Cindy Byfield, RD, PhD (Cand)
A dietitian working in a cardiac rehabilitation program will see many “obese” patients whose blood lipids, blood glucose, and/or blood pressure are elevated. Current dogma recommends weight loss as the first line of treatment. The dietitian may have strict orders from a cardiologist to “get this patient to lose weight.” Despite agreeing with the basic tenets of Health at Any Size, health professionals may be tempted to follow doctors’ orders and instruct the patient on a weight loss diet.
However, it is possible to implement the new paradigm in a clinical setting. In fact, it is truly in the patient’s best interest to do so. Whether people lose weight by crash-dieting or by using a “state-of-the-art” behavioral treatment program, the majority gain the weight back, hardly an effective means of promoting health and wellness.
If you are just shifting to the new paradigm, it may help to know that it is not unusual to feel some discomfort. After all, we live in this weight-obsessed society and as health professionals, we have been trained to believe that excess fatness equals poor health.
Start by observing your own thoughts about weight and how these thoughts might influence your work with large-sized clients. How do you feel about fatness generally—your own body fat and people who are fat? Do you believe that people can be healthy at any size? Do you feel uncomfortable with the concept of “size acceptance,” either for yourself or for your patients? If so, why? It will help to understand your own feelings.
Next, we need to realize that we have no real control over a patient’s weight and neither does the patient. Our task is to provide accurate and helpful information about lifestyle changes that are likely to improve health. Our clients’ task is to decide which changes they are willing and able to make. Together, behavioral goals can be set that improve health regardless of whether weight loss occurs.
To implement the new paradigm, large-sized patients must feel accepted as they are right now. Focusing on a patient’s weight, their “high level of body fat” or their “high-fat diet” will most likely lead to feelings of shame and guilt. This is not likely to produce long-term behavior change.
Large men or women who have recently suffered from a heart attack or undergone heart surgery may be very fearful of having another cardiac event and may want to lose weight right away. Your message to them must be firm and consistent: they can improve their cardiovascular health by making comfortable and realistic changes in diet and activity, and these changes are not just a means to weight loss. They improve health in their own right.
Using the phrase “low-fat diet” may encourage a diet mentality—you are a good person when you are on the diet, and a bad person when you fall off. This way of thinking promotes guilt and does little for health and wellness. Although you may think of a low-fat diet as healthful eating, many patients see a low-fat diet as just another diet.
Rather, focus on the positive aspects of a well- rounded “heart-healthy” eating plan. This way of eating involves adding foods to one’s diet to make it more healthful, such as fruits, vegetables, and whole grains. By emphasizing what needs to be added to one’s diet versus what should be eliminated, patients are less likely to feel deprived and are more likely to make changes. Although dietitians normally discuss increasing heart-healthy foods, in traditional treatment this topic tends to take a back seat to the fat restriction aspect of a heart-healthy eating plan.
It is also important to help patients become more aware of their hunger and satiety. Most people do not recognize true hunger or fullness, especially if they have dieted for many years. Get them to spend a week just noticing when they are hungry and full, and to notice how they respond to those feelings. Ask them to sit quietly at their next meal and to simply notice what it feels like to be comfortably full. They may need to relearn that this is the point to stop eating, not when a predetermined amount of food has been consumed, as traditional weight loss plans recommend.
It may be helpful to explain the concept of “metabolic fitness” (normal blood lipid, blood glucose, and/or blood pressure readings) and the choices that improve these parameters. Provide suggestions for limiting foods that aggravate metabolic parameters and suggest substitutions. Discover the changes they feel they need to make in order to improve their metabolic fitness and together find effective solutions to behaviors they would like to change.
Let’s take Nancy B., a 58-year-old teacher who has suffered a heart attack, as an example of how to implement this approach. Her blood cholesterol and blood pressure elevated and she weighs 223 pounds. She typically skips breakfast, has a light lunch, and a “meat and-potatoes” dinner. Before going to bed she enjoys a bowl of ice cream or a handful of cookies. She complains of having little energy on most days, and is not physically active. Her cardiologist wants her to lose 50 pounds.
The traditional approach to treating Nancy would be to advise her on a calorie-restricted diet and behavior modification techniques. She would be given an exercise plan and asked to keep a food diary. Most likely, she would be weighed once a week and commended when weight loss occurs.
Using the new paradigm, we discussed her thoughts on dieting, food, and exercise. Nancy stated that she had dieted frequently in the past and that she usually felt tired and weak when she dieted. She also admitted to frequent binge eating at night when she “fell off the bandwagon.” We decided together that dieting would not help her achieve her major goals of being healthy and physically active on a regular basis. Rather, eating breakfast and a more substantial lunch would give her the energy she needed to be active. Thus, Nancy’s first goal was to eat breakfast and to add some food to her current lunch to give her more energy for a brisk walk after school.
After 3 weeks, Nancy reported feeling more energetic and “proud of herself” for sticking with the changes she had made. Her weight did not change but her walking time had increased from 15 to 20 minutes and she reported having more energy in the evening.
Three months later, Nancy’s weight had dropped by only 2 pounds but she was walking 30 to 45 minutes, 5 days a week, something she never thought she’d be able to do. Her newfound confidence prompted her to make more healthful changes in her eating pattern, such as snacking on fruit in the evening instead of ice cream and using skim milk in place of 2 percent milk. These were all changes Nancy felt she could maintain indefinitely.
Would Nancy have responded better to a traditional treatment plan? Chances are she would have lost more weight, but would have been unable to maintain the weight loss. Her blood pressure and blood cholesterol levels are now within normal limits, and she’s established a physically active lifestyle. What more could we ask?
Health professionals in the clinical setting will be most effective by helping their patients believe that health can be achieved now, not just when (or if) they lose weight. Even people who have just had a heart attack can benefit from the Health at Any Size paradigm.
Cindy Byfield, RD, PhD (Cand), is currently working on a doctorate in nutrition at Colorado State University. She has worked in a clinical setting, mostly in cardiac rehabilitation, for about 8 years.