by Wilson, Bee
In 1955 the average person in Japan ate just 3.4 eggs and 1.1 kilogram (2.4 pounds) of meat a year, but 110.7 kilograms (244 pounds) of rice; by 1978, rice consumption had markedly decreased, to 81 kilograms (178.6 pounds) per capita, while people were now eating 14.9 eggs and 8.7 kilograms (19.2 pounds) of pork alone, not to mention beef, chicken, and fish. But this wasn’t just about Japan moving from privation to plenty.
More than anything else, it was a shift from dislike to like. Where once it was seen as extravagant in Japan to serve more than one or two dishes to accompany the evening’s rice, now—thanks to the new affluence—it was becoming common to serve three or more dishes, plus rice, soup, and pickles. Newspapers published recipe columns for the first time, and after centuries of silence at the table, the Japanese started to talk with great discernment about food. They embraced foreign recipes, such as Korean barbecue, Western breaded prawns, and Chinese stir-fries, and made them so much their own that when foreigners came to Japan and tasted them, it seemed to be “Japanese food.” Perhaps thanks to all those years of culinary isolation, when Japanese cooks encountered new Western foods, they did not adopt them wholesale, but adapted them to fit with traditional Japanese ideas about portion size and how a meal should be structured. When an omelet was served, for example, it probably did not have fried potatoes on the side as it might in the West, but the old miso soup, vegetables, and rice. At last, Japan had started eating the way we expect them to: choosily, pleasurably, and healthily.
There was nothing inevitable or innate in the Japanese spirit that gave them this near-ideal diet. Instead of being dispirited by the way the Japanese eat, we should be encouraged by it. Japan shows the extent to which food habits can evolve. We sometimes imagine that Italians are born loving pasta, or that French babies have a native understanding of globe artichokes that runs in their blood. The food scholar Elizabeth Rozin has spoken of the “flavor principles” that flow through national cuisine, often changing very little for centuries, such as “onions, lard and paprika” in Hungary or “peanuts, peppers and tomatoes” in West Africa. “It would be as unlikely,” Rozin writes, “for a Chinese person to season his noodles with sour cream and dill as it would be for a Swede to flavor his herring with soy sauce and gingerroot.” Yet Japan shows that such unlikely things do happen. Flavor principles change. Diets change. And the people eating these diets also change.
It turns out that wherever they are from, people are capable of altering not just what they eat, but also what they want to eat, and their behavior when eating it. It is startling that Japan, a country whose “flavor principles” included little spice except ginger, should fall in love with katsu curry sauce made with cumin, garlic, and chili. A country where people once ate meals in silence has shifted to one where food is obsessively discussed and noodles are loudly slurped to increase the enjoyment. So perhaps the real question should be: If the Japanese can change, why can’t we?
Just because dietary change can happen on a national stage does not make it easy to enact it at a personal level. Imagine what it must be like to be one of the 3.3 percent of the Japanese population who, despite the surrounding environment of slimness and good food, are in fact obese. The overweight in Japan are subjected to immense social pressure to change, including taunts of metabo—short for metabolic syndrome—and unwanted belly-patting from strangers. And yet none of this is enough to induce weight loss. Personal dietary change cannot be forced in this way.
Slimming magazines, whose stock-in-trade is transformation, specialize in “Before” and “After” photos. The aim of these is to show the readers that losing weight is feasible, although the effect can be to make them feel even worse about not yet being one of the success stories. The “Before” photo shows someone in oversized elastic-waist trousers, awkwardly avoiding the camera’s gaze. The “After” photo shows the same person half the size they were before, beaming in figure-hugging Lycra or a swimsuit. We are meant to be encouraged by the “After” photo, but the disparity between the two images is almost too great. When you are stuck in the “Before” stage, “After” can feel like another planet.
When I was an overweight seventeen-year-old, a couple of friends and I embarked—more than once—on diet and exercise programs together. We would start with high hopes, but we tended to overdo things on the first few days, get worn out from hunger and aerobics, and blow the diet before the end of the first week. It isn’t easy to go jogging in public when you feel self-conscious and out of shape; it’s no pleasure to “snack” on celery when all you can think about is Kit-Kats. One of the obstacles was that we didn’t really believe we were the kind of people who could ever reach the “After” stage. We used to complain among ourselves about the other girls, the ones for whom it seemed to come so naturally: the ones with the supermodel looks and honey-brown skin who genuinely preferred nibbling a small bowl of “power muesli” and yogurt to eating five slices of toast with peanut butter and jam. We found it deeply suspect that these girls would sometimes start eating something and stop halfway through because they said they just weren’t hungry anymore. They seemed as otherworldly to us as Japan. We could never be like them. We imagined that their ability to eat well was something ingrained and essential, impossible to imitate.
It is only now that I am through on the other side, in a place where food is not such a problem, that I can see our mistake. The healthy way these girls ate was not something they were born with, like hair color. They were habits and preferences that they had somehow acquired through a combination of circumstances and upbringing, just as we had somehow learned to cheer ourselves up with toast, reward ourselves with sugar, and finish everything on our plates even when we were stuffed. It is absolutely possible, I have discovered, to become the kind of person who craves a salad more than a sandwich—particularly if the salad is a tangle of tasty greens dressed with something flavorsome like anchovy, oil, and lemon, with buffalo mozzarella on the side. There have been encouraging developments in home cooking in recent years. As a reaction to the mainstream food culture, a new version of “healthy eating” has emerged, one that—quinoa aside—lacks the austere mood of 1970s health food. This new vegetable-based cooking is wisely driven by flavor as much as nutrition: Vietnamese summer rolls stuffed with mint and peanuts, crispy sprouts, smoky roasted red peppers, hearty chickpeas and garlic, sweet potato fritters. The food writer Diana Henry uses the phrase “a change of appetite” to describe the appeal of this way of eating.
A change of appetite does not involve a total change in personality. You still like the same music and films. You may never—despite what the health pages of magazines sometimes imply—develop supermodel looks and glowing skin. But if you can find a way of actively desiring—and therefore eating—a wide variety of healthy foods, the odds are that you will feel better, have more energy to exercise, get ill less, and enjoy meals more, because you can eat without guilt. Considering that most of us consume well over a thousand meals every year, this is a very good place to reach.
The great question is how you get there—and how you don’t. Anyone whose weight is edging upward, for whatever reason, may find themselves on the receiving end of unsolicited advice. People around you, from colleagues to family to doctors, have opinions on how you could change: diets you should try, things you shouldn’t eat, “helpful” hints about where you are going wrong. They seem to be under the impression that their finger-wagging or hinting will make you change, as if you haven’t noticed your own weight gain. But if it were possible to make other people change their eating habits through rational suggestions, then we would surely all be slender lentil-eaters. “One would think,” observes a textbook on personal change, “that the very real threats of kidney failure, blindness, and amputations would be sufficient to motivate people with diabetes to keep their blood glucose under control.” In many cases, however, these terrifying threats are not enough. Neither fear nor advice is a good motivator of change. Having othe
r people try to fix you is one of the things that, paradoxically, holds you back from reaching that magical place called “After.”
Dympna Pearson talks in a gentle Irish brogue, so quiet at times that you have to crane your neck to hear, but something in her voice makes you listen. Pearson’s lifework has been teaching dieticians to talk in such a way that those who are trying to lose weight—or stick to a gluten-free diet or manage diabetes, or make any of those other daunting dietary adjustments that people find so hard—can succeed in changing their behavior. Since the late 1990s, Pearson has personally given thousands of training courses for British dieticians. Her work has taught her that whether clients change their diet or not can come down to something as apparently trivial as how they are spoken to by members of the medical profession.
It is a bright day in early summer. A circle of around fifteen women are sitting on chairs in a community hall, drinking coffee. “I had to confess I found it hard to change the habits of a lifetime,” one woman confides. She is not talking about overeating or sitting on the sofa all day watching soap operas. This is phase two of one of Dympna Pearson’s courses for health-care professionals. The woman speaking is herself a dietician, and she is alluding to the habits of doling out weight-loss advice without really listening to the client. “Old habits die hard, don’t they?” replies Pearson, with a look of respectful sympathy.
Dympna Pearson’s firm belief, gathered from years of clinical experience, is that most dietary advice—however well-meaning—is not just useless but counterproductive. “One of our biggest banana skins,” she remarks, “is persuasion.” Those who enter the dietetic profession tend—for very good reasons—to have a fierce desire to change other people. It’s frustrating to be sitting in a room with a morbidly obese person who just cannot manage to lose weight, or even maintain much motivation to do so, even though if he carries on eating as he does, he is heading for gastric band surgery. There is an itch to fix the situation. There’s a tendency to come out with what Pearson calls “all these lovely persuasive phrases.” “Why don’t you use a smaller plate?” “Have you thought of eating an apple instead of a bar of chocolate?” “Maybe it would help if you chewed more slowly?”
It’s not that these suggestions are bad ideas in themselves, but to offer people diet advice in this way is to treat them like wayward children and yourself like an adult with all the answers. The trouble with this kind of talk—of which friends and family can be guilty as much as doctors and dieticians and governments—is that however nicely it is dressed up, with smiles and fake modesty, you are telling the other person what to do. And human beings don’t respond well to being bossed around, particularly when it comes to something as personal as what they put in their mouths. At best, such advice will render patients passive; they’ll seem to go along with what is being suggested without ever really taking charge of the situation for themselves. At worst, it will make them still more resistant to change than they were before, because when people are told what to do, they often do the exact opposite. Pearson has noticed that a client’s response to a string of advice tends to be a series of “Yes, but . . .” answers. “Yes, but I can’t afford to buy smaller plates.” “Yes, but the work canteen doesn’t sell apples.” “Yes, but I’m busy and I don’t have time to chew more slowly.”
Pearson trained as a dietician in Dublin “many moons ago” when the traditional model was all about reading out a diet sheet and waiting for patients to follow it. Or not. If they didn’t follow the advice given, it must be their fault. After she qualified, Pearson began working with diabetic patients and felt a zeal of enthusiasm to make their lives better, and to help them follow a diet that would save them from the worst consequences of untreated diabetes, such as blindness and coma. Yet she found that the conversations she had with her patients tended to be unproductive: she “cringes” now to look back on them. There was often an uncomfortable air in the room that she couldn’t quite put her finger on as she read out the diet sheet of forbidden foods. And, more often than not, her clients couldn’t manage to stick to their diets. She would find herself getting increasingly annoyed with people who dug their heels in and simply refused to change—such as the diabetics who left the session, went home, and gorged on sugary snacks. It was only when she took a counseling course that she saw what had been missing: with all that advice-giving, there wasn’t much time left to listen to what the patients actually needed or wanted. After the course, she rethought her whole approach to helping people change their diets. From now on, it wouldn’t be about advice or persuasion, but finding a way of talking that could help people change their own behavior.
“Motivation” is a word that Dympna Pearson uses a lot, but her idea of motivational talk is the opposite of what the word usually implies. It is not about running on stage in a cloud of dry ice and bombast and hectoring people into submission. Most of what Pearson does—and teaches others to do—involves either remaining silent or quietly paraphrasing back to people what they have just said: “reflective listening.” She is a big fan of a 1991 book called Motivational Interviewing, by William Miller and Stephen Rollnick, though she had already worked out much of her basic approach when she first read it. Miller and Rollnick developed “MI” in the 1980s as a way of helping people with problem drinking. Miller, who was treating and researching alcoholism at the University of New Mexico, decided to collect data on which patients were recovering the best. He was surprised to find that he could attribute two-thirds of the variation in how well alcoholics had recovered six months after treatment to “how well their counsellor had listened to them.” The clients who worked with the most “empathic” therapist all succeeded in managing their addiction, whereas only a quarter of those working with the least empathic counselor got better. Talk of empathy is not touchy-feely in this context. It can be the difference between kill and cure.
By the time someone reaches a dietician for weight loss, they are often in a state of defensiveness and despair. They may feel that they have “tried everything,” for years if not decades, and that nothing can or will make a difference. Some claim they do not actually want to change: they say they like their comfort foods too much, they are too busy to exercise, and anyway, they only came along because the doctor told them they had to. In this state, advice is the last thing that will help. Although it may sound counterintuitive, Pearson’s approach involves “rolling with the punches.” Instead of arguing and telling someone that they are wrong to eat such a bad diet—which will only create more hostility—you say something like, “Oh, so it seems as if it’s hard for you to eat healthily right now,” or, “Would you say you are pushed for time to exercise?” It doesn’t matter if there are pauses, because that shows that the dietician is giving the other person time to reflect.
As the conversation continues, maybe you ask them how important they feel it is to change. This is the point where Pearson gets very excited. If she hears the merest inkling of an intention to change, she echoes it back at the client. It might be nothing more than saying something like, “Maybe I do need to lose weight,” or, “I would quite like to get my diabetes under control,” or, “I wish my children ate better.” To Pearson, such statements are golden, because they signal an intention, however slight, to try something different. “We let this change talk fly away, we miss it all the time,” she says. But if a counselor can only hear it and repeat it back, the patient—just maybe—will see that he or she, and not the health professional, is the person who is calling out for change. “It brings a smile to my face when I hear them soften and say, ‘Well, I suppose I could . . .’”
We are all ambivalent about change. Faced with a particularly tempting platter of freshly baked cookies, we may feel a bit like Zerlina in Mozart’s opera Don Giovanni, who struggles—unsuccessfully—not to be seduced while singing the line, “Vorrei e non vorrei”: I want to and I don’t want to. A person can passionately want to lose weight but equally passionately desire the c
omfort of a soft pillowy hamburger with all the extras. It would be dishonest to pretend that there are no downsides to eating slightly less than you could every single day. But the part of us that wants not to eat the hamburger or the plate of cookies is also real. When a dietician hears the first inklings of “change talk,” says Pearson, he should not hurry the person on to the practicalities of dieting or an exercise program, but try to capture the desire for change in such a way that the patient can hear what she has said. The dietician’s job is not to persuade, but to strengthen someone’s own desire for change. At first, a client might say, “I want to, but I can’t.” Or, “I know I should,” which still has a tentative air to it. If the dietician can wait patiently enough, the person may nudge herself out of her own ambivalence. Pearson sees her task as enabling someone to move from saying, “I want to,” or “I should,” to “I will.” This, to her, is the most powerful phrase, because it signals a firm intention rather than just a vague inclination.
Pearson knows that this approach can sound “touchy-feely.” But in her own mind it is simply good, evidence-based medicine. In fact, although there is as yet no conclusive evidence that motivational interviewing is the best way to enable dietary change, the indicators are encouraging. Four controlled randomized studies found that sessions of MI made people more likely to stick with a diet program—whatever the program might be—than conventional dieting interventions alone involving advice, information, and cognitive training in how to change behavior. The signs are that MI can help people to maintain new eating behaviors long enough for them to become habitual. In one study, 148 obese women were all given a year of intensive diet treatment. Each of them participated in eighteen group sessions aimed at giving them the skills and information to make major dietary change. Half of them also received just three sessions of individual MI with a dietician. A year on, the women randomly assigned to the MI group had lost 2.6 percent more body fat than the others.