Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  MI to Address Weight Concerns and Disordered Eating 241

  By guiding the client to explore the costs of dieting, the client may become more open to the holistic messages of the HAES paradigm. In the following dialogue the practitioner elicits previous failed attempts at weight loss, highlighting the negative impact of dieting on emotional health with reflections and summaries. The practitioner uses an E-P-E technique to present the client with a non-diet approach.

  pRactitioneR: You shared that you tried [commercial weight loss

  program] and it worked at first but then wasn’t something that

  worked for you in the long term. [simple reflection] What did you

  like and not like about that program? [open-ended question]

  client: I liked that I ate really well and I lost weight.

  pRactitioneR: You felt good about your food choices and for a while

  it got you the result you were looking for. [simple reflection]

  client: Yes. People started talking about how skinny I looked.

  pRactitioneR: You liked that others noticed. [simple reflection] What

  about that eating plan, if anything, didn’t work for you? [open-

  ended question]

  client: Well it did work for me, for a while. I actually really liked it.

  I did it for about 3 months and, I don’t know, I just fell off the

  wagon one day when I gained weight for no reason. Then I didn’t

  want to go in for the weigh-in because I had blown it.

  pRactitioneR: You expected your weight to keep going down. When

  it stopped you found yourself less motivated to work the pro-

  gram. [simple reflection] This time, you want to do something that feels more sustainable, something that doesn’t make you feel

  like throwing in the towel part way through. [reflecting implied

  change talk].

  client: Yes, I guess you’re right. That makes a lot of sense and is

  actually a pattern, now that I think about it. As long as I’m losing

  weight I keep up with my diet, but as soon as I stop losing, I feel

  like throwing in the towel and giving up.

  pRactitioneR: You’re not alone in feeling that way. Many of my cli-

  ents have shared that very same experience. What foods, if any,

  were you missing while on your last diet? [open-ended question]

  client: Well, I wasn’t perfect on my diet. I did eat certain foods on the naughty list once in a while, but the food I found myself craving

  the most was cake. I could never really find a low-calorie alterna-

  tive for cake, so I was always blowing it every time I celebrated

  someone’s birthday.

  pRactitioneR: You experienced a lot of guilt while on your last diet.

  [complex reflection]

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  client: I really did. But it was the only thing that has worked for me.

  pRactitioneR: Overall, you noticed that you like the way your body

  feels when you eat well. At the same time, you don’t like hav-

  ing to miss out on celebrations, or the guilt associated with eat-

  ing dessert. You found that while on the diet program you had a

  negative relationship with the scale, which took an emotional toll.

  You’re here today because you’re looking for a different approach.

  [summary emphasizing the drawbacks of dieting and change talk]

  Does that sound about right? [closed-ended question]

  client: Yes, that sums it up.

  pRactitioneR: May I share with you some of my philosophies about

  weight, health, and dieting that I think might help you? [asking

  permission]

  client: Sure!

  pRactitioneR: You’re not alone with your experiences with dieting.

  Most dieters lose weight and then gain it back. It’s not you who

  failed; it’s the diet that failed you. Making changes in your eat-

  ing and exercise patterns is hard work, especially if those changes

  involve restricting certain pleasurable foods or activities. Research

  actually supports that the dieting process is a recipe for disaster.

  There’s also research that supports an alternative approach to

  dieting called non-dieting. [giving information] What have you

  heard about the term non-diet? [elicit]

  client: Nothing. But I have heard that crash diets don’t work.

  pRactitioneR: You’ve noticed extreme weight loss measures are inef-

  fective. [simple reflection] Can I tell you more about a non-diet

  approach? [asking permission]

  client: Please do.

  pRactitioneR: In a non-diet approach, the focus is on eating in

  response to hunger, fullness, and cravings instead of counting

  calories or points. You tune into how your body feels and choose

  foods that make it feel the best and eating times that honor your

  hunger. This approach also involves taking the focus off of the

  scale and pounds lost, and instead focusing your attention on how

  your body feels eating certain foods and doing certain activities.

  By shifting the focus away from the variations in your weight, you

  can more easily tune into your body’s wants and needs. This is

  a different approach to healthy eating. What do you make of it?

  [elicit]

  In this dialogue, the practitioner asked the client to share negative

  thoughts and feelings about dieting. The client voiced some aspects of

  MI to Address Weight Concerns and Disordered Eating 243

  the diet program that were negative, and the practitioner reflected those pieces as the change talk. In this case, change talk is the language the client uses that suggests that the old way of doing things (dieting) isn’t working. At times the practitioner took some guesses at some unspoken change talk using complex reflections. Her educated guesses were based on what she’d heard from previous dieting clients who were feeling restricted and unhappy. As a result, the client started to voice change talk for an alternative approach. The practitioner then used the E-P-E strategy to give the client a brief overview of a weight-neutral approach. She asked permission before giving information about the non-diet approach, provided the information, and then followed up the explanation with an open-ended

  question to check in with the client’s thoughts and feelings in the light of her own experiences and beliefs. If the client is open to exploring a nondiet approach, she may begin shifting her focus away from weight loss and toward eating and activity strategies that enhance overall health and well-being.

  Principle 3: respectful care

  Providing respectful care is to “acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias.” In addition, when one provides respectful care, information and services are offered “from an understanding that socioeconomic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.”

  Assumptions made about weight by health care professionals can

  result in the misdiagnosis of problems and the wrong plan of care for thin and fat clients. Health care professionals see a fat patient and assume he or she doesn’t eat well and is sedentary. This is a false assumption, as many fat patients are very fit and eat well. Some researchers have found that individuals in the overweight and obese BMI categories don’t necessarily eat more calories than those in the “normal” weight category (Fang, Wylie-Rosett, Cohen, Kaplan, & Alderman, 2003). Most concerning, clients told to lose weight often avoid their doctors, thereby missing the opportunity for routine preventive screenings (Amy et al., 2006).

  Conversely, healt
h care professionals often see a thin person and

  assume he or she eats well and is physically active. Given the genetic con-tributors of body weight, size, health, and disease, this is a false assumption. By making assumptions about one’s eating and activity patterns based on body size, health care professionals may inadvertently fail to discuss eating and activity patterns with their thin patients. Therefore, weight bias affects individuals across the weight spectrum.

  The spirit of MI is present in the context of providing respectful

  care. In order to deliver care that exudes acceptance, absolute worth, and

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  autonomy, examine the obvious and

  Examine the obvious and subtle

  subtle ways your clients might feel

  ways your clients might feel

  stigmatized. Consider the environ-

  ment of your office or workspace

  stigmatized.

  and try to see it through the eyes of

  your clientele. Is the seating adequate

  and comfortable for people of various shapes and sizes? Choose chairs or couches that allow larger clients to shift and reposition as they share their stories, experiences, thoughts and feelings with you.

  In addition, choose wall hangings with weight-neutral imagery. Hav-

  ing only pictures of thin, happy people sends the message that clients will only be happy or healthy when they are thin. Include images of people of various sizes and shapes. Does your office monitor clients’ weight, waist circumference, or fat fold thickness with each appointment? Consider the necessity of monitoring these data weighed against the potential negative psychological effects on clients.

  Finally, examine your own biases and make efforts to challenge them.

  The anti-fat attitudes of health care professionals are well documented (Johnston, 2012). In your attempt to care for your clients with compassion, demonstrating absolute worth, examine your counseling environment.

  Aim to create a comfortable, accepting, and inviting atmosphere for clients across the weight spectrum.

  Principle 4: eating for wel -Being

  The fourth HAES principle promotes “flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.”

  A non-diet approach, such as HAES, involves eating in response to

  physiological cues such as hunger, fullness, and a sense of well-being. Using internal cues to regulate food intake is also known as intuitive or mindful eating. This is very different from a restriction-based diet approach in which calories are counted and food is weighed and measured. Intuitive eating is about attending to body cues, allowing oneself to become gently hungry

  before eating, and eating until comfortably satisfied. In terms of deciding what to eat, individuals following a non-diet approach pay attention to eating in a way that feels good, both in terms of body function and taste.

  At times, certain foods are selected because they are ideal for main-

  taining energy throughout the day or assist with bowel regularity. At other times, foods are selected due to the enjoyment factor or the simple pleasure in satisfying taste buds. In drawing the client’s attention to these internal responses the client is able to focus on the intrinsic benefits of food choices.

  Mindfulness with eating involves slowing down and simply noticing or

  becoming aware of yourself and your surroundings as well as the pleasure

  MI to Address Weight Concerns and Disordered Eating 245

  you are experiencing from the food. On the contrary, mindlessness often involves eating more than was originally desired and missing the pleasure that food brings.

  When clients suffer from chronic conditions that require specific diet

  modifications, the intrinsic benefits of picking and choosing foods that honor well-being become most pronounced. For example, a client with a

  new diagnosis of lactose intolerance will find that the body gives feedback when the offending foods are eaten. The motivation to eat lactose-free, therefore, comes from wanting to continue to feel well and avoid discomfort. With conditions such as diabetes, the body may give more subtle cues such as symptoms associated with hypo- or hyperglycemia. For some conditions, such as high cholesterol, there may not be any obvious body signals when eating foods that worsen the condition, but the client can tune into other body cues to guide eating choices, such as fatigue or mood.

  Whether the body responds with a siren or a whisper, tuning in to the

  physical sensations before, during, and after eating can help clients navigate the waters of what, when, and how much to eat. If the client is interested in using a journaling exercise to gain awareness of body cues and feelings, the food and feelings journal presented in Chapter 5 could be provided.

  There is still a place for educating the client on certain offending foods when attempting to manage a disease or condition; however, by combining food knowledge with body awareness, the client may be more motivated to choose foods that make him feel better in the moment.

  In a non-diet approach, clients aren’t told how much or when to eat.

  Instead they are encouraged to become experts of their own body cues and nutritional needs. Clients are given full autonomy and are respected for their differences. In creating a partnership between the client and practitioner, the client is treated as the expert of his body and body cues. In the following dialogue, the practitioner shares a few insights about hunger and fullness, invites the client to focus on a topic of interest, and then guides the client toward beginning the journey of mindful eating.

  client: Have you ever heard of a food coma? That’s how I feel in

  the evenings. I do fine all day long, but once I eat dinner it’s like

  opening the floodgates. I don’t know how to stop it. I wish I could

  just push away my plate like my kids do. [change talk—desire to

  change]

  pRactitioneR: You don’t like the way you feel so stuffed after din-

  ner. And it also sounds like you’re interested in exploring a new

  approach with me today . [reflection of change talk] If it’s all right with you, I’d like to show you some different topics we could

  discuss today. [Handout 15.1]. [asking permission] Each circle includes strategies for eating more mindfully.

  Handout 15.1

  CIRClE ChaRt FoR huNgER aND FullNESS

  Removing

  Paying

  distractions

  attention to

  while

  hunger

  eating

  Emotional

  eating

  Paying

  Noticing

  attention

  stomach

  while

  fullness

  eating

  Eating more

  regularly

  throughout

  Tuning in to

  the day

  Eating more

  body signals

  and energy

  slowly

  levels

  From Motivational Interviewing in Nutrition and Fitness by Dawn Clifford and Laura Curtis. Copyright © 2016 The Guilford Press. Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details). Purchasers can download a larger version of this handout (see the box at the end of the table of contents).

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  MI to Address Weight Concerns and Disordered Eating 247

  Client: Sure.

  PraCtitioner: These are a few different directions we could go today.

  There are many reasons we overeat. One reason is referred to in

  this first circle, “Paying attention to hunger.” Sometimes it’s just

  a matter of eating a meal a little earlier when we aren’t quite so
<
br />   ravenous, or adding an afternoon snack. The idea is that if you

  go into a meal gently hungry, it will be easier to eat slower and

  to put a preferred amount of food on your plate. Another trigger

  for overeating is simply not noticing stomach fullness while eat-

  ing. So another topic we could discuss is slowing the meal down

  and removing distractions while eating that keep you from paying

  attention to your meal. We could also talk today about tuning in

  to your body and simply noticing what foods make you feel good

  and less lethargic. Or we could talk about food and emotions

  today. [giving information] Which circle on here, if any, really

  resonates with you right now? [closed-ended question]

  Client: I like the idea of slowing down. I’d say I’ve got just the right amount of hunger going into a meal, so that’s not the problem.

  The problem is that I’m not really paying attention to my meal

  while I eat and I’m sometimes going back for seconds when I’ve

  really already had enough. I just need to slow down. [change

  talk—need to change]

  PraCtitioner: Eating slower and checking in with your fullness cue

  periodically throughout the meal sounds like a good place to start.

  [reflection of change talk]

  Client: I’ve always been a fast eater. I was the youngest of five chil-

  dren, so I had to eat fast growing up if I wanted seconds.

  PraCtitioner: That eating fast reflex is hardwired and you want to

  do some rewiring. [reflection—eliciting change talk]

  Client: Right. Now it’s just me and my husband, so I have no need to

  eat that fast. [change talk—reasons for change]

  PraCtitioner: This is a good time in your life to make this change

  because you can do it without worrying about others at the table.

  [reflection of change talk] Describe that feeling of over-fullness

  that you’re hoping to avoid by slowing down. [open-ended ques-

  tion to evoke change talk]

  Client: Ugh, I hate it. I just feel like curling up and taking a nap after dinner. I have no energy to do the dishes.

  PraCtitioner: You feel exhausted. [reflection of change talk] What