by Wilson, Bee
A small 2014 trial also found that motivational interviewing helped obese and overweight children lower their BMI. Trials involving addiction rather than diet, however, have been mixed, with motivational interviewing proving more effective in some clinics than in others. Miller and Rollnick put this down to “differences in clinician skill in delivering MI.”
What is starkly clear is just how ineffective the old advice-giving is. As one article on MI says: “Confronting clients can lead to defensiveness, rapport breakage and, ultimately, poor outcomes.” When you hear Dympna Pearson modeling what the standard advice-giving conversation sounds like, it becomes obvious that—however good the intentions—this kind of talk will do no good at all. “The essence of it is how you are with people,” she says. Several times, I saw Pearson do role-playing exercises to demonstrate how easy it can be to slip into an unproductive conversation about change. To show other counselors what is not effective, she keeps jumping in with “helpful” pointers and talks more than she listens, with a very slight sharpness in her voice. Even though it is only role-play, you can hear the other person getting defensive and annoyed. It is painful to watch. It reminded me of the futile conversations I frequently have with my teenager, the ones where I confront him about not leaving his socks on the floor or clearing out his lunchbox; in these exchanges, nothing is achieved, except that both of us are left in a slightly worse mood than before. The more someone is pushed, the more he comes up with reasons why he can’t or won’t change.
It is a truism that no one can make someone else change. “We shouldn’t shove people into the swimming pool,” says Pearson, “when they’re not ready to get in.” Changing our diets always involves losses as well as gains. The water is cold when you first dip a toe in the pool. Giving up junk food involves a separation from some of your fondest childhood memories. Learning to like new foods can feel like leaving your old self behind. Recovering from an eating disorder entails giving up long-established coping mechanisms. Making yourself try foods that you find disgusting is, well, disgusting. The best anyone can do from the outside is help a person get past their own ambivalence. If Dympna Pearson is right, the hardest part, after so many false starts and wrong turns, after all the failed diets and half-watched exercise videos, after all the stigma and the shame, after all the times you’ve told yourself that this diet would be different and all the times that it wasn’t, is finding the motivation to get back in the pool and stay there long enough that you get acclimatized.
Most public health campaigns aimed at changing diets are based on the idea that, once we are made to see that certain foods and behaviors are unhealthy, we will give them up. The evidence, however, shows that change in diet does not work like this. Whether you are a dietician sitting in a room with a diabetic patient or a government tackling an “obesity crisis,” persuasion does not cut it, because this is not how we learn to eat. At a social level, the key to improving diet is not pushing people to do something they are resistant to doing, but removing the barriers to change. These barriers could be psychological, cultural, or economic, or they may have something to do with the environment in which we live. Sometimes our whole food system looks like a giant barrier to change, teaching us every day that it is normal to eat vast amounts of sugar and filling our heads with advertising images of beautiful, healthy people eating unhealthy food. We speak of helping people to make better food choices, but in many modern food stores, choosing healthy foods involves ignoring nine-tenths of what is on display.
It looks as if changes in people’s diets that last often come about through “seamless change,” that is, change that happens without conscious effort. Examples of seamless change would be automatically buying more of something when the price comes down, or unwittingly consuming different ingredients when manufacturers reformulate their products. From 2003 to 2010, the average salt intake in Britain fell by 15 percent, not through individual choice, but because food companies cut the amount of sodium in their products under pressure from lobbying groups and the government: a very benign form of seamless change. The trouble is that most seamless change makes us eat less healthily rather than more so. Croissants start to slip into your mouth every day, as if by accident, because you get a new job where they are laid out with the coffee. Or you don’t notice that the glass of white wine you always order is now much bigger and considerably more alcoholic than its equivalent a decade ago. A 2008 study of more than four hundred people in the United Kingdom found that around 40 percent were eating more takeouts and ready-to-eat meals than they did during childhood, but most could not say why: “The change just happened.” By contrast, when someone tries to make conscious changes to eat more healthily, their path may be lined with hindrances.
Let’s say you resolve to eat more fresh vegetables and fruits every day. You may never get beyond the planning and expense involved in shopping for them. One study found that resolutions to eat more bananas often collapsed at the first hurdle because there were no bananas in the house. Even assuming you manage to lay your hands on a supply of fresh produce, there’s the question of how to cook it. Among a sample of low-income families in Chicago, the ones who ate the fewest home-cooked meals were those who lacked the most basic kitchen equipment, such as chopping boards, peelers, and whisks. And whether you have these items or not, you may not have much idea how to use them. Your plans to eat a wider range of vegetables may also be confounded by other family members who complain that they do not like them, in which case, do you cook yourself a separate meal, or do you cook the disliked foods for everyone and risk more complaints, as well as having to throw good food away?
Culture is another barrier. As we’ve seen, traditional wisdom about feeding frequently clashes with the realities of our new food supply. In Britain, South Asians—from India, Bangladesh, and Pakistan, for example—make up the largest ethnic minority, and they are also statistically the ones with the greatest risk of heart disease and diabetes. Research has shown that among British Asians, there are multiple obstacles to engaging in healthier behavior. Among the older generation, especially, there may be a fatalistic attitude toward illness: the view is that diabetes has been caused by fate, or Allah, or the dreadful British climate, so nothing can be done. Exercise in a gym is viewed by some Muslim Asians as individualistic and selfish; it may be problematic for women, in particular, given cultural expectations in many families that they should not sweat, or be seen to hurry, or wear sports clothes. As for food, the notion of eating smaller portions and limiting rich foods is antithetical to beliefs about hospitality. “Indian sweets are supposedly for special occasions,” says Baldeesh Rai, a dietician who works with South Asian communities, “but in an Asian household, anything can be a special occasion.” Rai has found that in many South Asian families, it is possible to change diets only if the cook of the family—often the mother-in-law—is involved. It doesn’t matter how much information you have on the calorie content of ghee if you are not the one measuring it out.
If you spend too long thinking about all the barriers to change, it’s easy to endorse the common view that almost no one really succeeds in long-term weight loss. You may start to feel hopeless about your chances of sticking to a diet, if that is what you are trying to do. The general opinion is that you might be able to shed a few pounds in the short term, but you will put it all back on again later, with interest, and be worse off than you were before. Anyone with weight issues—or so the thinking goes—is fated to grapple with them for a whole lifetime, without much possibility of improvement. This is a very depressing thought, particularly if you are unlucky enough to have become obese as a child.
Fortunately, it isn’t true. No one could pretend that losing weight and keeping it off is easy, but the evidence suggests that around 20 percent of overweight dieters—one in five—do in fact manage long-term deliberate weight loss, defined as losing at least 10 percent of one’s bodyweight and keeping it off for at least a year. Relatively few s
tudies on weight loss have followed participants for long periods of time, but those that have indicate that a sizable minority do succeed in losing weight without regaining it one year on, and three years on, and even five years on. A little-publicized piece of good news is that, over the past two decades, long-term maintenance of weight loss has improved for those most in need of it. Dr. James Anderson, an endocrinologist at the University of Kentucky, has found that, compared with the 1990s, more of his severely obese patients are able to maintain a large weight loss, perhaps thanks to the use of more intensive and frequent sessions of behavioral coaching. It has proved possible for some patients who needed to lose more than a hundred pounds—and who might otherwise have been candidates for bariatric surgery—to achieve sustained weight loss (with follow-up after five years) using meal-replacement shakes, carefully managed main courses, and lots of fruits and vegetables, plus regular medical support.
The vital question is what it is about the successful 20 percent—referred to as weight “maintainers” in the literature—that makes them able to lose weight and keep it off. They seem to have certain habits in common that set them apart from the relapsers. One thing is that maintainers are much more likely to engage in regular exercise, ideally an hour or more of moderate physical activity every day. This pattern has been confirmed by numerous studies: relapsers do not exercise consistently, whereas maintainers do. We do not know whether exercise helps prevent relapse because of the expenditure of energy, because it’s time when you are not eating, or because it contributes to a sense of well-being: the dopamine and serotonin released when exercising can help prevent depression. Of course, it may also be that the kind of people who persist with weight loss are also the kind who persist with exercise. Correlation is not necessarily causation.
There are certain other habits that “maintainers” have in common. A study of more than 4,000 of them found that they tend to eat breakfast every day and stick to a consistently moderate diet across the week and across the year, rather than holding back during the week and splurging on weekends and holidays (5:2 dieters—take note!). Long after the initial weight-loss “diet” is over, they continue to monitor what they eat, and they are flexible enough to deal with small slips before they turn into major relapses, without beating themselves up. Some of their success may be because of their emotional state. They are less likely to be depressed, and they are much less likely to be binge eaters. “Disinhibition” around food and emotional eating is a strong predictor of weight regain. It is, as always with eating, hard to unravel the complex web of cause and effect here. Relapsers tend to have lower self-esteem and poorer body image than maintainers, but this may be precisely because when they look in the mirror, they feel bad about the weight they have regained. They also seem to feel worse about the whole process of eating.
Counterintuitive as it might sound, the maintainers enjoy their food more. This key difference between maintainers and relapsers was identified by a 1990 study from California. The lead researcher, Susan Kayman, a public health nutritionist, noted that “surprisingly little is known about those who lose weight and regain it.” Kayman decided to find out more by conducting in-depth interviews with three groups of mostly middle-aged women: formerly obese women who had successfully maintained weight loss, formerly obese women who had lost weight and regained it, and average-weight women who had neither put on weight nor lost it. The interviews revealed that in many ways, the maintainers were not so different from the relapsers. They did not differ much in marital status or whether they had children, though the maintainers were slightly more likely to have a university education and to work outside of the home. The most substantial difference was the way they ate.
Maintainers told interviewers that they had never completely restricted their favorite foods, and that they “made efforts to avoid feelings of deprivation while changing food patterns.” As time went on, their appetites had changed. They no longer wanted to eat such large quantities, and many had lost their taste for candy and doughnuts, finding them excessively sweet and fatty. They had changed the way they cooked, not frying food as much as before or using as much sugar, and they included more fruits and vegetables and made smaller portions. But the real change was on the inside, because this was how they now wanted to eat. Like the Japanese, they did not start off eating well; but they were able to change their habits and preferences until they got to a point where delicious food and healthy food were one and the same.
By contrast, the relapsers associated weight loss with eating foods they did not like. While the maintainers devised diet plans to suit their own lives and tastes, the relapsers tended to follow rigid diet programs that actively went against their own food preferences. While “on a diet,” the relapsers would forbid themselves from eating anything they actually enjoyed. As Kayman puts it, they “perceived their diet foods as special foods, different from the foods their family could have and different from the foods they really wanted.” The whole time they were eating these foods, they felt deprived. It didn’t take much for them to give up the struggle and return to the old patterns of eating. Seventy-seven percent of relapsers interviewed by Kayman said that the trigger for weight gain was life throwing up some kind of complication that made them revert to their normal foods. The major obstacle to dietary change is in some ways the most obvious one: no one—adult or child—wants to eat foods that they do not like.
Though this sounds obvious, it stands in contradiction to the way that almost all of our schemes for healthy eating up until now have been constructed—whether on a personal level or a social one. Adam Drewnowski, a professor of public nutrition who studies ways that diets can be improved in whole populations, notes that “nutrition education and intervention strategies aimed at improving diet quality have focused almost exclusively on the nutritional quality of foods and not on the taste or pleasure response.” This is a huge wasted opportunity, because nutrition will only improve if you get people to consume healthier food. And people will only consume healthier food over a lifetime if they consistently choose to eat it. Other things being equal, and assuming that healthier food is available and not too expensive, you will only choose it if it’s something that you enjoy. Instead of intervening at the level of nutrition and information—eat less sugar!—a better place to start would be pleasure. This can be illustrated with a list. The following shows, roughly speaking, how we arrive at the nutritional advantages of eating healthy food. Let’s take broccoli as an example.
1. Sense: You see, smell, and taste the broccoli: its green color; its sweet, crunchy stalks; and its soft, fluffy florets.
2. Response: You respond to the broccoli. Maybe with pleasure, maybe with pain. Your response here will be influenced by whether the broccoli is forced upon you or offered with enthusiasm, the skill with which it is cooked, whether you are a “bitter taster,” and how many times you have been offered the broccoli before.
3. Preference: Based on your response, you form a preference. Either you become a broccoli lover, a broccoli hater, or somewhere in between.
4. Eat: The preference you form about broccoli decides whether you regularly choose and eat broccoli or not.
5. Nutrition: Whether you eat broccoli will decide whether you gain all the nutritional advantages of eating it, which include folate, fiber, vitamin C, and calcium, along with certain disease-fighting phytochemicals.
There is small chance of getting the health benefits of broccoli unless we take the right path through 1, 2, 3, and 4. It doesn’t matter how much “nutrition” there is in a given food unless someone puts it in her mouth. Public health campaigns and diets, however, almost always start at stage 4 or 5. We are told how many benefits there are to eating green, leafy vegetables, and urged to eat more of them. When we fail to change our behavior, they tell us again. And then again. But no one thinks to check first whether we like green, leafy vegetables, or whether we have even tasted them. In 2010, Jamie Oliver’s TV serie
s Food Revolution revealed that many children could not correctly identify common raw vegetables by sight, including potatoes, cauliflower, tomatoes, beets, and eggplant. This suggests that the adults in their lives had never learned to like and cook these vegetables either. You are unlikely to eat something if you don’t know what it is. It’s like being pushed into the swimming pool. The real aim should be to get people to like healthy eating sufficiently that they jump in of their own accord. By the time we are at stage 4 or 5, it’s too late. For a real change in our diets to happen, we need to go back to 1, 2, and 3. When our preferences are in order, nutrition should take care of itself.
Back in the Introduction, I asked what it would take for us to enjoy a “hedonic shift” to enjoying real, whole food. It will perhaps come as no surprise by now that the answer is frequent, positive exposures to those health-giving foods. The surprising part is what a short time frame may be required to shift our palates in a healthier direction. Our tastes are built over decades and reinforced daily by meals and snacks. Yet experiments have shown that at least some of our flavor responses can be relearned over a matter of weeks. The olfactory system is one of the very few parts of the adult brain that is constantly regenerating itself. The brain is flexible enough (the technical term is “plastic”) to change its responses to flavors over a very short period of exposure. This has been demonstrated with salt and sugar, which you might expect to be the most immovable of our tastes.