Is It Time To Abandon The Notion Of Personal Choice In Dietary Counseling?
Wednesday, August 10, 2011
Traditionally, dietary counseling has focused largely on client education and prescriptive approaches to promoting better ‘choices’.
Based on the limited success that such approaches have had on changing long-term dietary habits, a rather provocative article by Bradley Applehaus and colleagues from the Rush University Medical Centre, Chicago, Il, published in a recent issue of the Journal of the American Dietetic Association, argues that it is perhaps now time to discard the notion of ‘choice’ in favor of a strategy based on a deeper understanding of the complex interaction between neurobehavioural processes and environmental determinants of overeating.
As the authors discuss, both counselors and clients frequently attribute obesity largely to poor ‘personal choices’ and studies have shown that dietitians rank ‘lack of willpower’ as far more important to the development of obesity than genetic or other biological factors. This is not only contrary to our current understanding of the complex neurobiology of ingestive behaviour but also only serves to stigmatise and frustrate patients, who in turn blame their own ‘failures’ on lack of motivation or personal ‘failings’.
“The term personal choice implies that human behavior derives from conscious, volitional decisions, and connotes that human beings have free will to decide between alternative courses of action independent of biological and environmental forces. An implication of this definition of personal choice is that individuals can be considered causally, financially, and morally responsible for their behavior”
“In contrast to the notion of personal choice, some argue that human behavior is explained by neurobiological processes and their interaction with environmental stimuli. Supporting this deterministic model of personal choice are studies demonstrating that future actions can be predicted by brain activation patterns up to 10 seconds before individuals become aware of having made a decision, behavior is strongly influenced by processes outside of conscious awareness, and individuals can be led to believe that they have caused actions outside of their control.”
Thus, the authors propose that rather than making adoption of a ‘healthy’ diet a matter of choice, dietetic practitioners may better serve their clients by basing their counseling strategies on the emerging understanding of neurobehavioural drivers of eating behaviours, particularly, on the issues of food reward, inhibitory control, and time discounting.
Whereas the concept of ‘food reward’ involving the brain’s complex mesolimbic reward circuitry (as in addictions) is readily evident, as is the complex neurobiology of the prefrontal cortex that determines motivation, impulsivity and inhibitory self-regulation, time discounting refers to the increased value of immediate (short-term) rewards compared to deferred (long-term) benefits routinely demonstrated in psychological testing and deeply ingrained in human behaviour.
Recognising and fully acknowledging how the brain’s neural circuitry that underlies these behaviours interacts with (and is thus ultimately responsive to) environmental situations and cues can perhaps provide a far more realistic and effective counseling strategy.
In their paper, the authors provide several specific examples of how such an approach may work.
For e.g., the tendency for the brain’s reward circuitry to drive the intake of highly palatable foods can be thwarted by eliminating such foods from the personal foodscape and avoiding temptation and exposure to such foods by sticking to grocery lists or online grocery shopping.
Similarly, inhibitory control can be made easier by avoiding situations that challenge (e.g. buffets) or weaken (e.g. stress) inhibitory control.
The tendency to discount time can be countered by focussing on short-term (immediate) rather than long-term (health) goals.
Many of these strategies may seem familiar to present recommendations, however, the context and manner in which these strategies are presented to and discussed with the client would be vastly different.
Thus, rather than making these behaviours a matter of ‘personal choice’ the counseling goal would be to have clients fully understand how their own genetic predispostiion and neurobiology drives them to these behaviours and how they have to adopt these ‘unnatural’ and ‘difficult’ strategies to overcome their ‘nature’.
As the authors point out:
“the model explains eating behaviors that promote obesity without invoking character flaws (eg, lack of willpower). By emphasizing genetically-influenced neurobiological processes that confer vulnerability to overeating in a toxic food environment, the model enables dietetics practitioners to more effectively address obesity without promoting stigma.”
In terms of the counseling process, the authors suggest that this approach
“…acknowledges that patients are working against potent genetic vulnerabilities and a toxic food environment, and normalizes patients’ (and dietetics practitioners’) frustration with failed attempts at weight control.”
and that
“…patients can better control their weight through strategies focused on the interaction between the brain and the environment. For the majority of dietetics practitioners, this second message constitutes a shift in strategy from urging patients to make the tough choices required for weight control to helping patients minimize the number of tough choices they encounter.”
While it remains to be seen whether or not such a shift in strategy will indeed produce better outcomes, I do appreciate the fact that this paper makes a serious attempt at recognising just how effectively biology drives eating behaviour and that the simplistic concepts of ‘personal choice’ and ‘will power’ are clearly not the most effective strategies to counter the toxic food environment that most of us are exposed to.
To use an analogy that I have used before, recognising that someone has a hypersensitive bronchial system that predisposes them to asthma should lead them to avoiding and eliminating air-borne pollutants in their immediate environment rather than simply trying to breathe less.
AMS
Edmonton, Alberta
Hat tip to Annette for pointing me to this article.
Appelhans BM, Whited MC, Schneider KL, & Pagoto SL (2011). Time to abandon the notion of personal choice in dietary counseling for obesity? Journal of the American Dietetic Association, 111 (8), 1130-6 PMID: 21802557
Wednesday, August 10, 2011
It makes sense. As anybody who struggles with keep weight under control knows, if you want to ensure you don’t eat something, don’t have it around.
One of the things that annoys me the most about the whole obesity scare campaign is the way everything is framed as wholly a personal choice. All these judgemental dieticians should read Sparkpeople forums and see how many people who are sincerely trying to change their eating patterns run up against sabotaging partners, friends and family, who are either indifferent or downright threatened by the person’s changing habits and will do everything to sabotage the best laid plans, from tempting with foods they know the person loves, to downright insisting the person accompany them in unhealthy eating.
Wednesday, August 10, 2011
Great article Arya. You’ve blogged on numerous occasions about the neurobiology of ingestive behaviour and I’m happy to say that I have passed this type of info to patients who are struggling with their weight. There is no question in my mind that this is an effective and much appreciated strategy. What it does is take away the shame and guilt that people feel when they find themselves eating things that they know are detrimental to their efforts at weight management. I’ve had a lot of feedback from patients that this sort of info is extremely useful and it does keep them motivated to find strategies that work for them.
Your analogy to asthma is a good one.
Wednesday, August 10, 2011
Such a simple little blog post, suggesting a cultural sea change.
As Alexie notes, those of us who do maintain losses (without surgical assistance) have to come up with endless strategies. It’s not difficult to minimize the influence of the toxic commercial environment. If you did an fMRI on me, a Burger King commercial would register in my brain as “Yuck. Barf.” No, it’s the social aspect of food that is so difficult to navigate.
I am sometimes jealous of people who have had surgery, because (if they are “out of the closet” about their surgery — and I suspect many come out because of this cultural problem) they are permitted to turn down foods they don’t want to eat. People understand that a food may make them ill. As a non-surgical maintainer, I don’t have that “excuse,” so when I turn down food, I’m either viewed as judging the other person for her food choices (which I am not) or I am viewed as insulting the other’s cooking/baking (which I am not).
People push, “Well, one cookie isn’t going to kill you!” I know they think they are being kind, but I sometimes want to blow up: “Look, don’t make my food choices for me! You have no idea what my hunger level is. You don’t know what I’ve eaten so far today or what is on my food landscape later, so you don’t know how I prioritize that cookie in the grand scheme. It might not “kill” me, but it changes how I have to approach other foods today, and, simply, I don’t WANT it. It’s not even a question of virtue or weight control really. It’s a question of personal agency. Please allow me the grace of not having to eat that cookie just to please you! Please don’t make it into a value judgement on yourself or a referendum on our friendship! I can appreciate that you worked hard baking those cookies, but NOW is NOT a good time for me to eat one. Please appreciate that.”
Instead, I say something like, “No, honestly. Thank you.” And if they persist (as often they do), I lie, “My tummy is kind of off kilter today. Thanks anyway.” If I’ve used the “off kilter” excuse with that particular person a few times already, then I’ll come up with another strategy. And then there is one person with whom I’ve had “the talk,” which starts, “I know you’re trying to be kind, but I make different food choices than a lot of other people, and I need you to understand . . .” For a while, when she would push, I’d have to remind her. Now the pushing has stopped. . . from her. But I still have to deal with dinner parties, church pot lucks and other places where food pushers abide. Sigh.
Wednesday, August 10, 2011
Not sure I agree that dietitians attribute obesity to lack of willpower. Weight management counselling is moving in the direction of self management education.Dr. B.Wansink in food pyschology has been a great educator in this area.Craving Change Workshops by dietitians and the Obesity Conference are telling us where dietitians are heading in helping their clients.
Wednesday, August 10, 2011
Thanks Dr. Sharma. Another good post and article for the piles I make. As a dietitian who subsribes to this type of counselling, I always wonder about dietitians that don’t…but I’ve been pleasantly surprised to see most dietitians I encounter also using this approach. Perhaps it’s because I work in pediatrics, and it’s so much easier to see how it isn’t a child’s personal choices making them obese.
Wednesday, August 10, 2011
I think that “consciously aware” are the two most telling words in the article. Great post. As always you have such range in your vision, Arya. BTW Alexie, not all dietitians are judgemental.
Wednesday, August 10, 2011
That is the only advise that will work long term, and possibly over correction to start. The facts are so diluted and sometimes wrong in Weight Wise that it is dangerous and useless. These may work with minor overweight, but the grossly obese and many of the obese need the full monty to make major corrections in there lives. The Weight Wise need a quick start hard program to get rid of food addiction, insulin/blood glucose issues, chemical reward, psychological reward and the like.
Low impulse control, continual temptation, and habit also play a role, as does whatever drives the gut hunger sensation, and what ever drives the craving sensation. A change in attitude toward food, along with a bit of knowledge to separate real information from junk science, expert opinion, and rat science also helps. A bit of physiology, bio-chemistry, bio-physics, will not go amiss.
Throw away your Canada Good Food Guide. Complete avoidance of sugars in all forms, wheat for sure, all grains to start with, omega 6 oils to get the trans fats out, and all the manufactured eatable products. Elimination or portion control of the dense carbohydrates, and portion control of fats, and meats is required by many. Greens do not matter much and are required at every meal.
The issue with omega 6 is that the labeled amount of trans fat is pre-processing, plus or minus 20 %. Trans fat always increase with cooking, deep fryers increase oxidation rapidly, and corn oil turns brown at about 24% trans fat. Most restaurants use the oil until it is a dark brown, and starts to brown the foods. Trans-fat become a death sentence.
Wheat has many issues. See http://www.wheatbellyblog.com/ for the full story. Sugar is just empty calories. Excess fructose is converted into fat in the liver, resulting in visceral fats.
We need to over correct to deal with the obesity problem, nothing else has worked yet.
(For the grossly obese and obese only) Meal sizes must be kept to a size that blood glucose does not go wild. Once we start to burn stored fat as a primary source of fuel, we need resistance training (MacGuff style is the safest), and adequate protein(1.2 gm/kg LBM), not reduced protein, adequate carbohydrates (20 to 150 gms, reduce to keep BG, 1 hr, <6.0 ), adequate vitamins and minerals, Omega 3, and adjust the fat to control the rate of loss and hunger. Every one with an obesity problem should know these facts off the top of there head but it takes much searching to fine the facts out. There is so much wrong advise. How is one to know what is right without study of each issue? Go against some of the “experts”, for there recommendations are mutually exclusive, but which ones?
Test it on your self, and see what works and what does not. Do the tests in short periods of time and track everything. But I digress. No SGO6, HB attitude.
Wednesday, August 10, 2011
This post dovetails with a book on goal setting I just read by psychologist Heidi Grant Halvorson. Weight loss comes up frequently in her book, and as a lay person interested in weight loss I couldn’t help think about how much of the science-based advice would be very useful for clinicians or people planning their weight loss goals; there are a lot of small details in setting up and executing a goal that greatly increase the likelihood of success. In short, will power and self control can be undermined by how one thinks about and executes a goal to the point that, if you go about a goal wrong, failure is almost guaranteed.
Wednesday, August 10, 2011
Avoiding food pushers has become easy. “….. messes with my blood sugar”.., and their eyes gloss over. Zero is an easy count.
Or I tell them what is wrong with it, and watch the room empty. Do you want to live to an old age? Sugar will kill mice at the first all you can eat dose. We use it as mice poison in the electrical control buildings.
Wednesday, August 10, 2011
Society is comfortable talking about will power and self control. Look at your patients and ask yourself how much real power and real control they have in life and more importantly has their power and control over their lives increased over time or has it eroded over time. Can’t think of greater powerlessness than not having your “no” respected when it comes to a chocolate chip cookie. It’s even more difficult when it comes to “yes” choices because that involves a re-allocation of money – a limited resource that advertisers and family members compete fiercely over.
Sunday, September 25, 2011
So many of these ideas are present in the 12-steps programs for various addictions.
For example in Overeaters Anonymous (OA), we talk about
the importance o identifying binge foods and having a food plan.
This sounds very much like:
“the intake of highly palatable foods can be thwarted by eliminating such foods from the personal foodscape and avoiding temptation and exposure to such foods by sticking to grocery lists or online grocery shopping.”
We also talk about having a progressive illness that is
cunning, baffling and powerful.
This sounds very much like:
“…acknowledges that patients are working against potent genetic vulnerabilities and a toxic food environment,…”
I hope the medical findings in this article help reinforce some of these ideas in those of us in OA
and that some medical professionals might fine some of the ideas of 12-step programs
helpful for their patients.
Some OA info can be found at:
http://www.oa.org/
TJ