2. health enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human wel -being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.
3. Respectful care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socioeconomic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
4. Eating for well-being: Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any external y regulated eating plan focused on weight control.
5. life-enhancing movement: Support physical activities that al ow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.
FIgure 15.1. The Health At Every Size (HAES) principles. From the Association for Size Diversity and Health (2014). Reprinted by permission.
*Health At Every Size and HAES are registered trademarks of the Association for Size Diversity and Health and used with permission.
MI to Address Weight Concerns and Disordered Eating 235
Diet Paradigm
Non-Diet Paradigm
Food
• Food is labeled as good or
• All food is acceptable.
bad.
• Quantity and quality of food is
• Quantity and quality of food
determined by responding to
is determined by external
physical cues such as hunger,
source such as calories,
ful ness, taste, cravings, and
grams, or exchanges.
body comfort.
Physical Activity
• Exercise to lose weight.
• Aim to be more active in fun
and enjoyable ways.
Weight
• Define a goal weight.
• The body will seek its natural
weight when individuals eat in
response to internal physical
cues.
FIgure 15.2. Diet paradigm versus non-diet paradigm.
doesn’t mean that attempting to lose weight is the answer, given the physical and emotional turmoil that often results. Across the weight spectrum, clients can aim to adopt eating and activity patterns that enhance physical and emotional health, regardless of changes in weight.
A key component of counseling using a non-diet approach is conveying
an attitude of acceptance of size and shape differences and respecting and celebrating size diversity. This is done through inviting the client to explore emotional and physiological consequences of previous dieting attempts
while at the same time exposing the client to a non-diet approach.
HAES messages are very different from traditional weight loss pro-
grams. Some of these key differences are summarized in Figure 15.2. Clients’ reception of HAES principles depends heavily on the counseling style in which they are offered. If the information is provided using the various motivational interviewing techniques discussed throughout this book, the client will be far more receptive to this alternative way of thinking about food and fitness.
APPlyIng the hAes PrIncIPles In An MI sessIon
The HAES paradigm is defined by the following five principles: weight
inclusivity, health enhancement, respectful care, eating for well-being, and life-enhancing movement (Association for Size Diversity and Health, 2014).
The remaining sections address each principle and include tips for providing nutrition and fitness counseling in a weight-neutral, nonstigmatizing manner that aligns with the spirit of MI.
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Principle 1: weight Inclusivity
The first HAES principle is to “accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.” Clients seeking nutrition and fitness counseling often present with significant body dissatisfaction. The media contributes greatly to this dissatisfaction, with unrealistic images of beauty and the message that women must be thin and men must be muscular to be attractive, successful, and healthy. It is no surprise, then, that exposure to media is positively correlated with body dissatisfaction (Richins, 1991).
However, messages about weight and size also come from peers, par-
ents, coaches, teachers, and relatives. It’s important to explore the root of the client’s body dissatisfaction within the context of a counseling session by asking open-ended questions, reflecting, and summarizing what you
hear.
Messages from others about weight and body shape are typically
received through direct and indirect communication. Often, clients will share stories of shaming comments made by parents during their formative years. Statements like, “Gosh, you’ve really filled out!” or “If you just watch what you eat, you could lose the weight you’ve gained,” are all too common. Family members also indirectly model unhealthy behaviors such
as dieting. They might weigh themselves regularly and make negative comments about their own physical appearance, setting their children up to do the same. Whether indirect or direct, these communicated messages can
play a significant role in an individual’s feelings about his or her own body.
One way to begin addressing your client’s weight concerns is to invite
him to share where the desire for changing his body shape or size comes from. Ask the client to share messages received about weight and shape
while growing up in order to shed light on the client’s current personal beliefs and how it relates to feelings of self-worth.
Here are open-ended questions that can evoke thoughts and feelings
about weight and body image:
“What do you hope will improve if you weigh less?”
“What is it about your body that you don’t like?”
“How do you feel about your body on a scale from 0 to 10, with 10
meaning you love your body and 0 meaning you hate it?”
“Describe the messages you heard about weight and size during your
youth.”
“How do your current negative feelings about your body size and
shape relate to messages you’ve heard?”
“What are some negative messages about your body that come up for
you during a typical day? How do these thoughts influence your
food and fitness choices?”
MI to Address Weight Concerns and Disordered Eating 237
“What are your thoughts when you step on the scale? How do those
thoughts affect you during the day?”
Some clients believe that losing weight is the only way to improve their body image. In reality, losing weight does not always improve body image.
On the other hand, sessions that include body image counseling can reduce body dissatisfaction (Rosen, Reiter, & Orosan, 1995). Body image counseling begins with having the client gain awareness of her negative body image, identify the negative self-talk surrounding body features, and find alternative positive self-talk statements to replace the old ones.
Larger individuals often feel that they have to change their bodies in
order to be healthy, attractive, and comfortable in their own skin. However, feeling bad about your weight may be worse for your health than
the weight itself (Latner, Durso, & Mond, 2013). Therefore, promoting a positive body image may improve health outcomes regardless of changes in body size.
Promoting a positive body image starts with the practitioner’s atti-
tude toward weight and size. The idea of having an unconditional posi-
tive regard for your client (discussed in Chapter 2) is communic
ated by emitting an aura of acceptance for
the client’s physical attributes regard-
Unconditional positive regard for
less of weight loss. This undercurrent your client is communicated by of acceptance is easily felt within the emitting an aura of acceptance client–counselor relationship and not for the client’s physical attributes only fosters trust but also models a regardless of weight loss.
positive self-talk.
Gaining proficiency and confidence in body image counseling requires
extensive training and practice. Practitioners who do not feel equipped to provide body image counseling can still help their clients by noticing body dissatisfaction and making referrals to trained professionals. (See Appendix 1, “Making Referrals.”)
In the following script, the practitioner uses MI to invite a male client to explore the birth of his body dissatisfaction and how it may negatively affect his current health patterns. While reading this dialogue, notice how a few well-placed evoking questions can help increase the client’s awareness of his negative body image, and how it may be hurting rather than helping his overall health and well-being. Toward the end, the practitioner elicits change talk for jumping off the yo-yo diet bandwagon.
pRactitioneR: You’ve already made some significant changes to the
way you eat. You’ve said a couple things, though, that lead me
to believe that you won’t feel successful unless you lose a certain
amount of weight. [probing for body dissatisfaction] What do you
think? [open-ended question]
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client: I need to lose 50 pounds.
pRactitioneR: You have an exact number in mind. [simple reflection]
Could you expand on that a bit? What is it about losing 50 pounds
that feels important? [open-ended question]
client: I’m sick of being obese. I’ve been big all my life. I’ve had a few ups and downs, but I’ve been overweight for as long as I can
remember. I take after my dad, I think. My mom was always sign-
ing me up for sports to try to keep my weight down and it sort of
worked, but now I’m in my 30s and it’s time to get real. The doc-
tor said I’m going to end up dying of a heart attack if I don’t do
something about my weight. [change talk—need to change]
pRactitioneR: You and your doctor had an intense conversation
about your heart health. [simple reflection]
client: She told me my cholesterol was high and she thinks I might be
prediabetic, but if I do something about it now I can stop it.
pRactitioneR: You’re thinking that your weight is to blame for your
high cholesterol and blood sugars. [continuing the paragraph
reflection] This message that you need to lose weight has come
from a few different places, starting with your mother in child-
hood. [complex reflection] What sort of messages did you hear
growing up about body weight, shape, and size? [evoking with an
open-ended question]
client: I think it all started with my grandmother. I remember one
time I was over at her house because she wanted to make me some
pajamas. I remember her measuring my waist and then telling my
mom I was twice as big as my cousin Jimmy and she couldn’t
make them for me because she didn’t have enough fabric. I think I
was 9 or 10. That was when I realized I was bigger than everyone
else.
pRactitioneR: That’s when you started to think there was something
wrong with you because of your size. You’ve heard it from your
grandmother, your mom, and now your doctor. [summary]
client: I hear it every day. I’ve stopped going out to eat because I feel like people judge what I order. The other day a little girl pointed
at me and asked her mom if I had a baby in my belly.
pRactitioneR: That must have felt really uncomfortable. [express-
ing empathy] You’re hoping that losing 50 pounds will protect
you from feeling like there’s something wrong with you. [com-
plex reflection] Could I share with you a little about the research
regarding weight and health? [asking permission]
client: Sure.
MI to Address Weight Concerns and Disordered Eating 239
pRactitioneR: Well, one thing we know from scientific research is
that body size is largely influenced by genetics. You mentioned you
take after your father’s body type. Research shows that people are
really good at losing weight, but not good at keeping it off because
our body is actually designed to fight back in order to survive
periods of starvation from an evolutionary standpoint. That’s why
dieters are always losing and regaining weight. Plus, many of my
clients have found that even when they do lose weight, they may
feel better about their bodies temporarily, but then new issues of
body image and self-worth arise. [giving information] What do
you make of this information? [eliciting the client’s response with
an open-ended question]
client: I know what you mean. I lost 45 pounds a few years ago when
I went on a low-carbohydrate diet. But I’m back where I started.
It’s pretty frustrating. [change talk for a non-diet approach]
pRactitioneR: Yes, it can be a roller-coaster ride. [metaphor reflec-
tion that emphasizes change talk] And the good news is that
making changes to the way you eat can improve your health no
matter what goes on with your weight. Plus, there are other ways
to improve the way you feel about your body so you won’t feel
so vulnerable to comments strangers make. [giving information]
How would you feel about exploring some of these alternative
ways to improve your health and body image? [asking permis-
sion]
In this excerpt, the practitioner used some evoking questions to
encourage the client to explore the root of his negative body image. The practitioner also provided some information to the client (with permission) regarding genetics, dieting, and body image. The practitioner validated the client’s concerns through the use of powerful reflections and increased his awareness of the complexities of weight and body image. A final reflection was provided that emphasized the client’s change talk for considering an alternative approach. At this point, the practitioner can continue to guide the client through this exploration (if doing so is within the practitioner’s scope of practice) or provide a referral to a therapist who specializes in body image counseling. (See Appendix 1, “Making Referrals.”)
Principle 2: health enhancement
The second HAES principle is “to support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.” This concept points
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to the necessity of expressing compassion for clients. An MI practitioner is not seeking self-gain, but seeking the betterment of his clients.
The HAES paradigm is a holistic approach where all components of
wellness are considered important to the individual’s health and overall well-being. Health is about more than
just diet and exercise. There’s spiri-
Health is about more than just
tual health, emotional health, social
diet and exercise.
health, intellectual health, environ-
men
tal health, and occupational
health, to name a few.
Clients often assume that dieting will improve physical health. That
is certainly up for debate (Tomiyama, Ahlstrom, & Mann, 2013). What is plain to see though is that dieting can come at a cost to the other facets of health and well-being. For example, in order to maintain motivation to eat less and exercise more on a daily basis a client pins a particularly unflatter-ing “before” picture of herself to the refrigerator. This way, every time she goes to the fridge to eat she is reminded of her body weight from before she started dieting. Since most dieters regain lost weight (Mann et al., 2007), it is likely that she will return to the same weight as in her picture but with even lower self-esteem. This cycle generates negative self-talk and results in body dissatisfaction adding to the toll on emotional health. When she decides not to meet up with old friends because she is embarrassed about her weight, she experiences the cost to her social health too.
In promoting health and human well-being, it may be useful to invite
your clients to consider the unadvertised costs of dieting. Clients often show up with great enthusiasm and interest for starting a new diet plan. In the spirit of MI, clients have complete autonomy to begin whatever diet plan they’d like; however, practitioners can offer concerns with evidence-based information, if the client is interested. Here are some evoking questions that can encourage exploration into the risks of dieting and help provide a platform for eliciting change talk toward a wellness-focused approach:
“Describe your dieting history. What diets have you tried and what
worked and didn’t work for you in the past?”
“What was it about the last diet you tried that made it hard to stick
to?”
“What is it about this new diet you’re considering that appeals to you?”
“What concerns, if any, do you have about starting a new diet?”
“What was the emotional cost, if any, of previous diets you’ve tried?”
“How did previous diets negatively affect your social life?”
“How does dieting influence your emotional health?”
Often clients won’t be interested in hearing an alternative non-diet
approach until they’ve expressed dissatisfaction with a dieting experience.
Motivational Interviewing in Nutrition and Fitness Page 32
