6 min read
If you’ve ever tried to give up smoking, or get rid of bodyfat, then you probably understand how hard it is to make changes. For everyone else, I’m sure you’ve had something you’ve wanted to change whether it’s an addiction, vice, or any unwanted behaviour. Smoking is an interesting example, because despite all the evidence showing it can cause lung cancer, all the scare tactics employed by anti-tobacco campaigns, and despite smoking making people feel ill in the absence of disease, people continue to smoke. It’s a similar situation with obesity, except the only difference is the number of smokers has reduced drastically over the years, whereas obesity prevalence continues to increase.
Let's see those stats again from my last article disussing how losing weight is so easy, but so hard at the same time. "48% of the UK population reported being on a diet in 2016 according to a survey performed by Mintel. We are a nation of dieters, yet obesity has risen from 15% in 1993 to 26% in 2016."
I listened to an interesting discussion on Talk Radio between radio host Harriet Minter and nutritionist Monica Price last week. Monica was doing well until she said these erroneous words, ‘It’s all about will power and self-control.’ I cringed because a few years ago I would have been mentally high fiving Monica, but now a qualified nutritionist myself, I knew these words to be wrong. It is correct what Monica said, that we control what food and drink goes into our mouth, but there are multiple factors that influence our eating behaviour, and to say it’s all about will power is, to be frank, ignorant and damaging.
‘You just need to eat less and move more,’ is a pervasive mantra among people who have never really been overweight, let alone obese. I’ve been one of these people. Shame. But I’m living walking proof that attitudes can change. Did my degree help? Probably. The biggest eye opener for me was when I saw an obesity causal map. It shows the degree of complexity surrounding the issue of obesity. Have a look for yourself. I can’t see that will power or self-control are even mentioned, because these factors are regulated by several hormonal, environmental and psychological cues.
The primary goal when eating is to meet energy requirements, but we’ve all been there at the end of a meal in a restaurant, full to the brim, and the waiter brings the dessert menu to the table, and as if by magic, you find room for that double chocolate brownie with ice cream. There’s a bunch of hormonal internal cues that are controlling these feelings of hunger, appetite, satiation (when you feel you have eaten enough during a meal) and satiety (how full you are after a meal), but our eating behaviour is governed strongly by what food is available to us and food accessibility. Physiological signals tell our brain we are hungry and when we are full, but appetite is different to hunger. Appetite, the desire to eat food whether hungry or not, reminds your brain of how good that brownie will taste. Other people may live in food deserts, or face food poverty, and may have limited food choices. Other people are spoiled for choice, and even though healthier options are available, there are factors vying against each other to determine what foods end up in our mouths.
There are 3 recognised eating behaviour constructs: hunger, restraint, and disinhibition (loss of restraint). Negative internal psychological cues such as anxiety, depression and stress, have all been found to increase appetite in the absence of hunger. Observational studies have demonstrated that these internal cues have greater influence on our eating behaviour than any environmental or physiological cue (Sung et al 2009, Koenders and van Strien 2011, van Strien et al 2012). Similar findings have been observed in weight loss intervention studies, with internal disinhibition (eating in response to cognitive and emotional cues) being strongly associated with greater weight loss, whereas external disinhibition (eating in response to environmental cues) had no association with weight loss (Neimeier et al 2007, Butryn et al 2009, Braden et al 2016).
To summarise, hunger and restraint are not consistently associated with BMI or weight change, but internal disinhibition is. Therefore, telling overweight and obese people they just need to, “have more self-control”, “just eat less”, and “you should only eat when you’re hungry,”
The research clearly shows us that emotional eating is an issue that is preventing people from losing weight. Furthermore, studies show that emotional eating can lead to binge eating, which can cause even more unwanted weight gain. Many individuals are stuck in a never-ending dieting cycle, often referred to as yo-yo dieting (Figure 1). ‘Dieting’ in the traditional context of food restriction is a form of disordered eating, and it can lead to eating disorders.
Figure 1. Conceptual diagram showing a cycle of disordered eating during energy restricted dieting.
Yup overweight and obese people have eating disorders. It’s not just skinny people. Harriet Minter told her listeners about a very common story. From a child she was told she needed to lose weight, so went on a diet, and another, and another, and they all failed. Later in life she gets diagnosed with an eating disorder. So, if you’re one of those keyboard warriors telling overweight or obese people they should eat less, chances are they probably have, and suffered for it.
How can we change this? There’s no straight answer as researchers are still trying to figure this out.
For years now, clinicians have been applying the transtheoretical model of change (TM) to health behaviour change, which was developed by Prochaska & DiClemente (1982 & 1986) in the early 1980s (Figure 2). This has come under criticism in the context of health behaviour change, as the model was designed to be applied to patients with addiction to ‘assess the stage of a client’s readiness for change and to tailor interventions accordingly.’ The model has very distinct stages with set time frames for each stage. Patients with addiction have a very clear end goal of complete abstinence, whereas behaviour is a far more dynamic variable. An individual could have maintained a single behaviour change for years but still need to make other changes. Until there is a new model for behaviour change, the TM offers a good framework to help assess how ready someone is to make change.
Figure 2. The Transtheoretical Model of Change
We need better weight loss interventions. We have learned that restrictive diet interventions tend to fail because emotional and psychological factors are not addressed. A recent review has suggested that nutritional coaching using trained professionals could be more effective than weight loss programmes and concluded that the latter is physiologically and psychologically detrimental. Coaching programs where the nutritionist places more emphasis on a behavioural strategy promoting sustainable change in eating habits using psychological tools and techniques, could be more effective but there is limited data to say this with certainty, and more long term intervention studies are needed.
Guidelines need to update in line with the research. When you visit the NHS website page on obesity, it gives plenty of practical dietary advice, but it doesn’t address psychological and emotional issues, except for saying cognitive behavorial therapy may help. Eating disorders can be treated, but this relies on the disorder being identified by a clinician. Many people will try and sort out their weight issues without medical help. Our goal as health professionals should be to help individuals achieve a healthy relationship with food.
In other words – get our clients off the diets.
If you can relate to this article, and are struggling to lose body fat, qualified nutritionists at Xeno Nutrition can help. Visit www.xenonutrition.co.uk for more details.