh or dried herbs for more flavor when
heating the oil prior to adding meat. If meat sticks to the pan, deglaze with wine, milk,
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66
or vegetable or fruit juice, water and herbs, or broth or water with bouillon cube to
brown the meat nicely. The liquid will gradually evaporate and it can be thickened to
make a gravy if desired. The alcoholic content of the wine does not remain.
• When using oil to saute foods, use a heavy, non-stick pan so a light coating of oil
will prevent burning of the food. Make sure the oil is hot before adding the ingredients
to reduce the amount of oil that soaks into the food. Substitutes for high-fat products are
effective only if the replacement is enjoyed.
For example, if clients enjoy butter on their potato and they replace it with a lower
fat product such as light sour cream or yogurt, which they don’t really like, then eventually they will crave the butter. For the true butter connoisseur, gradually using less
butter as an accent to the meal may be the way to go.
On the other hand, if the client enjoys the replacement, then the substitute will
work. Low-fat substitutes, such as diet margarines or diet butters, are high in water
content. They cannot be used for frying, as the pan quickly becomes dry because the
water from the product evaporates as soon as it is exposed to heat. The high water
content of these products can make hot toast soggy. Clients need to experiment and do
what works best for them.
• Meat can be browned in the oven instead of a frying pan. The meat can be coated
lightly with seasoned flour and placed on a rack set over a pan to catch the drippings.
Bake at 350°F (180°C) for 15 to 20 minutes. Chops can also be done in the oven on a rack
in a covered dish. Add seasonings instead of fat for flavor.
Roasting can be done on a rack in a covered roaster. The rack prevents the fat
drippings from coming in direct contact with the roast so the roast will be less greasy.
Use lower temperatures when cooking a roast, 325°F or 160°C (for tender cuts) and
275°F or 130°C (for medium tender cuts.) This process retains the moisture, reduces
shrinkage, and prevents the fat from going back into the roast.
Gravy can be added for flavor, color, and moisture. Remove the roast, then put ice
cubes in the fat drippings to allow the drippings to cool quickly. The number of ice
cubes added will depend on the volume of juices. Ensure that sufficient ice cubes are
added so that all the fat rises to the top as it cools. Remove fat and thicken juices with
flour or cornstarch. Lump-free gravy thickeners are also available to make the job easier.
Quark cheese (or Neufchatel cheese), yogurt, or oat bran can also be used as thickeners.
Add extra seasonings such as garlic or onion powder or milder herbs and spices to
add new flavors. If time permits, place the gravy in the freezer or refrigerator; this
allows the fat to float to the surface for easy removal.
• Less-tender cuts of meat are best cooked in liquid (braising, stewing, or pot
roasting) to create tender and flavorful dishes. Marinating meat helps to tenderize and
add flavor. Marinating liquids include wine, vinegar, seasoned vinegars, soy sauce,
citrus juices, beer, yogurt, and oil. The acidic ingredients soften the tough connective
tissue and the oil lubricates. Often the oil can be eliminated. Don’t use salt in a marinade because it draws out the moisture.
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• When microwaving beef, it is not recommended that beef come to room temperature before microwaving. Slightly undercook beef. Remember, cooking continues during
standing time. Large dense items need a standing time of 10 to 20 minutes. Overcooking
or cooking at too high a power level causes the meat to be dry and tough.
If clients are drinking whole milk, they can try diluting it with part-skim for a
week or two until they get accustomed to this taste. Then they can try part-skim milk
for a week or two. They can work their way down to mixing part-skim and skim and
then finally switch to skim milk. Skim milk has a fuller body than it did years ago due
to the higher solid content.
As clients become more aware of the different flavors and textures, they will
gradually acquire a taste for foods with a more refreshing, less thick texture. This is
much easier and more enjoyable than the diet approach of going from whole milk to
skim milk all in one swoop. Even if clients stop at part-skim milk, this is progress over
using full-fat milk. Any change is noted as a positive step towards a healthier eating
pattern.
MODIFYING RECIPES GRADUALLY
The nondiet philosophy does not mean turning to special low-fat versions of
recipes and spending a lot of time preparing new foods. It means modifying recipes
currently used and learning what can be done to enjoy new flavors and textures not
masked by fat.
Have clients use their own recipes, and let their creativity and new-found knowledge allow them to make slight changes so that they produce a product that is moist,
tasty and lower in fat and sugar content. Helpful step-by-step tips on how to gradually
modify recipes are illustrated below, on the following pages and in Appendix #4.
Modifying Cookies
• Sugar, flour, and fat are main ingredients. Cutting back on sugar and fat too
much does not allow creaming effect to occur and lessens sweetness of
cookies.
• Strategy: cut sugar back by about 1/2 and replace w/some sweeter spices
(nutmeg, cinnamon). Fat content can only be cut back slightly (by 1/4).
Cutting fat content too much will change nature of cookies. A crispy
oatmeal cookie may become a chewy oatmeal cookie that soon becomes
hard.
To keep cookies moist, add milk to replace moisture taken out by cutting back
fat content. Try storing cookies in tight cookie jar with a slice of apple. This
will help retain some moisture.
(Omichinski, 1993a)
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Modifying Muffins
• Fat adds moisture, flavor. Sugar is a tenderizer, and adds flavor (sweetness).
Sugar is necessary for egg to coagulate at higher temperatures, allowing
muffins to rise. Cutting out sugar completely will result in small muffins.
• Strategy: initially decrease sugar and fat by 1/4. Next time, try to decrease
sugar & fat more. Enhance new flavors by using sweeter spices (cinnamon,
mace, lemon extract, vanilla extract, lemon, orange peel). If recipe already
contains one of these, try doubling amount.
Retain moisture by adding milk, yogurt, light sour cream. Applesauce,
pineapple, juice, blueberries, shredded carrots, chopped raisins can add
back moisture and sweetness. Raisins are concentrated source of sugar—
a small amount goes a long way.
Replace leavening by adding more baking powder & baking soda w/sifted
flour (1/2 tsp (2 ml) baking soda & 2 tsp (10 ml) baking powder). Ensure
that you sift baking powder & baking soda w/flour, otherwise lumps of
these ingredients may appear in your muffins. If you can taste soda and do
not like it, add more sugar next time & slightly cut back on baking soda
content of recipe.
(Omichinski, 1993a)
Creative Cooking Tips
• Start with 1/4 tsp (1 ml) dry herbs or 3/4 tsp (3 ml) fresh herbs for a dish
that serves 4 people. Fresh herbs contain more moisture w/milder flavor. 3
to 4 times more fresh herbs than dried herbs will be needed. Example: 1
Tbsp (15 ml) fresh herbs = 1 tsp (5 ml) dried herbs.
• Crumble herbs between fingers to release flavor prior to adding to dish.
• Heat herbs in bit of oil to heighten & extend flavor.
• With soups, stews, & large quantity dishes, add herbs during last hour of
cooking so flavor doesn’t evaporate.
• Store herbs in cool place in opaque container to retain flavor. Do not store
near stove.
• Routinely replace supply of herbs. Ground spices retain flavor for about 6
months. Herbs dry out after 4 months.
• Rub herb mixtures onto meats prior to cooking.
• Until clients become experienced, they could use herbs singley & advance to
blending herbs together later. In this way, they will pinpoint which particular
herbs enhance flavor for them.
• When using seasoning packages, try using only 1/2 package as flavors are
usually too concentrated, especially in salt. Remaining amount can be used
for seasonings for home-made barbecue sauces or added to meats, etc.
(Omichinski, 1993a)
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USING HERBS AND SPICES
Herbs and spices are natural flavor enhancers. Clients can experiment with herbs
and spices to add flavor where fat was once the sole source of flavor. The talented cook
is the individual who can make a tasty meal without depending on fat as the only flavor
source. Herbs and spices can add a new taste sensation to a meal. Encourage clients to
try them out. They can learn that it’s fun to experiment. The following page provides
more tips for cooking with herbs.
Using Specific Herbs
• Basil & oregano are great for tomato-based dishes. Oregano is also good w/
beef (i.e. hamburgers).
• Sage is commonly found in poultry seasonings. It is good w/pork dishes &
w/mushrooms.
• Ginger is a stronger spice. It is great w/chicken alone or on carrots.
• Cinnamon is a sweeter spice & is used in cakes & cookies. Also great on
chicken or pork chops. Cinnamon is a key ingredient together w/meat
drippings that heightens the flavor of chicken gravies.
• Chili powder can replace black pepper on chicken or pork chops.
• Curry powder has similar taste to butter if used on chicken & also gives a
nice color to chicken. Fry spices in teflon pan w/oil. Or try a combination of
curry powder & chili powder if taste buds can handle something a little
more spicy.
• Limit quantity of spices/herbs used. A little goes a long way in heightening
natural flavor of vegetables. Milder herbs (thyme, oregano, chives, chervil,
parsley) are suitable for vegetables.
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Chapter Eight:
Hunger and Fullness
In Chapter Five, we presented the first step towards learning to eat in response to
physical hunger by using the carbohydrate/protein balance as a means for clients to
recognize physical hunger once again. In Chapter Six, we built on this concept by
detailing the technique of eating lower-fat foods by choice, not requirement. In this
chapter, we will expand on these nondiet concepts by defining normal eating, contrasting the diet versus nondiet approach to reducing food intake, and discussing psychological eating.
Dieting is so prevalent that people have gotten some very restrictive ideas about
what is normal and natural in eating. “Normal” eating is, essentially, positive and
flexible eating that depends on internal cues to regulate it (Satter, 1987).
• Normal eating is being able to eat when you are hungry and continue eating
until you are satisfied. It is being able to choose food you like and eat it and truly
get enough of it — not just stop eating because you think you should.
• Normal eating is being able to use some moderate constraint in your food selection to get the right food, but not being so restrictive that you miss out on pleasurable foods.
• Normal eating is giving yourself permission to eat sometimes because you are
happy, sad or bored, or just because it feels good.
• Normal eating is three meals a day, most of the time, but it can also be choosing
to munch along. It is leaving some cookies on the plate because you know you
can have some again tomorrow, or it is eating more now because they taste so
wonderful when they are fresh.
• Normal eating is overeating at times: feeling stuffed and uncomfortable. It is also
undereating at times and wishing you had more.
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• Normal eating is trusting your body to make up for your mistakes in eating.
• Normal eating takes up some of your time and attention, but keeps its place as
only one important area of your life.
In short, normal eating is flexible. It varies in response to your emotions, your
schedule, your hunger, and your proximity to food (Satter, 1987).
The positive result of lack of structure is flexibility. A rigid sameness about the way
people operate is an indication of a problem. The way people eat is a very individual
matter: there are no hard and fast rules. If clients have been used to following a diet,
they may think that this method cannot work since there is not a rigid pattern to follow.
However, you can help clients replace an old way of eating with an improved and more
healthful eating style. Focus and flexibility can replace structure.
The solution to overeating is to focus on and change personal and family dynamics
that encourage the overeating, and to restore a positive relationship with food. Clients
need to allow themselves to feel relaxed and comfortable about eating and in touch with
their internal cues of hunger, appetite and satiety.
The solution is not to “go on a diet.” A diet can increase pressure to eat and cause
rebound eating that in the long run makes people eat more, not less. The methods
described in this chapter are intended to keep clients responsible for their own eating.
They are not intended to promote undereating.
Clients need to learn to regulate the amount they eat as accurately as possible, in
order to arrive at the body that is right for them. It is not appropriate for them to try to
go hungry so they can achieve the body that society or their husband or their doctor
thinks they should have or wish they would have. Even the fat person is entitled to
regulate the amount of food he or she eats (Satter, 1987). The solution is to help clients
learn how to eat in a way that gives them more energy and keeps them satisfied.
FOCUS ON SUSTAINED ENERGY AND SATIETY
First, have the client begin eating regular, balanced meals and snacks. You must
reassure the client that he or she will get enough to eat. Plan snacks for specific times.
The client can eat as much as desired at meals and snacks. Meals should follow the
nondiet nutrition guidelines, ensuring a balance in carbohydrate and protein sources,
gradually cutting back the fat content in the food choices and food preparation methods
according to newly acquired tastes.
By following the nondiet nutrition guidelines, the carbohydrate/protein balance at
meals and at snacks where a meal may be delayed or for those with diabetes, hunger is
defined and the individual is satisfied for a longer period of time. The meals become
better proportioned throughout the day, along with the protein source so meals are less
likely to be top-heavy in the evening. It is important that clients not eat between these
times so that they can experience hunger. If they are constantly eating, they will not
experience hunger. If they are used to dieting and starving, they may be out of tune
with what normal hunger is, especially if they have been ignoring it for years.
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As discussed in Chapter Six, the second step is to learn how to slide smoothly into
lower-fat eating so that taste preferences are changed. Meals and snacks that are high in
fat can mask physical hunger signals due to the delayed emptying of the stomach
caused by fat. Showing clients how to tune in to texture and use fat as an accent instead
of masking the real taste of food, by making small changes in food preparation techniques, will facilitate the taste change that is desirable.
In time, food choices will reflect new preferences that are lower in fat, allowing the
client to receive more accurate hunger signals.
Next, teach the client to eat slowly and attentively. Learning to eat when pleasantly
hungry rather than starved helps this process. Slow, relaxing background music can also
help clients develop a slower eating pace. It has been shown that people who listened to
classical music while eating took longer to finish the meal, took fewer bites per minute,
and were satisfied with one helping (ESHA, 1991). (Those who listened to rock music
and marching tunes ate faster, ate more per forkful, and asked for second helpings.)
Eating slowly will give the client time to enjoy the food and to find an internal
stopping place. If the client does not feel deprived of food, he or she will be able to learn
to tolerate hunger and experience it as a positive, not a negative feeling. The client will
not fear hunger, because of knowing that hunger can be made to go away.
When you give people permission to eat and reassurance that they will get enough
to eat, they can learn to become more relaxed and orderly about their eating. Eating
more slowly, taking pauses through the meal, and delaying before a second helping are
not tricks to get your client to eat less. They are methods to develop sensitivity in detecting hunger, appetite and satiety, and learning to on those cues in regulating the amount
eaten. The most delicious, wonderful and scrumptious food in the world won’t be
satisfying if the client eats it too fast and doesn’t pay attention to it.
When clients are orderly and positive about eating, they can learn to eat in a way
that is self-regulated and satisfying — not the kind of satisfaction that leaves them
feeling so full they have to undo their belt. Instead, this is the type of satisfaction that
clients can find within themselves, again and again, and look forward to, and count on
for regulating food intake.
CUE SENSITIVITY
Some people are “cue sensitive” to food. That means that if there are food reminders to eat, they are likely to eat. If there is a lot of food around, they are likely to eat
more. These appear to be innate differences. Cue sensitivity, however, can be caused as
well as inborn. While studies of obese people indicate that they are more cue sensitive
than thin people, this can also be the product of restrained eating.
Obese people who are not restrained eaters are no more cue sensitive than normal
weight people who are not restrained eaters. Normal weight people who are restrained
eaters are as cue sensitive as fat people (Polivy and Herman, 1983).
Polivy and Herman gave 40 dieters, or restrained eaters, and 40 nondieters two
milkshakes each to drink, followed by an offer of ice cream, as part of a controlled
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study. The dieters finished their milkshakes and ate the ice cream too. The nondieters
ate very little ice cream once they finished the milkshakes. Why is there a difference
between the actions of the dieters and the nondieters? The dieters’ thinking is all-ornothing thinking: “I blew my diet anyway, so I’ll go for it and eat it all. Since I’ll go back
to dieting and depriving myself tomorrow, I’d better get my fill.”
Dieters either diet faithfully or not at all. Once they have been deprived for so long,
they may not be able to control themselves. The pendulum has swung the other way.
Often dieters are perfectionists and their “absolutely perfect” mentality transfers to
other aspects of their lifel: “I’ll clean the house completely or not at all. I’m that type of
person.”It is this all-or-nothing thinking that can lead to frustration when something
doesn’t proceed perfectly. This type of rigid thinking does not allow one to be human.
There is flexibility in the nondieter’s thinking and this is how it differs from the
dieter’s thinking. The nondieters, once the milkshakes were finished, chose to eat very
little ice cream because they were in tune with their bodies’ feelings of hunger and
fullness. They were satisfied with the milkshakes and were no longer hungry. The
added fact that they knew they could have more ice cream when they wanted it decreased the need to have it immediately. The nondieters were tuning in to their internal
cues of hunger. The dieters responded to the external cue of sight.
The second part of the Polivy and Herman study dealt with both groups being
given no milkshakes, after which both groups were offered ice cream. This time the
dieters ate no ice cream. The “all-or-nothing” response was: “I’m still on my diet, so
since I did not start to eat anything illegal, I’ll be able to forgo the ice cream. I have the
will power to say no.”
The nondieters who did not have milkshakes but were offered ice cream ate a lot of
ice cream. They were tuning in to their internal hunger signals. The nondieters were
physically hungry and therefore ate the offered ice cream. The chart below contrasts diet
and nondiet thinking.
Diet Thinking vs Nondiet Thinking
Diet
• All or nothing
• “I will have nothing”
• Perfectionist attitude
• Responds to external cues of sight,
smell, and power of suggestion
• Out of touch with physical hunger.
May eat in response to psychological hunger, i.e., when under stress
• Diet is in control
• Asks self, “Should I have it? Do I
need it?”
Nondiet
• Listens to the body’s needs
• “My will to need is flexible”
• Goes with the flow
• Responds to internal cues — eats
when hungry
• In tune with body’s internal cues of
physical hunger; listens to body,
does not turn to food when dealing
with stress
• Person is in control
• Asks self, “Do I want it? How
hungry am I?”
(Omichinski, 1993b)
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PSYCHOLOGICAL HUNGER
How can we help our clients shift their thinking to become nondieters? The first
step is for them to acknowledge what they are doing and accept it, just as they accepted
themselves as they are without conditions. Help them to go with the flow and learn
from their mistakes. Help them to care about themselves enough to listen to their body
and find out what is really causing them to eat. Have them ask themselves what is
happening that they need to distract themselves by eating or worrying about their
eating or weight. Teach them to take a moment to reflect on reasons why they are
eating.
Only the clients can uncover the reasons for their eating and learn new techniques
to deal with them more positively. Remember that if they feel they were not successful
in the past, it is not them that failed but the diets that failed them. Diets don’t work.
They can succeed by getting rid of the diet and the diet mentality. As they begin to
discover themselves, they will be drawing on their inner self, that is, they will be internally motivated.
Remember, action creates motivation. Once they have discovered why they are
eating, they can take action. Some possible reasons for eating are listed below.
Reasons for Eating
• Boredom
• Loneliness
• Frustration
• Stress
• Anger
• Rushed
• Comfort food
• Tension
• Low self-esteem
• Social occasion
• Everyone else is eating
• Happy
• Sad
• “See-food” diet (“I see it, I want it”)
• Tired
• Insomnia
• PMS
• Need for love and nurturing
OVERCOMING AUTOMATIC EATING
Automatic eating refers to eating that occurs unconsciously. Suddenly, the cookie
jar is empty and the client didn’t even realize it. Studies have shown that the most
satisfaction from eating comes from the first and last few bites and that the middle bites
are automatic. This means that the middle bites are eaten because they are there, not
because they are actually being tasted and savored. This food is not really being tasted.
Does this just translate into cutting back and taking a smaller portion? How is the
nondiet approach different from conventional diets that advocate smaller quantities and
eating in moderation? The following scenario will illustrate the difference.
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Bonnie walked into the ice cream shop with a couple of friends who were on diets.
She wanted a chocolate ice cream sundae so she ordered one. Her friends, on the other
hand, may have yearned for a sundae but since they were dieting they chose not to have
one and ordered coffee or a diet drink instead. Bonnie enjoyed the sundae without guilt.
She tasted and savored it and then a third of the way through she was satisfied and she
left it unfinished. She knew she could have another sundae any time she wished, so she
had no need to eat over her physical hunger.
Why did she leave part of it? Not because she felt pressured. Not because she had
to eat in moderation and cut quantities.
Dieters, once they start eating something, cannot stop until it is finished. Dieters
say, “I blew my diet anyway, therefore I will eat the whole thing and diet tomorrow.” Or
dieters may eat the sundae with guilt or in secrecy or too fast, and not feel totally satisfied, ending up bingeing on other “forbidden” foods. Or they may eat several sundaes
because of the feeling of being deprived. My client was exhibiting the nondiet mentality.
She no longer felt satisfaction from the sundae so she left it. It is true that the most
satisfaction comes from the first few bites because you look forward to the taste, and the
last few bites because you won’t have it again for a while. The middle bites give you no
greater satisfaction. They are eaten by dieters because of the external cue of seeing the
food. Nondieters are selective and eat only what they really want.
What did the dieters who just ordered coffee or a diet drink do when they got
home? They binged on everything in sight. They felt deprived — they had wanted a
sundae but it was an illegal food for the diet. When they got home they tried to find
something that would satisfy their craving for a sweet.
Usually these people eat more calories in the replacement food than if they had
eaten the sundae. For them, calories don’t count if no one else sees you eat it. This is diet
thinking that contributes to eating more, not less (Omichinski, 1993).
Automatic eating can also be reduced by changing cues to eat. If clients generally
eat somewhere, say, in a chair in front of the TV, it can be a reminder to eat whenever
they sit down there, whether they really want to eat or not. Perhaps they could opt to
eat only at the table, and while there, just eat — no TV, no books. They will have to
choose between eating and doing something else.
Once again, these cue-limiting tactics are not intended as tricks to get clients to
undereat. They are intended as techniques to encourage deliberate and attentive eating
that is likely to be satisfying. Clients appreciate being spared the necessity of thinking
about food, except when they are hungry and really want to eat.
CONFRONTATION VS WILLPOWER
In a confrontation situation, dieters would say that you shouldn’t have a chocolate
bar because it is illegal. It is not on the diet sheet. The fact that it is forbidden makes you
think about it more and want it more. When you deny this urge and don’t give in, this is
called willpower. If someone is successful in losing weight, the person is said to have
more willpower. A better term is “won’t power.” You think that restraining yourself
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from having the chocolate bar and not responding to the external cue will make it easier
to remain in control.
Dieters are using denial to deal with the situation. Nondieters tune in to their
hunger signals to check for actual hunger. If their blood glucose level is low, nondieters
may choose to have a snack first, knowing that the chocolate bar is available later on.
Otherwise, eating chocolate on an empty stomach when blood glucose is low may lower
it even further after the initial high. This could cause them to be unable to stop at one
chocolate bar. Also, nondieters eat foods that they like, not just foods that are there. If
the chocolate is milk chocolate and the individual prefers dark chocolate, the nondieter
may choose not to eat any at all. Why? Because they don’t care for milk chocolate. A
nondieter eats what he or she likes, not just what happens to be there.
Get clients to ask themselves: Do you really want the food or do you think you
want it simply because it is there and it is habit?
Clients need to learn that confronting the urge to eat the food will give them the
confidence to tune into their natural body signals. Tell them: Believe in yourself. Listen
to your body with regard to physical and psychological hunger. This will help you to
distinguish between what you really want versus what you think you want due to habit
(Omichinski, 1993a).
Confrontation is meeting the situation head on, and dealing with the cause of the
problem. It is a positive skill. Learning to change damaging, self-defeating thoughts that
lead to overeating by confronting them is a powerful tool. Confrontation decreases the
incidence of automatic eating, that is, eating simply because it is there. If the client has
the chocolate bar after a snack, it will have less effect on the blood glucose level because
it will take longer for the sugar to reach the blood stream. And he or she will probably
eat much less than if he or she ate it when very hungry.
LEARNING TO MEET YOUR NEEDS
Confrontation does not mean total denial. It means that clients will be satisfied
with a small handful of chips rather than the whole bag, as long as they allow themselves to taste and savor it without feeling guilty. Guilt does not let one pay attention to
the food.
Confrontation means tuning in to needs at the moment. Confrontation can apply to
any aspect of life, not just food. People often eat for other reasons that are not foodrelated. Loneliness, anxiety, depression, anger, or stress may be temporarily relieved by
food. This is using food as a comforter to take away the pain. Clients can learn to accept
that it is normal to feel depressed sometimes. If they allow themselves to experience
these feelings, they may discover why they are distressed and be able to work through
the feelings so they don’t seem so severe next time.
When clients eat for reasons other than physical hunger, they are eating to satisfy
their psychological hunger. Their physical hunger may be on “full” when their psychological hunger is on “empty”. That means that they are not focusing on the food but
using it as a crutch to help them deal with the situation. In this state they can eat a box
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of cookies without even realizing what they are doing, since they are preoccupied with
the psychological problem. To help them get more psychological enjoyment from food,
suggest they try tasting and savoring it when eating it.
The smaller quantity of food eaten that results from the nondiet approach may be
the same as if clients were on a diet. However, the nondiet reason for eating less is very
different. It’s not because they have to. Clients are confronting their problems and
dealing with them. Clients are learning to more appropriately meet their needs, and
they won’t have to eat as a substitute to try to feel good. When they do eat, if they taste
and savor their food and eat for physical reasons, they are satisfied with less quantity.
EATING WITHOUT GUILT
Eating food without guilt and the act of celebrating food can allow clients to taste,
savor, and enjoy their food to the fullest. It also allows them to be satisfied with less
quantity because they derive not only physical benefit, but psychological satisfaction as
well from the food. Self-acceptance allows them to believe in themselves and their
ability to be able to listen to their body with regard to its food and activity needs. It
channels their energy so that they can make positive lifestyle changes and gives them
the confidence that they need. If they feel good about themselves, they don’t need to
turn to food and eating to feel good. Food is used to satisfy physical hunger rather than
psychological hunger.
Nondieters eat for physical hunger. Otherwise, if one is always negative about
one’s self, this causes an energy drain where little is accomplished and one may turn to
food for energy. The end result is eating more.
Clients will become aware of their eating, enjoy the act of eating, and eat only what
they want. This allows them to be selective in their eating. They will learn to tune in to
what they really want. They will get to know themselves and become more conscious of
the reasons behind their eating, allowing them to deal with the causes. Once the reasons
are resolved, the psychological eating decreases.
By empowering your clients and giving them the tools (skills and techniques) to
make the choices, they become in charge of food and their life. These skills can last a
lifetime and may be used in any aspect of life.
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Chapter Nine:
Fluid Management
In this chapter, we will contrast how dieters and nondieters use fluids, and deal
with the vital question of how much fluid is enough.
Our body requires 6 to 8 glasses of liquid a day to maintain normal body functions.
Most of us do not drink enough fluids. Of the fluids we do drink, some of them may
actually be dehydrating. Coffee, tea and alcohol are some of the fluids that do not return
water to our system after it is lost; they do not rehydrate us.
Let’s look at the different types of fluids and their relationship to rehydrating the
body and quenching thirst, as shown in Appendix #5. Fluids listed as diuretic do not
rehydrate, due to their effect of ridding the body of fluids by increasing urine production.
When the body is dehydrated, it may send out hunger signals. Suggest to clients
that if they think they are hungry, to have a drink of water first, then decide if they are
still hungry. Perhaps they were just thirsty and the food appealed to them because there
is water in food. Food will give us some extra fluid. It is not the most efficient way of
giving our body fluids. Water is the most efficient fluid in rehydrating our body. However, many people do not like the taste of water.
MISUSE OF FLUIDS FOR WEIGHT LOSS
Quick weight loss on structured diets often results from manipulation of fluid
levels in the body. Because carbohydrate helps the body to retain water, diets often
restrict carbohydrate-containing foods. When the body’s carbohydrate stores become
exhausted by low-carbohydrate eating, the water that was used to store carbohydrates
as glycogen in the muscles is no longer needed and is shed by the body. This results in a
rapid loss of weight on the scale — weight which is mostly water.
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This weight will be quickly regained when the body’s need for carbohydrate
results in cravings, and the inevitable consumption of perhaps larger than normal
amounts of sweets. The body then can restore its glycogen reserves, which uses water.
This may help clients understand why eating a piece of cake on a low-carbohydrate
eating regimen can result in a 2 or 3 lb weight gain, which the caloric content of the cake
would not explain. It was simply the body rehydrating itself.
Many individuals in the diet mentality fill up with water, coffee, or soup to lessen
their hunger pangs temporarily. They are avoiding their natural hunger signals. Filling
up with liquids instead of a meal makes them feel bloated and temporarily full. However, by the following meal, they may be famished and eat anything and everything.
Filling up on water prior to the meal is the diet method of dealing with hunger
pangs. This makes one artificially full, causing one to eat less at the meal. In other
words, the bloating effect of the water causes one to eat less. This is not dealing with
physical hunger; it is avoiding the hunger or trying to dampen it artificially, only to
have it reappear later.
The nondiet approach is to eat when hungry and drink fluids when thirsty. Trying
to trick the body by filling it up with fluids when a person is actually hungry may work
temporarily, but will lead to uncontrollable hunger later on.
Adequate fluid intake is important for health and well-being. However, having
clients use the technique of tuning in to their body to determine when they are thirsty is
not as effective as it is for regulating hunger. Scientists don’t yet fully understand how
the thirst mechanism works. However, they do know that if we wait until we are thirsty,
then we are partially dehydrated. If the body is not getting enough fluids, the body may
signal one to eat more to obtain these fluids.
IS IT REALLY HUNGER OR IS IT THIRST?
Consider the following scenario. You go for a walk, your natural cooling mechanism causes you to lose some water through perspiration, and you need to rehydrate
yourself when you come back. Suppose you come back from your walk and see some
watermelon (which contains 92 percent water) in the refrigerator. You are thirsty and it
sure looks good. You eat four slices to quench your thirst when really what your body
wanted was water. Your fluids are replenished from food rather than from fluids.
Unfortunately, you may be even more thirsty now due to the high sugar content of the
fruit.
The nondiet approach would be to drink a sufficient amount of fluid, specifically
water, to rehydrate your body. If you still want the watermelon, have it after the fluid
replacement, and you may actually be satisfied with less watermelon. Filling up on
juice, ice cream, popsicles, or a milkshake to cool you off and replace fluids does not
address the real problem. These items do not effectively replenish the fluids in your
body due to their high sugar content. You may still be thirsty and feel unsatisfied.
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Signs of Dehydration
Symptom
Cause/explanation
• Dark urine, small amounts:
body tries to preserve all available water
• Headache:
brain is short of oxygen (blood carries
oxygen, and blood is mostly water)
• Fluid retention:
body tries to preserve all available water
• Elevated heart rate/
weak, fluttering pulse:
heart races to pump diminished supply of
blood to muscles
• Dizziness, confusion:
heart pumps less blood to brain
(0michinski, 1992)
How do you know if you are consuming enough fluids? Watching for the signs of
dehydration, as listed in the chart on the previous page, can give you the answer. Water
is as critical to the body as oil is to a car’s engine. The body needs fluids to function
properly. Fluids allow biological reactions to take place in the body.
Blood consists mostly of water; it carries oxygen and nutrients to the brain. Without enough water, one can get a headache. This pain in the head is caused by insufficient oxygen carried by the blood to the brain. Dizziness and lack of concentration can
also result if less nutrients and oxygen are carried to the brain.
Water is also the main ingredient in urine, which carries wastes away from the
body. Water is also needed to keep food moving through the intestinal tract to help
prevent constipation, which may occur if clients are eating more high-fiber foods.
Our body will naturally retain more fluid if we do not replenish the water stores in
our body. When the body gets less water, it perceives this as a threat to survival and
begins to hold on to every drop. Water is then stored outside the cells in extracellular
spaces. This shows up as swollen feet, legs and hands. Note that diuretics provide only
a temporary solution. The body perceives a threat and will replace the lost water at the
first opportunity. Thus, the condition quickly returns.
Inadequate consumption of fluids can lead to greater food consumption, since all
foods contain a certain amount of water. If the body’s daily requirement for fluid is
being met primarily by the consumption of food, then the body will tend to demand
more food than if an adequate amount of fluid was consumed during the day.
Upon feeling thirsty (a signal of partial dehydration), if water or fluid is not consumed, food may be eaten to obtain the water in the food. If water or fluids are consumed, the thirst is satisfied; the individual is rehydrated; and the urge to eat may be
reduced. It is important to meet our requirement for fluids by consuming fluids.
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ACQUIRING A TASTE FOR WATER
People do not drink simply to quench their thirst; they respond to a need that’s as
much in the mind as in the body. Psychological satisfaction is the reason they drink
even if they’re not really thirsty. They may simply want to enjoy the taste of the beverage. Going from soda pop or diet drinks to water is quite a drastic change. The more
enticing fluids attract us because of their appeal to our senses of color, flavor, and taste.
Clients may shift to drinking water because they feel they should drink it, rather than
because they enjoy water and like the taste of it. If they change to water gradually they
will get used to it and prefer it.
“I used to drink water when I was on diets. I’ll just go back to drinking water. Why
bother adding water to other juices or beverages?”
Going straight back to water is diet thinking. If clients haven’t continued to drink
water, they probably didn’t really find it psychologically satisfying. Adding water to
existing beverages serves three purposes:
• Adds a bit of pizzazz to boring water;
• Makes beverages more appealing to the eye and palate; and
• Allows clients to eventually appreciate the natural and refreshing taste of water.
Just as clients can gradually decrease the fat content of foods they choose, they can
gradually add water to beverages to learn to acquire a taste for less sweet drinks and
drinks lower in sugar. Diet drinks do not help them learn to prefer foods with less
sweet, more refreshing flavors. If they learn to acquire a taste for less sweet foods and
foods lower in sugar, then they may choose to pass up some sweet foods or have only a
few bites since the food will taste too sweet to them. The end result is less quantity
eaten because they choose to eat less —not because they feel they should stop eating
sweets, but because sweets no longer appeal to them.
Water can be gradually added to any juices, drinks, or diet drinks. This can also
apply to coffee or tea. Eventually clients will enjoy drinks that are, essentially, colored
water that will taste refreshing and will rehydrate them more effectively as well as
quench their thirst.
For those individuals with diabetes, the concept of learning to appreciate and
prefer foods lower in sugar content is especially important. Adding water to their
favorite unsweetened juices will give them a beverage that is more thirst-quenching,
with a lower sugar content and a less sweet taste. However, unsweetened fruit juices do
contain a considerable amount of natural sugar, equivalent to 2 tsp (10 ml) for a 4 oz
(125 ml) glass. It is for this reason that these types of beverages need to be taken with
some food in a diluted form towards the end of the meal, and why fruit after a meal
would be best. The above technique can successfully be used with artificially sweetened
beverages as well. The goal is to have beverages that quench thirst with a gradually
reduced amount of sugar or sweetener so that the original version of the beverage will
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end up too sweet for the individual’s taste. Some of this new appreciation for a less
sweet beverage may transfer to other foods. Clients just may end up telling you that the
cake they once loved is now too sweet for their taste and that they have reduced the
sugar and/or artificial sweetener in their recipe. Appendix #6, which lists many different kinds and forms of sugars, may be helpful for clients who are reading labels to
choose less sweet foods and beverages.
CAFFEINE
Caffeine is a mood-altering drug. When we drink a cup of coffee, the caffeine from
the coffee enters the bloodstream, and we feel alert because the caffeine stimulates the
body to release more glucose into the bloodstream. This artificially gives us a mental lift
and keeps our energy level high. However, the sudden rise in the blood glucose level
causes the pancreas to oversecrete insulin which causes the blood glucose levels to
quickly drop. This is why we may want another cup of coffee shortly after the first cup to bring the blood glucose levels back up (Gittleman, 1993).
Are clients “jump starting” their body with caffeine instead of food? Needing that
first cup of coffee to get them going signals a physical dependence on an unnatural
stimulant. Natural stimulants, such as physical activity and healthier eating, decrease
the dependence on these artificial stimulants.
Abrupt withdrawal of caffeine can cause such symptoms as headache, drowsiness,
lethargy, yawning, runny nose, irritability, disinterest in work, nervousness, mental
depression, nausea, and vomiting. It has been suggested that even overnight abstinence
of caffeine may cause low-grade withdrawal symptoms. For this reason, taking coffee in
the morning may give a lift because it suppresses withdrawal symptoms.
Switching from coffee to tea provides a gradual drop in caffeine content (see
Appendix #6). Since tea has about half as much caffeine as does coffee, withdrawal
symptoms would be lessened. Or clients can try eating a more substantial breakfast
followed by a single cup of coffee. This uses the beverage more for enjoyment than for a
lift. Using coffee appropriately will allow them to enjoy it. Using it in place of food will
not benefit health.
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Chapter Ten:
The Role of Exercise
The nondiet approach is focused on lifestyle change that is allowed to happen
naturally. In order to make an increased activity level a lifestyle change, it must be
increased gradually. For this to happen, it is necessary to understand the nondiet approach to fitness.
How diet thinking can sabotage active living efforts:
“I went for a walk to the donut shop where I can have one as my reward.”
“I ate a piece of cake, so I’ll have to go for a walk to wear it off.”
The old “calories in vs calories out” attitude traps one in the diet mentality of
focusing on exercise as a way to burn calories and lose weight. In order to work off a
donut, one must walk for one-half hour. If this was the only benefit that being active
gives us, it certainly would not seem to be worth the effort. Appendix #7 shows the
energy cost of various activities. Again, the message is more negative than positive: if
you really want to lose weight by exercise, you’d better be prepared to work very hard!
Perfectionist thinking that goes along with this attitude means that if a walk or
workout is missed one day, there is no point in continuing with the activity, so the client
gives up. Or once the weight is lost or they give up trying, they stop the activity. Going
into the fitness routine wholeheartedly and giving up just as suddenly — doing it as a
means to an end rather than for fun — is diet thinking.
In the past, exercise was viewed as a form of punishment rather than reward.
Push-ups or running around the gym were activities forced on us if we were bad.
Aerobics was also hard work. Each week we went to the fitness studio and put up with
the hour of pain. No gain without pain, we were told. We continued out of perseverance
or after a few months gave it up, feeling that exercise was not for us.
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Dependence on fitness classes or other structured group experiences for physical
activity means that, when clients move out of the activity structure, they aren’t active
any more. It’s the same kind of dependence that people place on a diet. They follow the
diet as long as they are involved in a group situation to reinforce and encourage. They
go off the diet as soon as they stop attending classes. When the reason for doing exercise
is weight loss and not fun, people find excuses not to go to classes. The focus of exercise
can be to encourage the development of individuals so that they find active living the
answer to exercise needs.
Active living is an entirely different way to view activity. It promotes enjoyment of
life and the awareness of what is going on around the person. The main focus is to have
people make choices for themselves, based on what they want and enjoy. Then they will
find new excitement in activity and it will become a pleasurable part of their life.
BECOMING ADDICTED TO ACTIVITY
Exercise addiction is now recognized as part of many eating disorders and results
from many of the same pressures that cause weight preoccupation and dieting. Some
people exercise intensely and suffer from withdrawal symptoms when they are not able
to exercise with the same frequency or intensity. They exhibit the same dependence on
exercise regimens as dieters do on diets. These individuals use exercise as an end unto
itself rather than a means to physical fitness and enjoyment. Some of them cannot stop
exercising, even when their muscles and joints have become seriously injured.
Note the symptoms in the chart below and see if you recognize any of these symptoms in any of your clients.
Symptoms of Exercise Addiction
• Need to exercise daily to maintain basic level of functioning.
• Express minor withdrawal symptoms (irritability, guilt, anxiety) when
unable to exercise for a day or two.
• Experience major withdrawal symptoms (depression, loss of selfesteem, lack of interest in other activities) when unable to exercise
for longer periods of time.
• Exercise even against medical advice.
• Risk physical injury. Deny pain.
• Organize life around exercise.
• Put exercise above everything else, including job or relationships.
• Strive for greater achievement, no matter how fit or healthy.
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If you recognize any of these symptoms in your clients, approach them and talk to
them about these symptoms. Many of these individuals may be unaware of how exercise is ruling their lives and of the potential harm this addiction can cause both physically and mentally.
Compare this intensity in exercise to the intensity that chronic dieters devote to
dieting. If you facilitate a group class, bring up the topic of the diet mindset in the
exercise field, using exercise addiction as the extreme case on the continuum. Exercise
addicts will identify with these symptoms and may not feel as threatened as if they
were singled out individually. Evaluate the situation and use the approach that is most
likely to succeed.
Understand that it will take time for someone to admit that exercise is controlling
their life at the expense of health, their social life and other activities. Acceptance of
exercise addiction is the first step; then clients can begin making small steps to bring
activity into perspective at a healthier level both physically and mentally.
EXERCISE FACTS AND FICTION
• No pain, no gain (False). If clients listen to their body and tune in to their body’s
needs, they will know what intensity of activity they should follow. Painful, intense
exercising will not lead to lifestyle change. Continued discomfort will discourage clients
from continuing the exercise. In fact, painful exercise can damage their body.
New fitness information emphasizes “train, don’t strain.” The old pain-for-gain
thinking destroys the sense of fun and enjoyment and does not fit into a new, active
lifestyle. The feeling of energy, vitality, and exhilaration that one gets from activity at an
appropriate intensity creates the desire to continue.
• Exercising vigorously burns more fat (False). Higher intensity activity burns
more carbohydrates than fat. In the first 12 to 30 minutes of activity, the body uses
mainly carbohydrates as the fuel source. This means that the body will be drawing from
the carbohydrate stored as glycogen in the muscles and liver.
Vigorous activity requires a continuous supply of quick energy, provided by
glycogen. Therefore, rather than switching over to using fat as a fuel for activity after
about 30 minutes, the body continues to use carbohydrate. Working at a higher intensity
may actually cause clients to crave carbohydrates after they finish because their body
will want to replenish its glycogen stores.
As well, working at this higher intensity may reduce the duration of the activity —
clients get tired sooner and quit before 30 minutes when the body switches over to
burning fat.
• Exercise increases appetite (False and True).
Sedentary people who do little activity may overeat because their appetite control
mechanism is not functioning properly. The stomach is not sending the fullness signal to
them when they are full. Exercise at a proper intensity puts this back in balance.
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With exercise at an appropriate level, the immediate rise in blood glucose after a
meal is less pronounced, and glucose is released in smaller doses. This is accomplished
by increased sensitivity of the receptors of the cells, permitting the insulin to allow
glucose to enter cells more readily. The absorption curve is flatter (not as steep) and
therefore, the glucose is released into the bloodstream at a slower, more gradual rate,
providing a more steady supply of energy. Clients feel energized, not exhausted and
famished after exercise.
However, exercising at a higher intensity depletes glycogen stores faster, resulting
in a lower blood glucose level. The result is that instead of activity controlling appetite,
it may actually increase it. Lower intensity activity will draw less from glycogen stores
and allow clients to sustain the activity for a longer period of time. Clients need to tune
in to their body and decide on the level that is right for them. Putting an extra strain on
their body with stressful activity gives no added benefit.
Exercise Consciousness Lesson for Clients
• Work at level that is comfortable, where you can sustain activity for a longer
period of time, rather than engage in short bursts of activity.
• Increase intensity gradually as you become more fit.
• Use activity that you enjoy, that leaves you feeling energized, not exhausted.
Assess feelings (energy level, appetite) before and after activity.
• Work at level that controls appetite, rather than feeling famished.
MAKING A LIFESTYLE CHANGE
The nondiet approach to activity is back-to basics active living, which is self-paced,
integrated activity. It refers to working out in more natural surroundings, such as a
garden, a playground, or skating rink. It involves natural movements used in everyday
living. One need only take the equivalent of a few half-hour walks weekly to increase
the odds of living a longer and healthier life.
Active living refers to enjoying physical activity and learning how to integrate it
into one’s daily life. It involves such activities as getting up, getting dressed, working,
lifting things, walking around, doing housework, going out in the evening, etc. Suggest
to clients that, when friends come over, they try going for a walk instead of talking
while sitting and eating.
Clients can pursue this active living at work as well. They can take the stairs
instead of the elevator; put a pair of walking shoes in their car and take a walk if they’re
early for an appointment; walk around the mall after lunch before returning to work;
park their car a distance away from their workplace, or get off the bus a few stops early,
so that they can enjoy a short walk before the day’s activities. All of these lifestyle
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changes do not take extra time; rather they give us time through increased focus and
productivity. These changes get us moving and keep us moving.
Living actively rewards us twice: immediately, in the pleasure of doing the activity;
and over time, through improved health, well-being, and quality of life. Tell your clients
that moving the way they like to move is good for them. It’s the moving that counts.
Boredom can make us feel lazy and tricks us into thinking that we are physically tired.
It catches all of us if we don’t watch out. Clients can learn to fight back by finding an
activity they really enjoy and sticking with it.
NONDIET BENEFITS OF BEING PHYSICALLY ACTIVE
Being large in a weight-conscious society can undermine self-esteem. Yet some
studies have shown that large men and women in physical training programs exhibit
marked improvement in self-satisfaction, self-acceptance, and a sense of personal worth,
and that physically active people report more self-confidence, a better self-image, and
greater psychological well-being than inactive people (Hanson and Neede, 1974).
Control over one’s life — the ability to make choices — is vital for a positive selfimage and a feeling of personal power. A renewed sense of control is expressed after a
period of regular activity, which facilitates the ability to resolve problems of personal
dissatisfaction and poor body image.
Nondiet Benefits of Physical Activity
• Improved self-satisfaction, self-acceptance, sense of personal worth.
• More self-confidence, better self-image, greater psychological health.
• Renewed sense of control.
• Increased muscular strength & endurance.
• Reduced stress & increased sense of well-being.
• Improved self-concept & sense of accomplishment.
• More free time to do the things they really want to do.
The body adapts to the demands of physical exertion by increasing muscular
strength and endurance, whereas long periods of food restriction produce diminishing
returns, and increase both physical and psychological stress. During periods of increased stress, feelings of lethargy often result with the release of adrenaline and cortisol, both stress-related hormones. These hormones are metabolized by exercise, decreasing their undesired effects. Long-term activities result in the secretion of endorphins by
the brain. These morphine-like substances can produce a feeling of exhilaration, which
reduces stress and increases a sense of well-being. The endorphins serve as a natural
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tranquillizer that soothes both the body and mind. Once clients experience the internal
benefits of activity, they find it difficult to do without it (Kingsbury, 1988).
The improved self-concept and sense of accomplishment resulting from exercise
may be instrumental in the development of long-term lifestyle changes that lead to
improved health and quality of life.
Physical activity helps one to think more clearly, be more efficient, have a happier
disposition, and have renewed energy: more can be accomplished in less time. The
result is that clients have more free time to do the things they really want to do.
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Chapter Eleven:
Lifestyle Strategies
The focus of this chapter is on implementing the changes in lifestyle we’ve defined and discussed throughout this course.
EATING OUT
Approximately one-third of our meals are eaten out and this rate is expected to go
up to two-thirds by the turn of the century. Obviously, this is a preferred lifestyle for
many people. However, many people eat unbalanced meals and/or binge when eating
out. For example, Marilyn used to be very strict with her diet during the week, and
looked forward to the weekends when she allowed herself to go off the diet and eat out.
Her ritual would be to have no breakfast and maybe no lunch to compensate for the
extra calories she consumed at supper. This diet mentality caused her to be overly
hungry by supper. She felt starved and therefore overate. She rationalized that it was
socially acceptable to binge when eating out.
Many people eat one way at home and differently when visitors come or when
they are at a restaurant. If they choose high-fat foods on these occasions, it means that
they have not yet acquired a taste for foods lower in fat.
A benefit to eating out is the opportunity to experiment with different flavors and
textures. The excitement of making new discoveries can add zip and variety to mealtime. In restaurants, clients can discover some lower-fat entrees that are both physically
and psychologically satisfying. This may help them to realize they don’t have to bring
out the high-fat meals when visitors come. Perhaps they can try one of their favorite
lower-fat restaurant recipes at home to impress their guests.
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With the nondiet approach, clients can go to any social occasion and be in charge.
Have your clients keep these nondiet principles in mind when eating out. The following
guidelines can be provided to clients.
• Eat regularly. Clients need to eat regular meals during the day and not starve at
breakfast and lunch to compensate for eating out at supper. This will allow them to feel
more energetic throughout the day rather than feeling dragged out, waiting for that
huge meal to devour at supper time. Instead, they will arrive at the meal pleasantly
hungry instead of famished. If supper time is planned to be later, and they know they
will be hungry, they should schedule a snack.
Being overly hungry leads to quick eating that means they won’t even taste their
meal. A pleasant hunger results in enjoying the meal thoroughly, allowing them to feel
in charge and being able to stop when pleasantly full.
A snack eaten prior to the restaurant meal and a little bread at the restaurant will
allow them to create the right atmosphere of relaxation so that they are able to eat the
meal slowly and fully enjoy it. If they fill up on bread, then they may not have enough
room for the meal itself which is really what they are paying for.
• Order what you really want. If clients order what they really want in a restaurant, they feel satisfied. But first they have to tune into what they really desire. If they
order what they think they “should,” or what is the least expensive, or most expensive,
they may be physically satisfied but not psychologically satisfied and they will crave
something more. If the meal is not enjoyable they may crave dessert to satisfy that
unfulfilled need.
Clients can have what they want in a restaurant, but they may need to learn to be
assertive. For example, the sandwich and fries may be the special of the day. If they do
not care for fries, they can order a salad instead, or order á la carte, or perhaps soup and
a sandwich.
Try this technique: Say to the server, “I know that the special comes with fries and I
would prefer to have the soup. So, could you arrange this?”
The words have special meaning:
“I know” indicates that you understand the situation. “And” states how you feel
about the situation. “So” introduces your request for their action (Omichinski, 1993a).
This form of confrontation can be used any time clients are in a situation where
they need to be direct in a polite manner.
Other requests that clients can make are:
-- Salad dressing on the side. That way they can decide how much they would like
to have on their salad.
-- Gravy on the side. If their plate is served with too much gravy, they can always
scrape off what they don’t want.
-- Butter or sour cream on the side. This allows them to be in control of the quantity they eat.
-- Two forks with dessert so they can share with a companion.
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• Use nondiet thinking. Diet thinking has very clear signals: “I’d better get my fill
of the cheesecake now because when I go back on my diet tomorrow I won’t be having
cheesecake for a while.” or “I feel full but I still have room for a big piece of pie. Afterwards, I’ll go lie down.”
This diet thinking can be replaced by the following more positive statements:
“I’ll take a small piece of cheesecake. It looks good and I wonder what it tastes like.
If I don’t try it, I may be wondering what it tastes like and end up feeling deprived.
That will lead me to binge on whatever is in sight when I get home.”
“I can always have more food later but I feel full now. I can ask the hostess if I can
take a piece of pie home for another day when I will appreciate it more. That way I am
not denying myself and I am not uncomfortably stuffing myself either.”
Observe different people at a social occasion. Nondieters are more selective in their
choices. They eat what they want and may eat a little more than usual, but their regular
eating habits prevent them from unintentionally bingeing or overeating.
It is easier for clients to resist food if they are feeling satisfied and realize this is not
the last time they will see lemon pie. After all, they can buy a pie, make one any time or
they can ask to take some home.
Slightly undereating at mealtime to leave room for dessert can be done on special
occasions if it doesn’t result in decreased enjoyment of the entree due to anticipation of
dessert. Eating very little at mealtime so that one can try all the desserts reverts to the diet
mentality. “I’d better eat all I can now because it may not be there later.” In a society of
plenty, running out of food is usually not a problem. Nondieters know this and are more
selective in choosing a meal. They will eat desserts only when they truly desire them.
• Look for a balance of carbohydrate and protein. Eating a balance of protein and
carbohydrate will result in a satisfying dining-out experience. Eating in this manner will
help them to focus their energy on the social occasion rather than just the food. Food is
no longer the center of attention for them. The company and entertainment are also part
of the evening. Clients will choose a balance of carbohydrates and protein, and its
sustained energy value, in their meal because they want to, not because they feel they
should. They will be able to taste and savor their food and have enough energy reserve
to enjoy the rest of the evening. Overeating makes us feel uncomfortable. Then we don’t
feel like being sociable; all we want to do is go home and go to bed.
Examples of Balanced Meals
Italian: Pasta w/meat, fish, or poultry in the sauce, salad & bread
Chinese: Stir-fried dishes that include meat, fish or poultry, vegetables & rice
Greek: Meat or chicken kabob, served w/rice & vegetables or in a pita w/salad
Fast foods and pizzas: Hamburger & salad; thick crust pizza & salad
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• Eat until you are satisfied. When eating out, clients have the option of asking for
a “doggy bag” if they cannot finish their meal. The leftover food may be a treat for
lunch the next day. They may also choose to leave what they cannot eat on their plate if
they are feeling satisfied and pleasantly full. Forcing the whole dinner down because
they paid for it is not truly enjoying the meal.
• Tune in to what it feels like to overeat. So the client overeats. Teach them to
experience and remember this uncomfortable, heavy sensation and decide whether they
like this feeling. Is it allowing them to enjoy the occasion, or are they too tired to care? A
big meal takes a lot of energy to digest, so the scenario of eating and lying down on the
couch is a common one. Not wanting to repeat this feeling can lead to more instances
where they will enjoy the food as well as the event but eat simply for the enjoyment of
it. Eating past the point of satisfaction is often no longer enjoyable.
RELAXATION
If clients find it difficult to relax, take time to eat, breathe deeply, or have a nap and
feel that these activities are unproductive and a waste of time, have them take a look at
relaxation from a new perspective. Clients can introduce these activities gradually.
Taking the time to relax can serve to recharge one’s battery and result in better health.
In a study done in England, 200 participants were divided into two groups. One
hundred participants were the control group and the other 100 were asked to have a
half-hour nap sometime during the day. The latter group decreased their risk for heart
disease by 30 percent. A little pause during the day can go a long way for health. Next
time you feel you’d like to lie down for a nap, don’t feel guilty. It may help you to
regenerate yourself.
Hobbies are important too. Taking time out allows people to acquire new concentration skills and an extended vocabulary, while relieving some of the pressures of
everyday life. Relaxed people handle stressful situations better. So, as you’ve observed
and learned from nondieters, try to observe those who have the ability to relax naturally
and learn how they do it. These people seem to be able to react positively even in
negative situations.
Clients can make eating a positive experience. By learning to focus on eating, they
will be celebrating food, and they will derive both psychological and physical satisfaction from the activity. If they’ve been eating in a rushed manner for years, they might
ask, “How do I go about tasting my food? How can I take time to spend time eating?”
Are clients feeling they are not worth the time? Have they ever considered that by
focusing on what they are doing while they are doing it they will actually free more
quality time for themselves and their family? Taking time to enjoy their meal and
making it a pleasurable dining experience can make their meals “special.”
Tasting and savoring one’s food allows one to focus on eating while eating and
therefore, one feels as if one actually ate a meal when finished. This disrupts the automatic eating that leads to taking in more than the body needs or wants. It also prevents
constant nibbling throughout the day and evening.
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Clients can create a more relaxed atmosphere in which to eat their food by breaking the constant rush of the day’s activities. If they are pressured all day and come home
only to hurry to feed themselves and their family, the enjoyment of the meal is gone.
Everybody feels tense. Clients can relax when they first come home, plan to have a
snack if they are very hungry, then actually enjoy the meal together as a family.
TAKING TIME FOR ONESELF
Society’s demands, pressures of the job, or their own high expectations create a
high stress level for many people. Often people go to extremes. They work too hard and
play too hard. The balance is gone from life. By building in a daily “time off” period,
clients can regain the relaxed composure necessary to enjoy the moment so that they can
eat their meal or listen to their children. They can give their interested attention. They
become more focused and better listeners. They also become more efficient because they
focus on the situation and enjoy it.
Building in time for oneself helps to stop that rushed feeling and allows one to do
things more systematically, thinking of what one is doing while one is doing it. It puts
one in a more relaxed frame of mind for the mealtime. One can enjoy the meal rather
than feel “let’s get it over with so that I can finally relax.”
Clients need to take their special time for themselves alone. In order to avoid
noise and distraction they may want to go for a walk to collect their thoughts, regain
their composure, and put the sanity back into their life. Another benefit of building a
daily relaxation period into one’s life is that one is not exhausted by the time a holiday
comes around, and vacations can be a pleasure and not a necessity for a person suffering from exhaustion. The relaxation scripts contained in Appendix #8 may be useful to
clients.
DEALING WITH STRESS POSITIVELY
Energy comes from a balance in food, activity and attitude. Too much stress can
drain our energy level. Just as we eat and exercise for energy, we can find the stress
level that is comfortable and stimulating for us without the feeling of being overwhelmed. We can find the balance in our lives so that stress can work for us to make us
feel alive and vital.
Through the process of self-discovery and self-acceptance, clients can learn how to
pull back when the stress level gets above their comfort zone. By not dieting, they
reduce both physical and mental stress. By setting themselves free from perfectionism,
the “all-or-nothing” way of thinking that can transfer from food to other areas, they
become more accepting. If something does not go quite the way they planned, clients
can ask themselves, “what is the worst possible thing that could happen?” “Could I live
with the outcome?” This usually puts things in perspective.
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Points to Include in Daily Routine
• Enjoy activity as release valve so that you exercise for fun.
• Build in time for yourself.
• Practice some relaxation techniques such as deep breathing.
• Incorporate exercises that can be done at the desk during the day.
Clients can learn to like themselves and accept themselves the way they are. This
does not mean that they won’t do anything to try to improve themselves. It means that
they care enough about themselves to nurture themselves and take care of their body
and mind. We encourage them to “Be the best that you can be!”
Clients find the following affirmation very motivating:
Allow yourself to be you. Release yourself from attaching your self-worth
to the number on the scale, your accomplishments, what others say about
you, compliments or criticism. Believe in yourself and have the confidence
in your own ability to accomplish goals by pursuing skills, such as confrontation, in everyday life situations. By confronting situations and dealing with them you will not move past your stress level zone. Focus on your
progress. The ability to take things calmly can defuse a potentially difficult
and explosive situation.
REDEFINING HEALTH
Redefining success in terms of lifestyle changes and health status rather than the
tangible result of weight loss puts a new perspective on how clients feel about their
weight. A fresh new approach to health is that the internal changes made by lifestyle
changes motivate people to keep practicing those lifestyle changes. The nondiet approach can be labeled The “3 Ps” to Long-term Success. Here they are.
• Perspective. With a positive perspective on life, you learn to be more flexible,
accept life’s highs and lows, learn from them. You no longer isolate specific
instances and blame others or yourself for shortcomings: you put problems into
proper perspective.
• Priority. With the new attitude that you have learned, you need to take time for
yourself and make this a priority. There can be a choice: to keep your life in
balance or to be overwhelmed with your unending list of duties and respond to
external cues. Feeling better about yourself and having confidence in your
ability minimizes the effect that comments from others have on you.
• Perseverance. “Hanging in there” is certainly worth the effort. The result is a
new lifestyle that puts your life in balance and gives you an inner glow that
radiates outward and brings with it health and vibrancy. You have a sense of
accomplishment. This way of life is one of celebration and doesn’t end when you
attain a temporary goal (Omichinski, 1993a).
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ASSESSING PROGRESS
What does success mean now to your clients? In the past it may have been defined
as weight loss visible on the scale. Chances are this success was not long-term. They
may be ready to try for something more permanent. By redefining success as the process of improving health and lifestyle, physical and mental stress is reduced. Success is
renewed confidence and self-acceptance, energy, enjoyment of increased activity, feeling
better about one’s self, and improved eating habits.
Chapter One showed why a nondiet approach to healthier living was necessary.
Chapters Two through Four discussed the techniques to help clients put a new perspective on how they feel about their weight. Chapters Five through Ten have provided you
with the tools to help your clients live the nondiet lifestyle and experience their new
definition of success. You can now evaluate your clients’ progress towards better health
using the following indicators:
How Far Have Your Clients Progressed?
• Are they eating regularly?
• Are they balancing their meals w/carbohydrate & protein?
• Have they cultivated a preference for lower-fat foods?
• Have they cultivated a preference for less-sweet and lower-sugar foods?
• Are they eating foods they enjoy?
• Are they listening to their body signals of hunger, appetite, & satiety?
• Are they starting to enjoy incorporating more activity into their lifestyle?
• Are they dealing w/why they were overeating in the first place?
• Are they using confrontation to request certain foods?
• Are they making small changes to build in time for themselves?
• Are they thinking like a nondieter?
When they can answer yes to these lifestyle shifts, physical health will almost
certainly be improved. If you rush this process, clients may end up in the diet mentality.
The more they have dieted and the older they are the longer it will take to make the
new process enjoyable. But if it’s fun and they have an attitude of self-discovery and
experimentation, it really doesn’t matter how long the new process takes. If they allow
changes to take place over a 5-year period, their body will readjust to its natural weight
comfortably, and will be more likely to maintain it. No matter what the outcome, they
are to be congratulated on taking this road. This is the way they will be healthier and
happier, independent of weight loss.
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It is important to remember that real change takes time. Although discouraging,
relapse is a normal aspect of change. Most people cycle through the stages of change
(pre-contemplation, contemplation, preparation, action, maintenance and relapse)
several times before succeeding in finding a healthy lifestyle -- without diets. Clients
will require continued support and encouragement. A valuable follow-up resource for
you and your clients is a collection of stories of actual people (Omichinski, 2000) providing a balance of inspiration and advice. These personal stories bring us the voices of
women struggling to maintain healthy lifestyles despite difficulties, providing gentle
words of empathy and encouragement for those times when making progress towards a
nondiet lifestyle is challenging.
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Chapter Twelve:
Freedom from Counting
for People with Diabetes
The person with diabetes requires an integrated, flexible and lifelong plan for
total health that accommodates lifestyle choices. However, the traditional medical
approach of restrictive diet and restrained lifestyle often leads to damaging and unhappy cycles of behavior and attitude that mimic the chronic dieting syndrome.
In contrast, the special needs of the person with diabetes can be uniquely met
through a genuine nondiet approach utilizing empowerment techniques. This model
puts the client in charge of building individual health parameters in consultation with a
facilitative health professional.
Slow, gradual and supported experimentation with different types of food and
levels of activity combine with positive attitude building methods to instill the necessary confidence for healthy decision making. Optimum blood glucose levels are attainable and retainable within this setting of client choice and responsibility. For both the
person with diabetes and the health professional team there are exciting new roles to
learn about “letting go” and empowerment. The results of self-stimulated lifestyle
choices are increased health potential.
People who have diabetes go through similar issues as those who have weight
problems. This is particularly evident with Type 2 diabetes, 80 to 90 percent of the
diabetes population. These issues are:
• Frequent feelings of hunger;
• Feelings of restriction and deprivation due to elimination of some favorite foods
• Feelings of awkwardness at mealtimes because of eating differently from family
and friends, or because of having forced sudden changes in eatinghabits on the
family
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• Feelings of guilt when “cheating” inevitably occurs, which often leads to
going off the diet
• Feeling of total dependence on the diet sheet resulting in total preoccupation.
The failure of the medical model is identified with four characteristics of this
traditional method of treatment shown below.
Traditional Method of Treatment
• Disease is the focus — treatment course prescribed is often weight loss to
achieve an ideal body weight or body mass index within the norms
• Health practitioners are in control
• Information is given to clients according to arbritary judgments on “what
you feel” they need to know
• Success is measured by external goals such as weight loss, following a diet
As practitioners we need to examine if this treatment is effective in stabilizing
blood glucose levels over an extended period of time. Despite the initial benefits of the
“improved” diet and exercise programs that have been prescribed for people with
diabetes in the past, estimates suggest that one third to one half of the people with
diabetes have difficulty following these programs for any length of time. Once blood
sugars have been brought under control, former eating and exercise habits often return,
along with the former lifestyle. Diet and exercise programs treat diabetes but make little
attempt to address the individual’s emotional response regarding food.
The alternative is the health promotion model based on a nondieting lifestyle
characterized and contrasted in the following ways:
• The individual client is the focus of treatment
• The individual is in control and takes charge
• Information is given so individuals can make choices
• Success is measured on intrinsic motivation and internal goals, i.e. feeling better,
improved well-being.
The application of the nondiet approach to the lifestyle issues of the person with
diabetes works because the emotional power of food is accommodated into client
choice. Weight-loss focus is removed from the client concerns.
The research facts support this approach as increasing amounts of literature point
to inconclusive benefits or actual risk with weight-loss regimens.
• Fluctuations in body weight are less healthy than if one stabilizes at a higher
weight (Lisner, et al., 1991)
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• Yo-yo dieting where weight is lost and then regained seems to be associated with
more fat being distributed around the stomach area (Rodin, et al., 1990)
• Increased risk of obesity-related diabetes has been associated with fat in the
stomach area rather than fat in the hips and thighs (Nutrition & the MD, July
1990).
One of the main health issues for people with diabetes is the development and
sustainment of a long-term plan that enables stabilized blood glucose levels within an
acceptable lifestyle. When one considers the destruction caused by chronic dieting
syndrome behaviors and the inconclusiveness of weight loss benefits, the questions
have to be asked....
• Why utilize weight loss as a goal and tr
eatment plan?
• Why prescribe the diet lifestyle (food and exercise have-to’s) for people with
diabetes?
• W
ith diabetes, the changes made need to be maintained for the rest of one’s life.
So how can we use the nondiet approach with this group of people? (See appendix #9)
Working in a Diabetes Education Centre over the past 12 years has given me an
opportunity to see clients with diabetes over the long term. Initially I used a traditional
approach of exchanges as per my training and in time moved to a nondiet approach as
outlined above. A number of years ago I took the time to follow some clients, their
weight loss, and blood glucose control and I found some interesting results as per the
table on the following page.
This internal study demonstrated to me that long-term maintenance of blood
sugars as demonstrated by HbA1C (a test that gives us the average blood glucose levels
over the past three months) has several factors other than simply weight loss. It is
unfortunate that so much emphasis is put on weight loss while a healthier attitude
towards food and activity, regular eating, a relaxed disposition, weight stabilization,
and balanced eating may be more important factors to consider. As you begin to use this
approach and ask the right kind of questions to determine one’s total well-being, you
too may discover similar results.
The example on the following page of Barb, who has Type 2 diabetes, can show
you how this approach can be put into action.
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Blood Sugar & Weight Loss
Client
Male
HbA1C (%)
6 mo.
Initial later Wt. Loss
Decrease 4.7 kg
9.1
6.9
(10.4 lb)
Comment
Some weight loss & good understanding of carbo/pro balance.
Male
9.8
7.2
Decrease 0.7 kg
(1.5 lb - 109%
of IBW)
Weight loss was minimal, client is
heavier than recommended, yet blood
sugars improved considerably. Weight
loss was not significant factor in
decreasing HbA1C.
Female
8.6
8.6
Decrease 2.3 kg
(5 lb)
Despite decrease in wt & active
lifestyle, client’s blood sugars did not
improve. Note that client is weightpreoccupied, possibly contributing to
increased mental stress level that has
effect on blood sugars to counterbalance positive effects that physical
activity and weight loss contribute.
Male
7.7
7.2
Increase 3.5 kg
(7.7 lb - 110%
of IBW)
Even though client’s weight increased
and client is at a higher weight than
recommended, this client has improved
blood sugars, which may be attributed
to the fact that he handles stress very
positively and has a very relaxed
attitude.
Female
7.5
6.6
Decrease 1.2 kg
(2.6 lb - maintaining weight
119% of IBW)
Even though this client is large and has
minimal weight loss, her understanding
of the balance of pro and carbohydrate
at mealtime has improved: adding
peanut butter to bread and trying whole
grain bread may be a contributor to
improved blood glucose.
PRACTICAL APPLICATION OF THE NONDIET APPROACH
In real life, Barb (not her real name) is a 65 year old woman who came to see the
dietitian after being diagnosed with elevated blood glucose levels. This dietitian used a
lifestyle, nondieting approach to educate the client about her diabetes.
Barb was introduced to the new skills she would need in the following way.
• Assessment of client’s nutritional knowledge. (What you already know: builds
up confidence). Barb was asked to divide food models into two groups — identifying
foods that did and did not contain natural sugar.
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• Education. (What you need to know: simple, easy-to-understand and remember
guidelines). The dietitian expanded on the concept of balanced meals using nondiet
nutrition concepts. Food models assisted in illustrating the purpose of carbohydrates for
energy and protein sources for slower release of energy to stabilize blood glucose levels.
Barb was advised about the 2/3 to 3/4 carbohydrate and 1/3 to 1/4 protein combination.
• Verification of concept. (Assimilating the known and the unknown, using familiar examples). Barb was asked to describe the types of meals she might eat using her
existing knowledge about the content of food and the new concepts she had been
shown.
• Portion control. Barb was advised on how to tune in to her body by recognizing
the natural signals of hunger and satiety to determine the amount she could eat. She
was encouraged to be experimental and note how she felt before and after eating.
• New health choices. Barb was advised that she would be able to learn how to
gradually make changes in her cooking techniques, eating and activity patterns. Her
desire to make these changes was supported with the guidance that lifestyle change is a
skill-building process that takes time.
Barb left feeling positive and began to gradually make the suggested changes in
her lifestyle. A short time later though, the dietitian received a phone call from Barb’s
daughter. She was indignant that her mother had not received a diet instruction sheet.
She wanted the dietitian to administer a diet as soon as possible. The dietitian advised
Barb’s daughter that her mother’s scheduled one month follow-up was the following
week at which time her progress would be assessed.
How could this situation be handled using the empowerment model — the nondiet
approach?
If the dietitian was new to the nondiet approach, the reaction of Barb’s daughter
might be intimidating. It could be tempting to yield to her request rationalizing that the
nondiet approach is not for everyone and perhaps the client’s wishes should be considered. We know that people are used to getting diet sheets and being weighed to indicate
progress and success.
In actual practice, here is what did happen. Barb reviewed her meals in detail with
the dietitian, which soon revealed that she had an excellent grasp of the concepts of
balanced meals and hunger and satiety signals. The dietitian maintained her new role
that focused on building the client’s confidence level and affirming her capability for
making healthy choices about her lifestyle. The dietitian told Barb that she did not need
the restrictions of a diabetic diet per se. In addition, Barb had an improved blood glucose
level, indicating her capability to handle the concepts.
Barb was encouraged to continue with her present course since she was doing just
fine. Suggestions about fine-tuning her cooking techniques were also provided at this
time. In keeping with the client empowerment ideal, Barb was advised to let her family
know how well she was managing her new health condition — the dietitian did not
take responsibility for contact with the daughter!
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As a cautionary note, sometimes clients will follow a strict diet before having a
blood test to get a good reading. A total health profile and HbA1C levels may be a more
accurate indicator of the client’s real hand on the disease.
In this way, there is a shift in the model for diabetes education. Client education is
at the top of the pyramid. The empowerment of individuals through recognition of the
complexity of their personal needs when faced with their health condition starts the
process for the desire to learn what they need to know to take care of themselves — the
choice for permanent healthy living.
They are then supplied with the tools, techniques and facts that enable the client’s
choices to occur. An integrated program may be needed to cover all aspects of lifestyle
change.
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Chapter Thirteen:
Five Health Care Myths
Much of current obesity health care is based on misinformation, myth and size
bias, rather than accurate information. Consider these myths and controversies:
MYTH #1
Obesity causes health risks, such as type 2 diabetes, hypertension and heart disease.
Fact: We don't know, but it seems unlikely. Obesity is associated with higher risk, but
causation has not been established. The evidence suggests that both obesity and its
related risks may be caused by a third factor or set of factors — studies strongly implicate genetics and inactivity. Increasing physical activity dramatically reduces health risk
even without weight loss (Taylor, 2004; Petersen, et al., 2004; Miller, 1997; Blair, et al.,
1993; Barlow, et al., 1997; Berg, 2004a)
MYTH #2
"Healthy weight" defines the range of lowest health risk.
Fact: The weight associated with lowest mortality is close to or within the "overweight" range, well above the midpoint of so-called healthy weight (BMI 21.7). Lowest
death rate is at a BMI of about 24.5 for Caucasian men and women, 27 for African
American men and women, and after age 55, 26.5 for Caucasian women and 29.8 for
African American women, with only weak association after age 75, according to an
extensive review of 236 randomized, controlled studies by the National Institutes of
Health, NHLBI. (Despite this evidence, NIH defines “healthy weight” as a BMI of 18.5
to 24.9; overweight 25 to 29.9; obesity 30 and over.)(HIH-NHLBI, 1998; Berg, 2004b)
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MYTH #3
Health is always improved by weight loss.
Fact: Long-term studies indicate higher risk with weight loss. At least 15 large
comprehensive studies show higher death rates, including the Framingham Heart
Study, Harvard Alumni Study, and NHANES I follow-up. Researchers suggest that loss
of too much lean mass from muscle, bone and organs, may jeopardize health (NIH
Technology assessment conference, 1992; Andres, et al., 1993; Williamson, et al., 1995;
Allison, et al., 1999; Berg, 2004c).
MYTH #4
Current weight loss treatment is safe and effective.
Fact: All weight loss methods must be considered experimental. None are proven
long-term safe and effective.
• Dieting leads to short-term weight loss, disturbed eating, bingeing and food
preoccupation, followed by regain or weight cycling, which has its own risks, and often
a higher weight.
• Drugs provide only minimal weight loss (5 to 11 lb) and must be taken long-term,
involving increased risk: of 6 million adults who took fen-phen/Redux, FDA reports
one-third developed leaky heart valves and others died of primary pulmonary disease.
• Gastric surgery carries risks of over 60 complications including severe infection,
leaks, obstruction, blood clots, malnutrition, and early and late deaths that include
suicide (NIH Technology assessment conference, 1992; Lee, et al., 1996; Kassirer and
Angell, 1998; Garner and Wooley, 1991; Lissner, et al., 1991; Berg, 2004c)
MYTH #5
Scare tactics and pressure to be thin help prevent obesity, promote weight loss, and
do no harm.
Fact: Increasing social pressures to be thin over the past three decades have paralleled the steep rise in obesity. These social pressures and scaring people about the risks
of obesity can lead to malnutrition, hazardous weight loss, eating disorders, body
hatred, size discrimination, stress, anxiety, potential immune suppression, and higher
health risks. Thus, these tactics fail to prevent obesity or help people lose weight, and
have caused harm (NHANES III, 1994; Levine, 1995; Pipher, 1994; Fallon, et al., 1994;
Grange, et al., 1995; Smolak and Levine, 1994; Berg, 2004d)
The fiction these myths keep alive is that overweight is a severe risk, threatening
the health of most Americans, adding greatly to healthcare costs, and therefore weight
loss treatment is urgently needed. They benefit the weight loss industry, but not individuals or the public.
Increasingly, health providers are moving ahead to the “Health At Any Size”
approach (also known as Health at Every Size), which focuses on wellness and wholeness, living actively, and eating in normal, healthy ways. It promotes compassionate
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health care, acceptance, respect and appreciation of diversity, and defines health by
physical, mental and social well-being, not weight.
— Frances M. Berg
(Reprinted and adapted from Underage and Overweight: America's Childhood Obesity Crisis – What Every
Family Needs to Know, by Frances M. Berg. New York: Hatherleigh Press. Copyright 2004 by Frances
M. Berg. All rights reserved. The author permits use of this 5 Health Care Myths feature as a
handout or in nonprofit newsletters for educational purposes only, provided it is reproduced in its
entirety with this citation. Written permission is required for use in books or publications for sale.
Contact Healthy Weight Network, 402 South 14th St., Hettinger, ND 58639 (701-567-2646; fax 701567-2602). For more information visit www.healthyweight.net.)
REFERENCES
Allison DB, Zannolli R, Faith MS, et al. Weight loss increases and fat loss decreases all-cause mortality rate:
results from two independent cohort studies. Intl J Obesity 23:603-611, 1999.
Andres R, Muller DC, Sorkin JD. Long-term effects of change in body weight on all-cause mortality: a
review. Ann Intern Med 119:737-743, 1993.
Barlow CE, Kohl HW III, Gibbens LW, Blair SN. Physical fitness, mortality and obesity. Intl J Obesity 19
(Suppl 4):S41-44, 1995. Miller W. Health promotion strategies for obese patients. Healthy Weight J
11(3):47-51, 1997.
Berg F. Underage and Overweight: America's Childhood Obesity Crisis – What Every Parent Needs to Know,
p 12-29. New York: Hatherleigh Press. 2004a.
Berg F. Underage and Overweight: America's Childhood Obesity Crisis – What Every Parent Needs to Know,
p 137-156. New York: Hatherleigh Press. 2004b.
Berg F. Underage and Overweight: America's Childhood Obesity Crisis – What Every Parent Needs to Know,
p 157-194. New York: Hatherleigh Press. 2004c.
Berg F. Underage and Overweight: America's Childhood Obesity Crisis – What Every Parent Needs to Know,
p 195-205. New York: Hatherleigh Press. 2004d.
Blair SN, Kohl HW, Barlow CE. Physical activity, physical fitness, and all cause mortality in women: do
women need to be active? J Am Coll Nutr 12(4):368-371, 1993.
Blair SN, Bodney S. Effects of physical inactivity and obesity on morbidity and mortality: Current evidence and research issues. Medicine and Science in Sports and exercise 31:S646-S662, 1999.
Fallon P, Katzman M, Wooley S, edits. Feminist perspectives on eating disorders. Guilford Press, NY. 1994.
Garner DM, and Wooley SC. Confronting the failure of behavioral and dietary treatments for obesity. Clin
Psych Rev 11:729-780, 1991.
Grange D, Tibbs J, Selibowitz J. Eating attitudes, body shape, and self-disclosure in adolescent girls and
boys. Eating Dis 3(3):253-264, 1995.
Kassirer JP, Angell M. Losing weight: An ill-fated New Year's resolution. N Engl J Med 338:52-54, 1998.
Lee IM, Paffenbarger RS Jr. Is weight loss hazardous? Nutr Rev 54(suppl):S116-124, 1996.
Levine P. President's message. Eating Disorders Awareness and Prevention Newsletter. pgs 1-3, Spring 1995.
Lissner L, Odell P, D'Agostino D, et al. Variability of body weight and health outcomes in the Framingham
population. New Engl J Med 324:1839-1844, 1991.
Miller W. Health promotion strategies for obese patients. Healthy Weight J 11(3):47-51, 1997.
NHANES III. Third report on nutrition monitoring in the US, Vol 1-2, Dec 1995. Research Office, US
Health/Human Serv, US Dept. of Agriculture. National Center for Health Statistics, NHANES III.
Advance Data Nov 14, 1994.
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NIH-NHLBI Clinical Guidelines on Identification, Evaluation, and Treatment of Overweight and Obesity.
National Institutes of Health, National Heart, Lung, and Blood Institute. Bethesda, MD. Pre-print,
1998.
NIH Technology assessment conference: Methods for voluntary weight loss and control. Conference
report: program and abs. March 30-April 1, 1992. Office of Medical Research, Bethesda, MD 20892.
Petersen KF, Dufour S, Befroy D, et al. Impaired mitochondrial activity in the insulin-resistant offspring of
patients with type 2 diabetes. N Engl J Med 350:664-671, 2004.
Pipher M. Reviving Ophelia. Ballentine Books, Random House, NY. 1994.
Smolak L, Levine M. Toward and empirical basis for primary prevention of eating problems with elementary school children. Eating Dis 2(4):293-307, 1994.
Taylor R. Causation of Type 2 diabetes – The Gordian knot unravels. N Engl J Med 350:639-641, 2004.
Williamson DF, Pamuk E, Thun M, et al. Prospective study of intentional weight loss and mortality in
never-smoking overweight white women aged 40-64 years. Am J Epidemiol 141:1128-1141, 1995.
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Chapter Fourteen:
The Journey to Building Momentum and
Unity for Health at Every Size
“Never doubt that a small group of thoughtful, committed citizens can
change the world. Indeed, it is the only thing that ever has.”
Margaret Mead, US anthropologist & popularizer of anthropology (1901-1978)
Tenets of HUGS — Health focused, centered on Understanding Lifestyle Behaviors,
Group supported and Self-esteem building.
In my journey towards Health At Every Size (HAES), my light bulb moment happened when a participant after class said to me, “Linda, I am no longer starving and
bingeing. I am eating more regularly. I am beginning to enjoy healthier foods and feel the
energy those foods bring me. I am enjoying walking for the fun of it. But I am not losing
weight. What am I doing wrong?” That hit me like a ton of bricks. I responded, “You
aren’t doing anything wrong. You may be at the weight your body was meant to be.”
This change in direction from equating health with weight loss to focusing on
improved emotional and physical behavior was reinforced when the National Eating
Disorder Information Center confronted me on my book tour in 1992, indicating that I
was giving mixed messages. My five-year personal and professional journey turned
down a new path.
Nineteen years later, as an important spoke in the wheel of the HAES movement,
HUGS has become the only worldwide HAES program: this is Health At Every Size at
work on an international scale. In many ways, however, we took a major hit in the
recent days of the Atkins culture, and feel at the same point we were at a few years after
beginning the journey.
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HAS HEALTH AT EVERY SIZE GROWN OVER THE PAST 19 YEARS
TO BECOME MORE MAINSTREAM?
The HAES movement remains fractured, with everyone doing their own local
offering: there is no unified cohesive momentum. For example, although HUGS is an
international program, Weight Watchers is still seen in the minds of health professionals
as the program of choice. In my role as coordinator for International No Diet Day 2006, I
felt more cohesiveness in the HAES movement for the first time, a pulling together for
one common cause instead of everyone doing their own thing separately. The timely
release of the film documentary Dieting: At War with our Bodies contributed considerably
to that cohesiveness and momentum. This film challenges the viewer to ignore society’s
ideals and abandon a culture that promotes thinness, congratulates the dieter, and
demoralizes the fat. Christie McNabb, the film’s producer, shares her reason for creating
the documentary: “Watching a loved one suffer from an eating disorder made me very
aware of our society’s damaging attitudes about weight. I wanted to be a part of changing those attitudes.”
Dieting: At War with our Bodies defies the dominant diet culture, suggesting that we
reclaim health, not weight loss, as our lifestyle change goal and let the fat fall where it
may. As it follows a group of nondieters facing life with a new attitude of health and
acceptance, the film lets us hear from a divergent obesity researcher, and follow trendsetters as they affirm that weight loss is unnecessary to obtain health and happiness.
Summing Up
Summing Up the film Dieting: At War with our Bodies and Concepts
• We can be healthy at any size.
- Thin people can be healthy or unhealthy, and large people can be healthy or
unhealthy.
• Dieting leads to bingeing and weight cycling (weight loss/regain).
- Other problems may be appetite dysregulation, body dissatisfaction, changes in
how the body stores fat, disordered eating and stress on the body.
• Dieting and restrictive eating often lead to higher weight gain.
- People often get heavier the more they diet, apparently due to body disruptions
(look at your weight when you started dieting compared with what you are today).
- Dieting may be contributing to the increasing weight of the population
• Statistics on the risks of overweight are being exaggerated by the diet industry.
- Why isn’t this in magazines or in newspapers? If it goes against what is popularly
thought, the media tends to ignore it. What gets published is mostly in sync with
current wisdom. People just assume it is true and don’t read or believe the
research against it.
• Listen to your body, not just your head, with healthy alternatives to dieting.
- Being self aware means listening to your body for cues of hunger and fullness,
reasons for eating, and plugging in to your basic needs.
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Summing Up ... continued
Summing Up the film Dieting: At War with our Bodies and Concepts
• Desired outcome needs to be health, not weight loss.
- If you focus on weight loss and you don’t lose weight or keep it off, you are
unlikely to maintain the lifestyle change. Also consider the effect dieting mothers
have on their children.
• Improving lifestyle habits provides enormous health benefits, without weight loss.
- Being healthy at your size involves small gradual “baby steps” where you are
responsible for your own health, and the journey is enjoyable (if change is sudden
or drastic and can’t be sustained, it is simply a diet under the guise of lifestyle).
(Developed together with Francie Berg of Healthy Weight Network)
GAINING MOMENTUM FOR HAES: INTERNATIONAL NO DIET DAY 2006
The 2006 International No Diet Campaign (INDD) was well received with the
release of Dieting: At War with our Bodies. This year Canada, the United States, Australia,
New Zealand, South Africa, Iceland, Malta, and Korea participated in INDD worldwide. Many did an INDD event for the first time. HUGS will continue to build on the
momentum created by using the campaign for 2007 INDD. We are accumulating feedback to help you plan for HAES in your community for INDD or at any time. Reports
back so far indicate that those who came out to INDD events found the film to be
powerful and the discussion to be one of openness, and support. Even tears were shed:
“At the center of each comment was the same core... that ‘we’ have been duped. That
‘we’ are each so much more than our bodies... and that we need to remember that
first, and we need to teach that fact to the next generation(s). To have the contrast
between those of us uncomfortable in our skin and the vastly different sizes and
shapes... absolutely mind blowing. To bring a room full of virtual strangers together and have them share such intimacy and depth was just incredible. There
wasn’t a dry eye in the room. The tissue box made the rounds. But it wasn’t a
negative feeling at all. It was moving and powerful. At the end, we were 15
women united in one voice—and to think that the same thing was happening in
other places in the world made us (at least me) think that we actually CAN make a
difference. To sit in that room and not hear a sound for 40 minutes of film doc, and
then stand in front of them and lead them in a discussion that allowed them to
open their souls to strangers… it was absolutely incredible. It was an experience of
a lifetime and I doubt that I will ever feel the depth of emotion I felt that afternoon. The producer attended this event and writes, ‘The discussion
afterward was so wonderful and insightful and emotional and uplifting.’”
Penny, HUGS leader, Mississauga, ON
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“....Some people came talking about wanting to lose weight... They laughed at the
page of ‘before and after’ pictur
es with the phrase ‘**results not typical.’ Mostly,
however, they were quiet and inscrutable. At the end, I stood and asked them
what they thought. One of the women said she thought it was ‘incredibly uplifting,’ and the other woman agr
eed with her. The discussion that followed was
productive and upbeat. None of them had previously heard of Health At Every
Size (HAES). Nevertheless, they said everything about it made sense to them.
(That speaks well for the DVD.) They said it made them feel relieved. The 10-yearold girl even participated.As a fourth grader she has friends who are turning
“creepy” about food and she knows of cr
uel girls who are setting a diet agenda for
the rest of her class. I talked a bit about my own journey and told them that I felt I
should own a tee-shirt that says “**results not typical.” I also admitted to not
being a perfect HAES practitioner. The group ended wanting more.”
Debra Sapp-Yarwood, Kansas City
“I thought that the film At War with Our Bodies was very well done. I plan to use it
again and again. It captured the frustration, the loss of self-esteem, and the hopelessness that constant dieters experience. It also discussed the fear most overweight people feel when they are without the guidelines of a diet and that HUGS
is not a weight loss program but a healthy living program. The experts’ information gave hope to the overweight that there is a way for them to feel better about
themselves and their bodies, that making life style changes can make them
healthier, and that health is more important than being thin. This was the first time
I have participated in the No Diet Day and I really enjoyed it. I showed the
film and all of them thought it was well done and informative. W
e discussed it
and our personal experiences with weight. Their main stumbling block was that
all of them wanted to lose weight as well as getting healthier. I eminded
r
them
that losing weight was often a byproduct of this lifestyle change (and) that being
healthier was more important that being thin, but I am not sure they really were
ready to hear it. Hopefully though, the seed was planted and next year I will have
a larger turnout.”
Debbie Clapp, Quincy, MA.
Others gave great insight into why diet plans are attractive and people have a hard
time letting go of the structure offered in weight loss programs:
”…the film sparked some great discussion among us here, and also provided some
helpful information for our phone support person regarding a particularly difficult
case she dealt with recently—that of a binge eater who had recently lost a lot of
weight on a popular rapid-weight-loss diet plan, but having finished the plan, was
then of course punted out the door with no life or coping skills to actually address
her bingeing problem. She asked us “what should she eat?” When told she should
eat what she wanted, she seemed unable to compute this and responded “oh great,
now I’m going to weigh 250 pounds again.” What the film showed us, and what
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struck me the most, was the fundamental conviction shared by all the subjects that
they are unable to govern or manage themselves. It seems what attracts them to
constant diet “plans” is the need to have a structure imposed on them, rules to
follow, the belief that they cannot make any of these decisions for themselves. And
when one set of these rules after another supports the belief system that some
foods are “good” and some are “bad,” then the bingeing situation is well set up:
labelling food as “forbidden” de facto creates the bingeing impulse. This makes
perfect sense from a behavioral perspective. Any parent knows that the quickest
way to get our children fascinated with something is to tell them it is forbidden:
don’t put your finger in the socket, don’t pull the cat’s tail, don’t go near the liquor
cabinet. Further, it is not effective to merely try to remove a negative behavior,
rather you need also to replace it with a new positive one or you are left with a
“behavior vacuum” that will continue to be filled by the negative action. That’s
how I got my son to stop drawing on the walls when he was little, anyway. Drawing itself was not labelled as a negative behavior, and I presented him with a
positive behavior option of drawing on paper—if my son knew he could draw as
much as he wanted on paper, then he didn’t need to draw on the walls (and he
didn’t). By the same token, eating is not a negative behavior; on the contrary
, it is
an essential one, but we label it negatively, and various foods as forbidden. Yet we
must eat, so what do we do when we tell ourselves we can’t eat? While negative
behavior (bingeing) may be temporarily extinguished by a rigid diet plan, if there
is no new, positive behavior (normal eating) introduced to replace it, then the
bingeing will return to fill the behavior vacuum. The answer is to stop labelling
food and eating as forbidden. However, I now have much better insight into how
flummoxed such individuals must be at the suggestion that no food is forbidden or
bad. They ar
e simply not ready to accept such an idea, and feel unable to make
those choices themselves. Years of eating to rules may have completely robbed
them of their ability even to correctly identify what hunger feels like.”
Meredith Johnston, Program Coordinator,
National Eating Disorder Information Center, Toronto
Contacting me from South Africa, Maya had difficulty with the size of the individuals in the film documentary. She writes,
“Fantastic documentary! My only objection is that all the “dieters” featured are so
big… We don’t have so many large people in South Africa, and the majority of our
clients are nowhere near that size, so they may not identify with these women, but
they are just as stuck in the dieting trap. I’ll let you know how the screening goes
tomorrow—I’ll do a bit of an introduction and then also facilitate discussion afterwards. I let my mother watch it this weekend, and her comment was something
along the lines of, “…but it can’t be a very good program if the participants are still
so big”… While I know that people come in different shapes and sizes, I also have
to admit that I conclude that someone isn’t quite getting it right just yet if they are
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still very heavy. Just looking at my own experience, when I started eating like a
non-dieter, I lost weight and it didn’t stop until I was quite slim. I think everyone
should be able to attain at least a comfortable size? It’s certainly a very interesting
question to ponder why Americans are so much larger than South Africans.”
In my response to Maya, I indicated that her own personal experience will not
apply to everyone, so she should be careful around this issue.
“You are young and haven’t dieted much—what about people who have dieted for
25 years and the status of their metabolism, or those that are genetically meant to
be large no matter what they do? As for those in the DVD, Penny, the leader, has
lost about 50 pounds and the others to be fair to them are early on in their journey.
They haven’t failed IF they don’t lose weight—this is the diet industry’s message,
not ours: HUGS is a journey, not a quick fix. We want to focus on health, not
weight loss, and sometimes people lose weight at the expense of health (diets),
and sometimes people get healthier without weight loss (HUGS), and sometimes
our HUGS clients do lose weight. It is individual for everyone. You may be early
on in your journey as I was around your age. Often society and health pr
ofessionals do have some fat prejudice and the pressures to be a certain size are so enormous. Yes, you are right that North Americans especially Americans are big
people—they have been fed the myths of dieting for a very long time and this is
part of the outcome. Diets do make you fatter... and there are huge pressures
to diet over her
e... Tell South Africans this is where one ends up with continuing
the diet cycle for so many years.”
Maya reported that International No Diet Day went well:
“The response to the documentary was very positive, and the discussion afterwards
very lively! I must admit that the part in your story where you tell of your light
bulb moment is one I always chose to ignore. I printed a copy of my letter to you,
voicing my concerns about the big ladies, and your response to it, and kept it with
me during the discussion after the documentary. The question of course came up,
and I read the relevant parts out of our e-mails to the group, and I’m glad that I
did. It’s very tough to not promise people that they will lose weight if they normalize their eating pattern, because it’s such a strong selling point, but I know that
you are right in what you’re saying. It’s (a message) that is met with a lot of
resistance which is sometimes very frustrating, but the results in the people that
manage to grasp its principles are so powerful that it inspires me to keep going!”
International No Diet Day was observed in Iceland for the first time in 2006:
“…the first INDD, or “Megrunarlausi dagurinn”… received a great deal of attention.
We were in all of the major media, did radio interviews, magazine and newspaper
interviews, and there was a report about us in the TV news. Our goal was first and
foremost to raise awareness and promote discussion, and I would say that in this
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we succeeded brilliantly. We also invited people to attend a seminar of sorts, a
three-hour program where we had lectures on the culture of thinness and showed
the film. We advertised this all over town and sent special invitations to health
professionals and those in the fitness industry… those who turned up were very
interested in the whole thing and there were excellent discussions after the film
near the end. I think everyone who attended left very satisfied with the afternoon.
Also, I was invited to go to a town in the West Fjord of Iceland and show the film
there… again, those who turned up were very enthusiastic and we talked a lot
after the film. And then they will talk to their friends and family and so on...
Afterwards, I searched the web for discussions of INDD in Iceland and was quite
surprised to find 6 whole pages at Google on the subject. Two weeks ago there was
nothing... I think most people in Iceland now know what INDD is. Also, we were
very fortunate to have the Icelandic Feminist Association with us. They are very
excited about this battle and are going to stay on board for next year also. They
promoted the day at the Icelandic Bureau for Equality and also at Unifem. On the
whole, we are very satisfied with this start and will learn from this when planning
next year’s event.”
Sigrun Danielsdottir, licensed psychologist, Iceland
And, finally, my own experience at my local INDD event this year left an indelible
mark on me. We had incredible publicity and 60 people attended. We live in a farming
community and the first gorgeous day in a week did affect the numbers. People were
quiet, taking the film in. A panel discussion followed, covering topics like fat prejudice,
diets not working, and the pressure on young people to be thin. Dr. Moe Lerner and Al
Levine of the National Film Board of Canada’s film Fat Chance, along with Byran
Gusdal, founder of a residential eating disorder recovery centre, were the panelists
along with me. I shared my personal story about HUGS and my light bulb moment, and
lost it—I was in tears for awhile before I could begin. One of my colleagues, early HUGS
facilitators and supporters, and friends shar
ed this incredible personal piece. We had
lots of lively discussion and, I think, changed some lives that day.
All of the testimonials cited here demonstrate clearly how a communication tool
such as this documentary can help address the problems of cohesion and momentum in
the HAES movement, by providing a focal point around which to stage events, galvanizing interest and wider discussion, and inspiring people to think more, learn more,
and do more about Health At Every Size. The following section is a list of additional
suggestions towards this same goal.
MAINTAINING MOMENTUM TO MAKE HEALTH AT EVERY SIZE MORE MAINSTREAM
1) Respond to articles with letters to the editor. When Randy Bachman, a musician in
Canada who has his own radio show, bragged about going to the United States for
gastric surgery and how he was a changed man, I wrote a letter to the producer
and it wasn’t mentioned again. We CAN make a difference.
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116
2) Educate the health professionals. Once something is in a film documentary format, it
feels like it’s more mainstream. Use HAES tools like the film documentary discussed here to bring the message to health professionals, counseling, classes, and
presentations. Consider holding an International No Diet Day event, ensuring
enough lead time to get your promotion in place. Help spread the word.
3) Listen to your clients. If they aren’t ready for the pure “Health At Every Size”
message, and most of them won’t be, meet them “where they are at” regarding
their goals and attitudes about dieting and weight loss, and gently nudge them to
the health focus. You can still help them with an empowering message. Otherwise,
the reality is that they may not become your clients and/or you’ll be out of business before you begin.
4) Consider using the film documentary as a tool in university settings to educate the
soon-to-be doctors, nurses, and dietitians. Linda Hooper from the University of
Washington writes, “The film was amazing. I am very excited about the potential
it has to reach people everywhere. I am a nutrition/RD student at the University
of Washington with a background in body image/eating disorder community
outreach. I plan to work as a clinical dietician with a non-diet approach, and I
think this concept NEEDS to be brought to the table with nutrition and other
healthcare professionals everywhere. I did not host an INDD event, but our nutrition student organization intends to host a viewing/facilitated discussion for the
Nutrition program (students and faculty) next fall. After that, we will decide
which audience to target next. At our school, we have a large medical school,
school of public health, nursing school, etc. So we are considering hosting the
film/facilitated discussion for various students going into healthcare fields.”
5) Target eating disorder prevention outreach at college campuses. Even though there
aren’t young people in the film, the message is a valuable one to gauge dieting
behaviors and fat prejudice, to acknowledge that dieting pressures start young,
and to look at alternative approaches to dieting that, if adopted, can stop the diet
cycle. In addition, the film can help dispel the “obesity crisis” myths. Christie, the
film producer, writes, “I just wanted to let you know that when I was deciding
what to focus on for the doc—whether to include eating disorders or teen dieting
or many of the disturbing stats on preteen dieting etc. I kept coming back to some
of the things that Sandra Friedman had said about little girls emulating their
mommies. I decided that I would essentially focus the attention on the
“mommies”, on the women that the young girls look up to. We want our teens to
stop obsessing when we haven’t made it there yet! “
WHAT HAVE WE LEARNED?
Here I have listed what I think are the principal issues currently facing HAES
advocates. They are hurdles that must be recognized and overcome if Health At Every
Size is to move forward with momentum to gain the social prevalence this important
health message deserves. Consider these points as you construct your HAES programs:
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1) Support, a strength of diet weight loss programs, is often lacking in health at every size
programs. People need support while our diet culture continues its prominence;
otherwise, they go back to diet programs. Limited funding of organizations leaves
no avenue by which the support can occur; and people may just end up caving
into the pressure to diet, and go back once more to the diet program.
Benefits of a Support System
• Increases self-esteem
• Connects you to others who can share their experiences
• Boosts your success at making important changes in all facets of your life
• Life enrichment through connections and shared affections with like-minded
people
• Encouragement to help you succeed
• Provides a supportive environment to share your emotions
• Offers valuable feedback
1) Appeal to the community of frustrated dieters. Health At Every Size is a health promotion message aimed at fundamental attitude and behavior change at a community
level. Dieters are a community of people with shared concerns, values, and goals,
and research has shown that for health behaviour change to be achieved in a
community, health promotion strategy must take a bottom-up approach. This
means approaching the community by acknowledging and working with its
values and desires, not trying to impose your new message onto it from the top
down (Laverack, 2000). Due to government intervention and the scare of the
“obesity crisis,” the message of Weight Loss=Health is even more prominent than
when we started HUGS 19 years ago. We are finding, however, that we can appeal
to frustrated dieters if we position ourselves as the alternative to dieting. The fact
is that your clients will care about weight loss, at least initially. Saying in the
promotion of your event “it’s not about weight loss, it’s about health,” may lose
your audience and not get many people out, because it ignores the concerns and
goals of your target community. Acknowledge diet and weight loss concerns
without condemning them, and realize that it’s normal if clients still want to lose
weight as they hear these messages not only from peer pressure and the media,
but also from the doctors and health professionals they see. Deal first with getting
the focus off the scale and numbers and onto health. As the program progresses
they will begin to accept the new focus. It’s a process, a journey that will take time.
Meet individuals in their own space on the diet/health at every size continuum,
and be careful not to fall victim to rigidity and all-or-nothing thinking yourself.
2) Counter fat prejudice. There may be more HAES programs being offered, and more
size acceptance people on major TV shows; but fat prejudice and weight loss focus
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118
is even stronger with the government emphasis on “the obesity crisis.” As Al
Levine, panelist at our International No Diet Day (INDD) event and subject in the
award-winning National Film Board of Canada documentary Fat Chance: The Big
Prejudice said, “Films come and go, programs come and go, there still is a lot of fat
prejudice and pressure to diet from health professionals.”
Steps to Planning an HAES Event (details at HUGS.com)
1) Book a location to hold your event, like a community hall, church, school,
library, hospital, health center conference room. Since you are offering a “free
education service” to the community, the location may be donated (no
charge).
2) Place public service announcements on local radio and TV stations—often
can be done over the Internet. Sample follows:
“International No Diet Day is an annual celebration of body acceptance
and diversity. Celebrate International No Diet Day with the premiere screening
of the film documentary Dieting: At War with our Bodies followed by a panel
discussion. May 6, (date, location, contact info).”
3) Use a discussion sheet to lead the post discussion or line up a panel and
include yourself as one of the panel members. Don’t be promotional.
4) Amend the poster on the HUGS website with your local contact info/info on
your event, photocopy on colored paper and post everywhere, (post office,
library, health centers, restaurants, MacDonalds, grocery stores, hairdresser,
fitness places). If possible, form a small committee and get others to help you
out. Let others help you spread the word.
5) Amend the press release on the HUGS website to your event and get it out
during the last week before the event, leaving your contact information for
possible interviews. Send to newspapers, radio stations, TV stations. Always
follow up.
Details of these steps can be found at HUGS.com
©2010, Nutrition Dimension/Gannett Education, Inc.
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Appendix #1
122
Medical & Empowerment Models
©2010, Nutrition Dimension/Gannett Education, Inc.
Medical Model
Empowerment, Facilitative Model
Expectation - compliance
Counseling Question - "Are you watching fats in foods?"
Message - Client needs to comply to 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 & cleaning your plate..."
Message - Client becomes more aware of why he/she is eating;
feels 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 Suggestions - What do you think is causing your frustrations; how can you prevent these situations?
Message - Client has choices & inner desires that can be expressed.
Issues of confrontation, acceptance of things beyond personal control, & making time for self will be explored jointly.
Result - daily management
Counseling Questions - Are you measuring your pasta
& 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 & other needs? This technique is your key to
nurturing yourself. Often our body is disconnected from our mind, if
we are not in touch w/feelings. New ways of doing things takes time.
Message - Capacity to balance life is w/in client’s 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 weight gain? What did you do differently?
Message - Client learns that setbacks are part of growth process.
Effect - Immediacy
Counseling Statement - Let's weigh you & 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 meal w/out overeating.
This is success for client who used to starve & 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 & will advise you accordingly.
Responsibility - Individual in charge
Counseling Suggestion - What steps will you take as result of our
discussion? What will you be doing differently over the next month?
Message - As health professional I trust you to do the best you can
w/ the knowledge you've gained from our discussions.
Info dissemination - filtered by health professional's
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. Client could continue
to suppress his/her feelings w/food or address causes w/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 weight after 2 months on the diet.
Message - You failed.
Success - feeling better - improved well-being
Counseling Suggestion - You're doing more fun things & 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 & improve
your perspective & overall health.
Omichinski, 1995
Appendix #2
123
Case Study #1
Sally accepts consequences of past dieting as she sets new goals for her future health.
Background — Sally went on a quick weight loss program, lost 80 lb. She eventually stopped dieting & started to
gain weight back. Now she was at a decision point. She wanted two things — to follow a nondiet program emphasizing healthier living; & to avoid gaining back any more weight. Yet, the very consequences of dieting might interfere w/
her desire to stop weight gain. Change in composition occurs w/dieting where along w/fat loss, there is loss of water
& muscle mass. The effect is lowered metabolism. So, Sally could choose to start vicious diet cycle again w/predictable
effect of weight gain plus some or she could choose nondiet approach to health w/out any focus on weight issues.
When Sally is equipped w/knowledge about how her body will react to either choice, she is empowered to take
responsibility for her past actions & her own health. She can choose health goals over weight loss/gain goals. The key
here for health professionals is parameter of models for counseling.
In medical (diet) model, client & health professional view weight gain as failure, non-compliance & reason to give
up. In empowerment model, health professional facilitator guides client through self-discovery so client concludes
diets don't work & is empowered to focus on improved well-being, not weight loss.
Facilitator's role as enabler makes Sally aware of 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 & external goals are no longer the
endpoint. Sally studies process of identifying factors that will allow to improve quality of life. She discovers her own
patterns for food & activity levels that keep her energized. She learns to let go of the constant preoccupation with food
& weight. She begins to listen to her body for signals of hunger, fullness. Facilitator recognizes that this process makes
an impact on Sally's life that is more likely to have long-term effect. Sally no longer needs people to police progress w/
daily management of eating or life.
Contrast these positive results w/experiences most health professionals have w/diet treatment. Perhaps we recommend exercise for 1/2 hour - 3 times/week, using prescribed exercise plan. Or prescribe specific individualized regimen
or meal plan for those who will attempt to follow it to seek our approval. We retain control w/this method, doing what
we feel is best for individual. If they don't comply or adhere to plan w/implied limitations, its “should's & shouldn'ts,”
we feel we failed, that client doesn’t have enough willpower.
This new role for facilitator is often uncomfortable. Traditionally, she might have been used to didactic approach
of telling Sally what she should do.
With practice, empowerment approach is reinforced through satisfying experiences.
©2010, Nutrition Dimension/Gannett Education, Inc.
Case Study #2
Hazel started to sort out lifestyle situations that were affecting her enjoyment of food.
Hazel is a 43 year old woman w/arthritis. Her doctor suggests that she decrease weight to ease discomfort. I asked
Hazel about her weight history. She felt that genetically her body weight was large. Previous attempts to cut back on
kcal resulted in no weight loss. Hazel was 114-120 lb when she got married. Six children later, she is 215.
I built an expanded profile on Hazel w/further discussion using open ended questions...
• ate under stress
• ate more since didn't taste food due to guilt feelings.
• craved sweets
• frequently didn't taste food
• perfectionist tendencies
• got too hungry before eating therefore ate quickly
• “all or nothing” diet mentality
• came to table too hungry
• ate for psychological hunger
• habit of cleaning plate
• ate automatically to suppress feelings
• overate because she likes food
• felt guilty when eating sweets
• spent little time on self; resentment & frustration built up. Hours spent on renovating daughter’s room created a
lot of frustration for Hazel — her 18-yr old leaves room messy.
Hazel had tangled her emotional needs into her physical hunger needs & needed help to establish new patterns
for energizing healthy routines.
The client w/this type of profile is very suited to empowerment approach to health.
If Hazel had been put through traditional diet w/expectation of weight loss, only one type of result is measurable.
If she didn't lose weight, outcome of diet/lifestyle counseling would be failure.
Omichinski, 1995
Appendix #3
124
The Big Decision
THE BIG JUMP
THE SMOOTH SLIDE
First action
on decision
Brace yourself! Quickly eat all of your favorite foods
because they won't be part of your diet tomorrow.
Look at yourself & feel good about you!
Feel good that you have made decision to start making slow changes that will reflect healthier lifestyle.
1st shopping trip for
healthy food
Stock up on foods that are "light", "low-fat", and/
or "diet" on labels regardless of whether you enjoy
them. Your family likes whole milk but now that
you've made the decision to "eat healthy", you buy
skim milk.
Stock up on wide variety of foods you & your family
enjoy, paying more attention to moving towards
more CHO foods & less protein. Buy herbs to
highlight flavors of foods. Your family likes whole
milk, now you buy some 2% milk & plan to serve it
to your family. If they don't like it at first, mix it w/
whole milk, until they prefer lighter mouthfeel.
Feelings of
cook after
1 week
Frustrated & overwhelmed. Food is drier than the
family enjoys. Still has strong resolve to keep this
up, even if rest of family isn't as enthusiastic.
Encouraged by how easy it has been to make small
changes to foods, cooking techniques & CHO/protein balance that they already enjoy. Surprised family
hasn't even noticed changes. Notices that foods have
nicer color & texture w/all the taste they had before.
Reaction of
family after
1 week
Concerned that food will never be "tasty" anymore.
Tired of the new chewier, drier tastes & textures of
new foods. Longing for last weeks menu. Quite agile
at slipping food to grateful canine under table. Wishing that budget allowed more “order in” or “eat out”
foods for next week. Snacking & eating away from
home as much as possible.
Surprised that even though decision to "go healthy"
was made, they still get to eat foods they love!
Notice foods they love have more color & as much,
if not more flavor than before. Feel more energized
after eatting rather than tired & overfull.
Almost ready to give up because no one (including
cook) is enjoying food that is prepared. Disappointed
& feeling deprived. Misses cooking & eating all food
they used to eat. Wishes cooking wouldn't be such
an overwhelming chore. Sneaking "favorites" more &
more.
Excited that process is still so enjoyable; not thinking
about quitting; having more & more fun experimenting w/old & new recipes; pleased w/results, flavors,
textures.
Ready to move to neighbors during meal time.
Wishes "health kick" would stop kicking. Eating out
or ordering in as much as possible & when eating
foods they enjoy, eat lots. Snacking & sneaking
foods they love on a more & more frequent basis.
Still enjoying food that is on table. Asking for certain
favorites often, "When are you going to make that
great bread again?" Noticing they aren't hungry
between meals as often.
Disillusioned w/"health movement". Feeling disappointed & guilty, they give up and return to the old
ways of eating & cooking. Some of the family only
feels "joy" because they finally get to eat what they
love!
Feel good about themselves & new ways of eating
& preparing foods. Energized by successes, whole
family wants to keep moving on smooth slide toward
healthier eating. As an experiment, try some old
ways of cooking & eating. Surprised & pleased to
find they actually like new ways better. Prefer new
flavors, textures, tastes & don't want to go back.
©2010, Nutrition Dimension/Gannett Education, Inc.
Feelings of
cook at 1
month
Reactions
of family at
1 month
Situation at
3 months
Appendix #4
125
Recipe Modification — Marble Cheesecake
Original Recipe
1 cup (250 ml)
3 tbsp (45 ml)
3 tbsp (45 ml)
3 cups (750 ml)
3/4 cup (175 ml)
1 tsp (5 ml)
3
1 oz (30 gm)
graham cracker crumbs
sugar
butter or margarine, melted
cream cheese, softened
sugar
lemon or vanilla extract
eggs
square unsweetened chocolate
Yields 1—9 inch (23 cm) springform pan
1. Combine graham crumbs, 3 tbsp (45 ml) sugar, & butter in bowl. Press mixture to
bottom of 9-in (23 cm) springform pan.
2. Bake at 350°F (180°C) for 10 minutes. Remove from oven & cool.
3. Combine cream cheese, remaining sugar, & vanilla in mixing bowl. Mix at medium
speed until well blended.
4. Add eggs, one at a time, mixing well after each addition. Once all eggs are added,
whip until light & fluffy.
5. Melt chocolate. Add to 1 cup (250 ml) of cream cheese/egg batter in a separate
bowl. Blend together. This is the chocolate batter.
6. Spoon plain batter & chocolate batter alternately over crust. Cut through batters w/
knife several times to create marbled effect.
7. Bake at 450°F (230°C) for 10 min, then reduce oven temp to 250°F (120°C) & continue baking for 30-40 min or until done (cake no longer jiggles & feels somewhat
firm when touched).
8. Loosen cake from rim of pan as soon as it is out of oven; cool before removing rim.
9. Chill before serving.
Variation #2
1 cup (250 ml)
graham cracker crumbs
omit sugar
2 tbsp (30 ml)
butter or margarine, melted
3 cups (750 ml)
quark cheese
3
eggs, separated
3/4 cup (175 ml)
sugar
1 tsp (5 ml)
lemon or vanilla extract
3 tbsp (45 gm)
unsweetened cocoa powder
fresh or cooked fruit topping for garnish
©2010, Nutrition Dimension/Gannett Education, Inc.
1. Prepare crust as per original recipe; omit sugar.
2. Put quark cheese in mixing bowl & whip until light and fluffy. Add egg yolks, one
at a time, mixing well after each addition. Add sugar & lemon extract gradually to
mixture, beating until well mixed & light & fluffy.
3. Remove 1 cup (250 ml) of cheese mixture & place in separate bowl. Stir in cocoa
until well blended.
4. In a clean bowl, beat egg whites until stiff. Fold into plain (not chocolate) cheese
batter. Place in pan as per original recipe. Bake at 300°F (150°C) for 1-1/4 to 1-1/2
hours or until browned on top & toothpick comes out clean. When completely
cool, remove springform pan outside ring & serve with topping. Do not loosen rim
before cooling.
Notes
• The graham crumbs have their own sweet flavor. The decrease in sugar in crust is
not noticeable.
• Quark cheese has a similar texture & flavor to cream cheese, is lower in fat, &
slightly higher in protein.
• As fat is decreased, this cheesecake requires a longer baking time to set.
• Separating eggs & beating whites gives recipe lighter, fluffier texture w/greater moisture compensating for decreased fat. Chocolate will become a layer at bottom.
Variation #1
1 cup (250 ml)
2 tbsp (30 ml)
2 tbsp (30 ml)
3 cups (750 ml)
3/4 cup (175 ml)
1 tsp (5 ml)
3
1 oz (30 gm)
graham cracker crumbs
sugar
butter or margarine, melted
light cream cheese, softened
sugar
lemon or vanilla extract
eggs
square unsweetened chocolate
1. Prepare crust as per original recipe.
2. Continue to prepare as per original recipe. When mixing cream cheese and egg,
make sure to whip mixture until light & fluffy.
3. When baking cheesecake, place a pan of water in oven beside or under the cake.
This increases moisture & prevents cheesecake top from cracking during baking.
4. Bake at 450°F (230°C) for 10 min, then reduce oven temp to 250°F (120°C) & continue baking for 50-60 min. Cooking time seems to increase slightly as fat content
decreases. Serve as per original recipe.
Notes
• The graham crumbs have their own sweet flavor. The decrease in sugar in crust is
not noticeable
• The crust stuck together well even with decreased butter.
• Light cream cheese has less fat than regular cream cheese, with the same flavor and
texture.
• As fat decreases, this cheese cake requires a longer baking time to set.
Variation #3
1 cup (250 ml)
graham cracker crumbs
2 tbsp (30 ml)
butter or margarine, melted
3 cups (750 ml)
1% cottage cheese, pureed
3
eggs, separated
1/2 cup (125 ml)
sugar
1 tsp (5 ml)
lemon or vanilla extract
3 tbsp (45 ml)
unsweetened cocoa powder
fresh or cooked fruit topping for garnish
1. Prepare crust as per Variation #2.
2. Beat pureed cottage cheese until light & fluffy.
3. Continue, bake, refrigerate cheesecake until firm.
Notes
• Pureed cottage cheese has a similar texture & flavor to sour cream. Adding it to
this recipe increases protein & decreases fat content. Cottage cheese has more
moisture than quark cheese & may require a longer baking time.
• This variation has a fluffy souffle-like texture.
• You may substitute skim milk quark cheese for pureed cottage cheese in this variation. Skim milk quark cheese is lower in fat & higher in protein than cream cheese
(Variation #1), & is lower in fat than regular quark cheese (Variation #2). Overall
texture of cheesecake is lighter.
Tips: will help you make choices & add variety to your meals.
• You may not be familiar with quark cheese. It is a soft, sharper tasting cheese that has a slightly thinner consistency than
cream cheese. It is lower in fat & slightly higher in protein content than sour cream & cream cheese. In recipes for these
products, it is a tasty substitute. Some stores will offer skim milk or low-fat quark cheese which has a fat content similar to
1% cottage cheese. Neufchatel cheese may be substituted for quark cheese.
• Skyr cheese is lower in fat content than quark cheese but higher in fat than 1% cottage cheese. It is slightly more liquid than
quark cheese but otherwise has similar qualities.
• For a more gradual transition from Variation #2 to Variation #3, try using half quark cheese & half skyr cheese. Be sure to
adjust the cooking time to 1-3/4 hours due to higher moisture content of skyr cheese.
• Chocolate squares are high in saturated fat. 1 oz (30 gm) of unsweetened chocolate can be replaced w/3 tbsp (45 ml) of cocoa
in any recipe calling for unsweetened chocolate baking squares. Chocolate is still a rich dark color & flavor.
• Separating eggs yolks & whites can give a dessert or cake added volume while decreasing fat. Beat egg whites until they are
fluffy & fold them into cakes or desserts at end of mixing process. Result is a dessert w/lighter, fluffier & moister texture.
Omichinski & Hildebrand, 1995
Appendix #5
126
Fluids & Their Functions
Type of Beverage
Rehydration
Quenches thirst
Coffee/Tea
No, they are diuretics
Yes
Coffee & tea cause blood vessels to dilate as result of xanthine content. Although caffeine is strongest stimulant in coffee, tea, cocoa, these drinks also contain other related
xanthine compounds such as theophylline and theobromine that have similar effects.
Caffeine is main xanthine in coffee, but theophylline predominates in tea; cocoa contains
large amounts of theobromine. These chemicals contribute significantly to stimulant effects of tea & cocoa.
Decaffeinated coffee
No, it's a diuretic
Yes
Note that decaffeinated coffee still contains 2 other stimulants called theophylline &
theobromine. Cutting out coffee & tea can cause caffeine withdrawal symptoms such as
headaches, so taper off coffee & tea consumption gradually. Switching from coffee to tea
can lead to a gradual decrease in caffeine content. 5 oz (150 ml) of strong tea brewed for
5 min contains 45 mg caffeine while 5 oz (150 ml) of percolated coffee contains 110 mg
caffeine. Use substitution of tea for coffee only if you enjoy taste of tea; otherwise, you
may feel psychologically deprived by using what you would classify an inferior substitute.
Milk
Soft drinks
No, net effect is dehydration due to high calcium &
protein content
Partially
Yes
No, due to high sugar
©2010, Nutrition Dimension/Gannett Education, Inc.
Diet drinks
Yes
Somewhat
These drinks are artificially sweetened & have sweet taste. Substituting these for regular
drinks doesn’t allow you to acquire a taste for less sweet foods. Increased consumption
of artificially sweetened products has not decreased society’s craving for sweets or incidence of obesity. However, diet drinks do have their place. If you particularly like certain
diet drinks, try adding water to them. Gradually increase amount of water added. This
will allow you to achieve goal of learning to acquire taste for less sweet foods.
Juices
Partially
No, high concentration
of natural sugar, makes
you more thirsty
Usually drinking pop or juices leaves you w/feeling of wanting more.
Alcohol
No
No
Even though alcoholic beverages aren’t diuretics, they do have diuretic effect in that they
increase urine production. Alcohol inhibits secretion of antidiuretic hormone. During an
alcoholic bout, lack of this hormone combined w/dilating of vessels of kidney add to this
effect. Diuretic effect of alcoholic beverages can cause state of dehydration commonly
known as hangover.
Omichinski, 1993a
Appendix #6
127
Hidden Sugars & Caffeine
All These Words mean “sugar”
Brown sugar
Carbohydrate
Corn sugar
Corn syrup
Dextrin
Dextrose
Fructose
Glucose
Honey
Invert sugar
Lactose
Levulose
Maltose
Mannitol
Maple syrup
Molasses
Sorbitol
Sorghum
Starch
Sucrose
Sugar
A soft sugar whose crystals are covered by a film of refined dark syrup.
Sugars and starches.
Sugar made by the breakdown of cornstarch.
A syrup containing several different sugars that are obtained by the partial breakdown of corn starch.
A sugar formed by the partial breakdown of starch.
Another name for sugar.
The sweet sugar found in fruit, juices, and honey.
The type of simple sugar found in the blood, formed from food & used by body for
heat & energy.
A sweet, thick material made in honey sac of various bees; sweeter than sugar.
A combination of sugars found in fruits.
The sugar found in milk.
Another name for fruit sugar.
A crystalline sugar formed by the breakdown of starch.
A sugar alcohol.
A syrup made by concentrating the sap of sugar maple.
The thick, dark to light brown syrup that is separated from raw sugar in sugar manufacture.
A sugar alcohol.
Syrup from the juice of the sorghum grain (sorgo) grown mainly for its sweet juice.
A powdery complex sugar (CHO), i.e. cornstarch.
Another name for sugar.
A sweet carbohydrate.
©2010, Nutrition Dimension/Gannett Education, Inc.
Caffeine Content of Foods
Source
Amount
Caffeine
Brewed coffee
Instant coffee
Decaffeinated coffee
Tea (5-min brew)
Tea (1-min brew)
Colas
Chocolate milk
Hot cocoa from mix
Milk chocolate
Dark chocolate
Baker's chocolate
6 oz (175 ml)
6 oz (175 ml)
6 oz (175 ml)
6 oz (175 ml)
6 oz (175 ml)
10 oz (300 ml)
8 oz (250 ml)
6 oz (175 ml)
1 oz (28 gm)
6 oz (175 gm)
1 oz (28 gm)
66-180 mg
60-100 mg
2-5 mg
40-100 mg
20-45 mg
22-50 mg
2-7 mg
6-30 mg
1-15 mg
5-35 mg
26 mg
Omichinski, 1993a
Appendix #7
128
Energy Expenditure for Various Activities
(in calories per minute)
©2010, Nutrition Dimension/Gannett Education, Inc.
Activity
Kg
Lb
Archery
Badminton
Baseball
Basketball
recreational
competition
Calesthenics (light)
Canoeing
2.5 mph 24 min./mile
4.0 mph 15 min./mile
Cycling
5 mph 12 min./mile
10 mph 6 min./mile
15 mph 4 min./mile
20 mph 3 min./mile
Dancing
active (square, disco)
Aerobic (vigorous)
Fencing (moderate)
Football (moderate)
Golf
Foursome (carry clubs)
Power cart
Handball (moderate)
Hiking, pack (3 mph)
Hockey, field
Hockey, ice
Horseback riding (trot)
Horseback riding (gallop)
Jogging (see running)
Judo
Karate
Mountain climbing
Paddleball
Racquetball
Roller skating (9 mph)
55
120
59
130
64
140
68
150
77
170
82
180
86
190
91
200
95
210
3.8
4.4
3.8
4.1
4.7
4.1
4.5
5.1
4.4
4.8
5.4
4.7
5.4
6.2
5.3
5.7
6.6
5.6
6.0
6.9
5.9
6.4
7.3
6.3
6.7
7.6
6.6
6.0
7.8
4.1
6.5
8.5
4.5
7.0
9.2
4.8
7.5
9.9
5.2
8.5
11.2
5.9
9.0
11.9
6.3
9.5
12.5
6.6
10.0
13.2
7.0
10.5
13.8
7.3
2.3
5.3
2.5
5.8
2.7
6.2
2.9
6.7
3.3
7.6
3.5
8.0
3.7
8.5
3.9
8.9
4.1
9.4
2.3
5.1
8.7
12.8
2.5
5.5
9.5
13.9
2.7
5.9
10.0
14.9
2.9
6.4
10.9
16.0
3.3
7.2
12.4
18.1
3.5
7.6
13.1
19.2
3.7
8.1
13.8
20.3
3.9
8.5
14.5
21.3
4.1
8.9
15.3
22.4
5.4
7.3
4.0
4.0
5.9
7.9
4.3
4.3
6.3
8.5
4.6
4.6
6.8
9.1
5.0
5.0
7.7
10.3
5.7
5.7
8.2
10.9
6.0
6.0
8.6
11.5
6.3
6.3
9.1
12.1
6.7
6.7
9.5
12.7
7.0
7.0
3.3
2.3
7.8
5.4
7.3
8.0
5.1
6.9
3.5
2.5
8.5
5.9
7.9
8.7
5.5
7.5
3.8
2.7
9.2
6.3
8.5
9.4
5.9
8.1
4.1
2.9
9.9
6.8
9.1
10.0
6.4
8.7
4.6
3.3
11.2
7.7
10.3
11.4
7.2
9.8
4.9
3.5
11.9
8.2
10.9
12.1
7.6
10.4
5.2
3.7
12.5
8.6
11.5
12.7
8.1
11.0
5.4
3.9
13.2
9.1
12.3
13.4
8.5
11.6
5.7
4.1
13.8
9.5
12.7
14.1
8.9
12.2
10.2
10.2
7.8
6.9
7.8
5.1
11.0
11.0
8.5
7.5
8.4
5.5
11.9
11.9
9.2
8.1
9.1
5.9
12.8
12.8
9.8
8.7
9.8
6.4
14.5
14.5
11.2
9.8
11.1
7.2
15.4
15.4
11.8
10.4
11.7
7.6
16.2
16.2
12.5
11.0
12.4
8.1
17.1
17.1
13.1
11.6
13.0
8.5
17.9
17.9
13.8
12.2
13.7
8.9
Adapted from Melvin Williams, Nutrition in Sport (4th ed), WM C Brown, 1995.
Appendix #7 cont.
129
Energy Expenditure (kcal/min)
Kg
Lb
55
120
59
130
64
140
68
150
77
170
82
180
86
190
91
200
95
210
Running (steady state)
5 mph, 12 min./mile
7 mph, 8.35 min./mile
9 mph, 6.40 min./mile
11 mph, 5.28 min./mile
7.3
10.2
12.9
16.0
7.9
11.0
14.0
17.3
8.5
11.9
15.1
18.7
9.1
12.8
16.2
20.0
10.3
14.5
18.4
22.7
10.9
15.4
19.5
24.1
11.6
16.2
20.6
25.4
12.2
17.1
21.7
26.8
12.8
17.9
22.8
28.1
Sailing (small boat)
Skating, ice (9 mph)
3.3
5.1
3.5
5.5
3.8
5.9
4.1
6.4
4.6
7.2
4.9
7.6
5.2
8.1
5.4
8.5
5.7
8.9
Skiing, cross country
2.5 mph, 24 min./mile
4.0 mph, 15 min./mile
6.0
7.8
6.5
8.5
7.0
9.2
7.5
9.9
8.5
11.2
9.0
11.9
9.5
12.5
10.0
13.2
10.6
13.8
Skiing, downhill
Soccer
Squash (normal)
7.8
7.2
8.0
8.5
7.8
8.7
9.2
8.4
9.5
9.9
9.0
10.1
11.2
10.2
11.5
11.9
10.8
12.2
12.5
11.4
12.9
13.2
12.0
13.5
13.8
12.6
14.2
Swimming
back stroke (30 yds/min)
back stroke (40 yds/min)
breaststroke (30 yds/min)
breaststroke (40 yds/min)
front crawl (35 yds/min)
front crawl (50 yds/min)
4.2
6.6
5.7
7.6
5.9
8.5
4.6
7.2
6.2
8.3
6.4
9.2
4.9
7.8
6.7
8.9
6.8
9.9
5.3
8.3
7.1
9.6
7.3
10.6
6.0
9.4
8.1
10.9
8.3
12.0
6.4
10.0
8.6
11.5
8.8
12.8
6.7
10.6
9.1
12.2
9.2
13.5
7.1
11.1
9.5
12.8
9.7
14.2
7.4
11.7
10.0
13.5
10.2
14.9
Table Tennis
Tennis (sngls, recreational)
Tennis (dbls, recreational)
4.1
6.0
4.1
4.5
6.5
4.5
4.8
7.0
4.8
5.2
7.5
5.2
5.9
8.5
5.9
6.3
9.0
6.3
6.6
9.5
6.6
7.0
10.0
7.0
7.3
10.6
7.3
Volleyball (recreational)
Volleyball (competition)
3.5
7.8
3.8
8.4
4.1
9.1
4.4
9.8
5.0
11.1
5.3
11.7
5.6
12.4
5.9
13.0
6.1
13.7
Walking
2 mph, 30 min./mile
3 mph, 20 min./mile
3.5 mph, 17.1 min./mile
4 mph, 15 min./mile
4.5 mph, 13.2 min./mile
5 mph, 12 min./mile
2.5
3.3
4.0
5.1
5.7
6.5
2.8
3.5
4.4
5.5
6.2
7.1
3.0
3.8
4.7
5.9
6.7
7.7
3.2
4.1
5.1
6.4
7.1
8.2
3.6
4.6
5.8
7.2
8.1
9.2
3.9
4.9
6.2
7.6
8.6
9.8
4.1
5.2
6.5
8.1
9.1
10.4
4.3
5.4
6.9
8.5
9.5
10.9
4.5
5.7
7.2
8.9
10.0
11.5
6.0
6.2
10.2
6.5
6.8
11.0
7.0
7.3
11.9
7.5
7.8
12.8
8.5
8.9
14.5
9.0
9.4
15.4
9.5
9.9
16.2
10.0
10.5
17.0
10.6
11.0
17.9
©2010, Nutrition Dimension/Gannett Education, Inc.
Activity
Water skiing
Weight training
Wrestling
Adapted from Melvin Williams, Nutrition in Sport (4th ed), WM C Brown, 1995.
Appendix #8
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©2010, Nutrition Dimension/Gannett Education, Inc.
Relaxation Scripts
Deep Breathing Technique
Progressive Relaxation
Discuss the technique of deep breathing as a method of putting the pause into your lifestyle and as a relaxation technique.
Method: Demonstrate using soft music in the background if
possible. Discuss proper method of breathing.
Rationale: To allow participants to acquire another skill that
they can use when feeling anxious or tense using the right
technique of deep breathing.
Proper technique: Note that as you inhale slowly and steadily,
expand your abdominal area rather than the rib cage.
Many people do this incorrectly by sucking in their stomach
when they breathe in. Exhale slowly, allowing the abdominal
area to contract naturally. Although difficult to learn initially,
this technique can be very effective. It occurs naturally as you
begin to fall asleep — observe.
The purpose of the following technique is to achieve complete
relaxation all through the body by relaxing groups of muscles
in sequence. Start with the facial muscles, then work down
to your feet and toes. The technique is to tense each group of
muscles as you identify them. The tension should be coordinated with your feeling (tension phase = inhalation phase).
Keep your eyes closed and imagine yourself relaxing (visualization).
Note that the inhalation phase is the invigorating phase,
the tension-producing phase. It is important in reversing
the relaxed state and is used to come out of the relaxed
state.
• When ready to terminate an exercise a deep breath or
two will create tension and help bring you back to your
normal level of alertness — used somewhat like a yawn.
• Usually combined with flexing and stretching of
muscles (i.e. much like one does when awakening from a
state of sleep).
Exhalation phase: relaxation phase.
• A feeling of "sinking down", slowing down, heaviness, a
feeling of "relaxation" is felt.
• These sensations listed coupled with the exhalation
phase of the breathing cycle carries you into a deep state
of relaxation. The focus is on this phase to achieve a feeling of relaxation.
The purpose of progressive relaxation technique is to
achieve complete relaxation all through the body by relaxing groups of muscles in sequence. Start with the toes,
and then work up to the facial muscles so that your mind
is alert and you experience the state of relaxation more
readily. As you identify each group of muscles, tense
them. Coordinate the tension with your breathing. Keep
your eyes closed and imagine yourself relaxing.
1. Close your eyes and breathe slowly and deeply.
2. Inhale. Raise eyebrows. Tense them. Hold for count of 3.
Relax eyebrows. Exhale.
3. Inhale. Close mouth and eyes tightly. Squeeze. Hold for
count of 3. Relax eyes and mouth. Exhale.
4. Inhale. Bite down on teeth. Hold for count of 3. Relax jaw.
Exhale.
5. Inhale. Pull shoulders up. Hold for count of 3. Relax shoulders. Exhale.
6. Inhale. Tense all muscles in arms. Hold for count of 3.
Relax arms. Exhale.
7. Inhale. Tense all muscles in chest & abdomen. Hold for
count of 3. Relax muscles. Exhale.
8. Inhale. Tense all muscles in legs. Hold for count of 3. Relax
legs. Exhale.
9. Inhale. Tense all muscles in toes. Curl toes. Hold for count
of 3. Relax muscles. Exhale.
10. Keep your eyes closed for a short while. Gradually open
them.
1. Close your eyes and breathe slowly and deeply.
2. Inhale. Tense all muscles in toes. Curl toes. Hold for
count of 3. Relax muscles. Exhale.
3. Inhale. Tense all muscles in legs. Hold for count of 3.
Relax legs. Exhale.
4. Inhale. Tense all muscles in chest & abdomen. Hold for
count of 3. Relax muscles. Exhale.
5. Inhale. Tense all muscles in arms. Hold for count of 3.
Relax arms. Exhale.
6. Inhale. Pull shoulders up. Hold for count of 3. Relax
shoulders. Exhale.
7. Inhale. Bite down on teeth. Hold for count of 3. Relax
jaw. Exhale.
8. Inhale. Close mouth and eyes tightly. Squeeze. Hold for
count of 3. Relax eyes and mouth. Exhale.
9. Inhale. Raise eyebrows. Tense them. Hold for count of
3. Relax eyebrows. Exhale.
10. Keep your eyes closed for a short while. Gradually
open them.
Omichinski, 1992
Appendix #9
131
©2010, Nutrition Dimension/Gannett Education, Inc.
Using Nondiet Approach in Diabetes Treatment
Concept
Why
Contrast With
Regular eating including snacks according to physical hunger
Overeating is less likely to occur,
therefore pancreas is less stressed
due to decreased sugar load at any
one meal.
Eating according to diet sheet
Carb./pro. balance as nondiet nutrition concepts: visual aid of 2/3 - 3/4
carb & 1/3 - 1/4 pro – gradual shift
in balance
Protein slows down release of sugar (from carb) into bloodstream,
aiding in stabilizing blood sugar
as well as longer satiety value. In
addition, protein is distributed to
all meals instead of high protein
load at evening meal. Lower protein
also poses less stress on kidney
(kidney disease is a complication
of diabetes).
Calculating exchanges or counting carbos robbing enjoyment of
food & resulting in preoccupation
around food.
Tune into taste & texture by gradually
increasing fiber content of meals
Allows tastes to change gradually
& body to adjust to different foods.
Sudden increase in fiber, person
feels bloated & constipated & says
it is not for them then drops fiber.
Eat when hungry, stop when full
Internal regulator of portion control, listen to body, taking care of
bodys needs.
Portion control according to exchanges & diet
Tailor your Tastes for gradual approach in change of tastes
Small changes allow one to change
taste resulting in eating healthier
by preference rather than because
one “should”
Eat low fat. low sugar & high fiber
resulting in drastic changes in way
of eating likely to be abandoned
early as tastes don’t change. Diet
temporarily changes because one
feels one should eat this way.
Build activity into one’s lifestyle.
So it becomes integrated into a
person’s lifestyle. Encouraging
research indicates physical training, even w/out weight loss, seems
to increase body’s sensitivity to
insulin, making available insulin
work better.
Do a certain amount of exercise
daily. It becomes an “add on” that
one may never get to.
... continues on following page
Appendix #9 (cont)
132
©2010, Nutrition Dimension/Gannett Education, Inc.
Using Nondiet Approach in Diabetes Treatment
Concept
Use blood glucose monitor as way
of testing how foods affect blood
sugar (i.e. try eating fruit in middle of
afternoon & test your blood sugar a
couple hours later). For many people
w/diabetes, this type of food has a
great effect on blood sugar. If this is
the case, try adding a little protein like
small amount of cheese w/fruit or a
more complex carbo. that releases
sugar more slowly such as a whole
grain bun. When Ann tried this, she
discovered that w/fasting blood sugar
of 6 (110), her blood sugar increased
to 12 (215) or 13 (235) when she ate
a fruit in the middle of the afternoon.
She tried adding a small piece of
cheese and her blood sugar only
increased to 8 (145) or 9 (165).
Why
This way one can test concepts
& learn to work diabetes & foods
into daily way of life
Contrast With
Take your blood sugar every day
or several times/day & record it.
This method doesn’t allow you
to determine how food & activity
affect your blood sugar.
Add water to unsweetened juices
(which contain natural sugar) and/
or have them at end of a meal
Adding water to juices which are
naturally highly sweetened allows
you to begin to appreciate tastes
that are less sweet tasting and will
quench your taste better. Having
them at end of meal means there
is food in your stomach so it will
take longer for sugar to get into
your bloodstream.
Make small changes gradually &
accept where weight stabilizes.
Due to genetic predisposition or
history of chronic dieting, weight
may not change much even though
lifestyle changes are made. Even
a small amount of weight loss, as
little as 5-10 lb, results in improved
glycemic values. By losing even a
modest amount of weight (as little
as 10 lb), these patients may lower
their insulin resistance to point
where the insulin the pancreases
produces is sufficient to keep blood
sugars down. (reference 18 & 19,
21 chapter 1 of YCCD). Even if
weight is not lost, in many cases
blood glucose improves w/a nondieting lifestyle as demonstrated
by some examples in Chapter 11.
Drink diet drinks & diet juices.
This will still cause individual to
have cravings for sugar as they
still like sweet tasting foods. Diet
drinks have their place in eating
pattern of a person w/diabetes,
but relying on them by switching
from regular to diet food or drinks
does not allow one to enjoy foods
lower in sugar, true measure of
permanent change.
Losing weight to reach ideal body
weight or BMI (body mass index)
being main focus where individuals lose weight by following a rigid
diabetic diet only to go off diet
once weight is lost & inevitably
regain weight.
Linda Omichinski, RD, HUGS, International, Inc. Tailoring Your Tastes Workshop Tour.
Examination
133
LWM10
©2010, Nutrition Dimension/Gannett Education, Inc.
Answer each question by checking the correct answer online or filling the circle corresponding to the correct answer on the answer sheet. There is one best answer for each question. If you want a record of your
answers, photocopy the answer sheet or record your choices on another piece of paper. Do not detach the
examination from the book. This exam has 40 questions.
1.
Weight loss may continue to be recommended because:
a. even short-term weight-loss is beneficial
b. we can show that dieting has long-term benefits
c. some health professionals believe that weight loss is necessary to reduce one’s health risk
d. there is a positive proportion of benefits to harms for dieting
e. self-discipline is necessary in life
2.
An empowerment approach:
a. views the professional as a facilitator
b. redirects expertise and education to alternative goals
c. allows clients to take ownership of the process and goals
d. all of the above
e. none of the above
3.
Children receive nondiet messages when:
a. they are asked to clean their plate
b. they are rewarded for good behavior
c. they are allowed to honor their internal signals of appetite and satiety
d. all of the above
e. none of the above
4.
Nondiet nutrition concepts include:
a. portion control through weighing and measuring
b. teaching the client how to ignore or mask their hunger
c. lists of foods allowed/not allowed
d. none of the above
e. all of the above
5.
Cutting back on carbohydrates:
a. produces long-term weight loss
b. results in cravings for sweets
c. is best done by ensuring that protein makes up at least 1/2 of the meal
d. can harm the kidneys
e. is recommended in the nondiet approach
6.
Higher-fiber foods are recommended in the nondiet approach because:
a. they fill you up quickly with fewer calories
b. they provide a variety of flavors and textures
c. the water-insoluble fiber helps keep cholesterol levels down
d. they prevent constipation
e. they are higher on the glycemic index
Exam, cont.
7.
A focus on sustained energy and satiety allows clients to:
a. go hungry to lose weight
b. eat as much as they want at meals and snacks
c. experience hunger as a negative feeling
d. depend on an eating plan to tell them how much to eat
e. use vitamin-mineral supplements to ensure proper nutrition
8.
Clients using the nondiet approach generally eat less because:
a. they “should”
b. they feel guilty if they don’t
c. the food is less appealing d. they learn to exercise more efficiently
e. none of the above
9.
The nondiet approach to fitness includes:
a. balancing energy consumed with energy expended
b. a requirement that activity be conducted regularly or else there is no point in doing it at all
c. insistence that exercisers always achieve maximum heart rate
d. a dependence on fitness classes for structure
e. promotion of active living that is self-paced
10. The nondiet approach employs the three “P”s to long-term success:
a. perspective, priority and perseverance
b. patience, passiveness and penalties
c. perspective, perfectionism and penitence d. pasta, pastry and potatoes
e. none of the above
11. Dieting includes:
a. choosing foods based on how many grams of fat they contain
b. counting food group exchanges
c. deliberate alteration of food intake to lose weight
d. denial of hunger signals
e. all of the above
©2010, Nutrition Dimension/Gannett Education, Inc.
134
12. Restrained eating results in:
a. the ability to control oneself at all times
b. increased risk for eating disorders
c. women being able to conform to society’s expectations for thinness
d. increased self-efficacy and intellectual well-being
e. none of the above
LWM10
Exam, cont.
13. Disordered eating patterns can result from:
a. weight loss dieting
b. underlying psychological problems
c. pressure to be thin d. all of the above
e. none of the above
14. Body types:
a. are inherited
b. can be changed through a healthy lifestyle
c. include the “pear” and “apple” shapes d. all of the above
e. none of the above
15. A balance of carbohydrate and protein in a meal is needed to:
a. keep blood glucose levels steadier
b. get all the vitamins and minerals needed
c. increase the release of glucose into the bloodstream
d. reduce the need to eat more than twice a day
e. get all the essential amino acids
16. It is important to eat slowly to:
a. get the most flavor and texture enjoyment from your food
b. fool your body into thinking it is taking in more food than it actually is
c. prevent anorexia
d. a and b
e. none of the above
©2010, Nutrition Dimension/Gannett Education, Inc.
17. Current lifestyle practices that can result in high-fat eating patterns include:
a. use of convenience foods
b. eating meals away from home
c. eating less meat and feeling deprived d. eating specialty gourmet foods
e. all of the above
18. Reasons for overeating:
a. are always known to the client
b. are addressed by following a diet plan
c. can be overcome by using willpower d. are usually just excuses for lack of willpower
e. none of the above
135
LWM10
Exam, cont.
19. If you wait to drink until you are thirsty you:
a. may already be dehydrated
b. may eat more to get needed fluids from foods
c. may damage your kidneys
d. a and b
e. none of the above
20. When eating out at supper time, it is important to:
a. cut back on food earlier in the day to save exchanges or calories for the evening
b. choose the menu items that have the least fat
c. choose a meal that is physically and psychologically satisfying
d. eat everything they serve you in order to make the day’s starving worthwhile
e. get the most calories for your money
21. Relaxation:
a. is a waste of time
b. is needed to be able to enjoy a meal
c. can help you to enjoy your vacation time more d. b and c
e. helps you control hunger pangs
©2010, Nutrition Dimension/Gannett Education, Inc.
22. Which of the following statements are true?
a. all fluids rehydrate
b. diet drinks can help to reduce the cravings for sweets
c. caffeine stimulates the body to release more glucose into the bloodstream
d. a and c
e. none of the above
23. Willpower differs from confrontation in that:
a. willpower gets to the root of the problem
b. confrontation depends on denial of the need for the food
c. confrontation decreases the incidence of automatic eating
d. confrontation means masking your immediate needs for long-term goals
e. none of the above
24. Normal eating is:
a. flexible
b. following a food guide on a daily basis
c. never overeating d. the same each day
e. vegetarian
136
LWM10
Exam, cont.
137
25. Eating breakfast:
a. increases the total amount of food clients eat in a day
b. leads to overeating later on
c. means people are less likely to go for long periods without eating
d. depends on genetic predisposition. Some people are born with a dislike of breakfast.
e. is irrelevant to health, fitness and weight management
26. A positive, healthy living cycle:
a. begins with self-acceptance
b. requires an acceptance that diets don’t work
c. gives the client permission to develop who they are
d. all of the above
e. has no place in counseling for health
27. Nondiet therapy can be applied in the following situations:
a. type II diabetes
b. a new non-smoker
c. for premenstrual syndrome d. all of the above
e. none of the above
28. Shifting the focus from weight to other goals means focusing on:
a. adherence to an eating pattern
b. changing one’s BMI
c. enjoyable eating and activity patterns d. all of the above
e. none of the above
©2010, Nutrition Dimension/Gannett Education, Inc.
29. The nondiet approach to healthy living:
a. implies that improved lifestyles will produce weight loss
b. worsens the preoccupation with weight and dieting
c. has self-acceptance as a first step
d. has health and energy as goals secondary to weight loss
e. is only for those who have failed repeatedly at dieting for weight loss
30. Evidence that obesity is related to poor health is based on:
a. well-controlled studies
b. studies that can be generalized to both men and women
c. the assumption that large people receive the same medical treatment as thin people
d. studies that take into account past dieting habits
e. common sense
LWM10
Exam, cont.
138
31. Candidates for a nondiet lifestyle program:
a. are clients who believe they can lose weight and keep it off
b. accept their body and want to move forward
c. need a diet plan to give them a sense of control
d. do not believe that they can take time for themselves for a non-weightloss program
e. need to pass a comprehensive physical exam with lab tests
32. A lifestyle adjustment:
a. is a prescribed regimen
b. results in weight loss
c. is artificial and unpleasant d. can be achieved in a day or two
e. is a step-by-step process
33. The “diet mentality”:
a. allows people to live spontaneously
b. allows us to accept and appreciate our bodies
c. shows concern with health and fitness
d. results in trust of body signals of appetite and satiety
e. often results in excessive or inadequate exercise
34. Body image is:
a. the mental representation of our physical body
b. influenced by our families and friends
c. unrelated to popular ideals d. stable and realistic
e. a and b
©2010, Nutrition Dimension/Gannett Education, Inc.
35. Sudden decreases in the fat content of clients’ foods are:
a. likely to result in feelings of deprivation
b. part of the “diet mentality”
c. not recommended in the nondiet approach d. all of the above
e. of no concern
36. The best way to reduce the overall amount of fat a person eats is to:
a. switch to margarine and cut out eggs
b. try new recipes that are fat-free
c. count grams of fat d. become a vegetarian
e. gradually learn to enjoy new flavors and textures
LWM10
Exam, cont.
37. People that are “cue sensitive” are:
a. less likely to eat if there is food around
b. helped by going on a diet
c. always overweight
d. more likely to finish their plate of food
e. so insecure they can’t resist the temptation to eat bad foods
38. The nondiet approach uses liquids to:
a. meet the body’s needs for water
b. mask feelings of hunger
c. reduce caloric intake because liquids are a less dense source of nutrients
d. all of the above
e. none of the above
39.
Which of the following statements are true?
a. exercise must hurt to be useful
b. working at a high intensity can cause carbohydrate cravings
c. exercise at a proper intensity results in improved appetite control
d. if you don’t constantly increase exercise, it has no lasting value
e. b and c
©2010, Nutrition Dimension/Gannett Education, Inc.
40. Signs of dehydration include:
a. headache
b. fluid retention (swelling)
c. elevated heart rate d. weak, rapid pulse
e. all of the above
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