Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  that exercise can have a negative effect on a certain disease or condition.

  For example, clients with type I diabetes may have trouble with low blood sugar (hypoglycemia) during vigorous workouts. The fear of hypoglycemia may be enough to discourage them from participating in routine physical activity. People who have had a heart attack, stroke, or are rehabilitating from orthopedic surgery are among those who may struggle with the fear

  of exacerbating their condition.

  Clients tend to get stuck in three common traps when thinking about

  physical activity: (1) the all-or-nothing trap, (2) the guilt trap, and (3) the exercise as a punishment trap.

  the Al -or-nothing trap

  Every year, January 1 comes around and New Year’s resolutions start forming. People tend to expect themselves to be able to do more than they actually can or are willing to do. They make vague goals that focus more on extrinsic reward than the intrinsic process and give up when they don’t see it going their way. For example, one such goal is with weight loss.

  Ted has been wanting to lose weight. He’s being pushed by his wife

  and doctor to reduce his heart disease risk. He has high cholesterol,

  and it was recommended that he do some light physical activity on

  most days. Ted has been mostly sedentary for the past 2 years and

  elects to start jogging after work for 60 minutes and weighing himself

  weekly to track his progress. He decides to jog 5 days a week at the

  park near work. After 2 weeks he’s exhausted and sore but excited to

  check in with the scale. Not only does Ted find that he has not lost

  weight, he has gained 2 pounds. He becomes discouraged and throws

  up his hands, saying, “I quit!” He feels bad about himself and fed up

  with trying to get healthier. His wife comes home, surprised to see Ted home so early, sitting on the couch watching a football game.

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  Ted fell into the all-or-nothing trap. He set himself up to do too much and had unrealistic expectations. On top of it, he saw himself getting further from his goal, so he quit. Alternatively, this could all have been avoided if someone had helped guide him toward a more specific, process-driven, intrinsically motivated goal from the start. At this point, Ted has no intrinsic motivation for being active. His extrinsic motivators are to lose weight and lower his cholesterol, which he believes will decrease his risk of developing heart disease. He is also extrinsically motivated as a result of the pressure he gets from both his wife and doctor. It’s not unusual, therefore, for him to quit, especially when the extrinsic reward is removed. (He didn’t see any weight loss.)

  Let’s start over at the beginning. Ted comes to you with orders from

  his doctor to lower his cholesterol and start doing some light physical activity on most days. Using MI, you can help guide Ted to make a goal that supports his doctor’s orders and sets him up for a sustainable and intrinsically motivated healthy habit.

  pRactitioneR: Hi, Ted, what brings you in to see me today? [open-

  ended engaging question]

  teD: My doctor told me to come see you. The last couple times I’ve

  seen him, he’s been on me about my cholesterol. He thinks some

  exercise will help.

  pRactitioneR: Your doctor is concerned about your cholesterol and

  had recommended you do some physical activity to help get it

  down. [simple reflection] What do you think about that plan?

  [open-ended question]

  teD: I think it’s a great idea. I used to be pretty fit, but lately I’ve just gotten out of the habit.

  pRactitioneR: You’re pretty excited to get started and feel the way

  you used to when you were in shape. [reflection, taking a guess at

  unspoken change talk]

  teD: Yeah. I’m thinking about bringing my workout clothes to work

  and heading over the park for a jog before I go home. [change talk]

  pRactitioneR: You’ve really thought about this and you’re ready to

  start feeling better again. When you used to be fit you felt differ-

  ent. [reflection emphasizing change talk] How did you feel back

  then? [open-ended question that evokes change talk]

  teD: I had more energy. I felt good about myself. Strong. [change talk]

  pRactitioneR: You were energized and confident. You want that

  back. [reflection emphasizing change talk]

  teD: Yes, I want to look in the mirror and see my old self again.

  [change talk]

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  pRactitioneR: You want to see a person who’s goal oriented and

  happy with a regular workout routine. [reflection of change talk]

  Take me through your plan. [open-ended question]

  teD: OK. So I bring my workout clothes with me to work, change at

  the office, then drive over to the park. I’m thinking that an hour

  jog takes me around the entire loop three times. That’s what I was

  doing before. [change talk]

  pRactitioneR: Three loops around the park or about an hour jog

  is your ultimate goal. [reflection of change talk] How confident

  are you on a scale of 0 to 10 that you’ll be able to do three laps

  on your first day, with 0 being not confident and 10 being 100%

  confident? [scaling question]

  teD: I think it’s about a 7.

  pRactitioneR: How come a 7 and not an 8 or 9? [probing questions

  to explore possible barriers]

  teD: It’s been a while since I’ve been out jogging. I’m a little worried that I might not make it for the whole hour. [sustain talk] But any

  time is good, right?

  pRactitioneR: When you really think it through, you’re seeing that

  60 minutes sounds like a lot right off that bat, but you’re willing

  to get out there and see what you can do. [complex reflection]

  What would you think about doing an experiment this week to

  ease in more gradually? [open-ended question]

  teD: What do you have in mind?

  pRactitioneR: One idea is to take this week and go through the

  motions to make sure you’ve got everything set up right. Maybe

  just put on your clothes at work and head to the park. You could

  jog a little if you feel like it, but set the goal of just “showing up”

  this week. Then maybe next week, after you’ve played around

  with this part of the goal, you could set a certain number of min-

  utes or laps that line up with your current fitness level. Some of

  my clients have found it useful to use this fitness journal when get-

  ting started to write down your activity and how it feels each time

  you go. [giving information] What do you think? [elicit]

  teD: I like this. I can do this each day this week and let you know how it goes when I come in next week. [change talk]

  pRactitioneR: You’re feeling more confident. How confident are you

  on that scale from 0 to 10, now that we’ve readjusted your goal?

  [scaling question]

  teD: Now I’m a 9 or maybe even a 10!

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  Ted came in with some pretty high expectations for himself. The prac-

  titioner used a scaling question to see how confident Ted was in his goal and found he had some reservations. The counselor was able to suggest

  a fitness journal to help Ted gauge his abilities and gave him the permission to alter his goal as he went. This technique ultimately supports Ted in making goals that go at his own pace. Next week he’ll be likely to have experienced some success, since his goal was developed arou
nd the process instead of the outcome.

  the guilt trap

  The all-or-nothing trap tends to transform into the guilt trap. When clients perceive they have not met their goal for the day, instead of brushing themselves off and starting anew, they throw in the towel and say, “I just can’t do this,” “I’m not worth it,” “Why did I think I could do this in the first place?” This negative self-talk breeds a mindset of failure and squashes any motivation that recently sprouted.

  When a client comes back to you feeling dejected and discouraged,

  explore the guilt and shame she may be experiencing. She may think the

  guilt-filled thoughts will ultimately motivate her to restart. By asking a good evoking question, you may be able to help her recognize the damaging nature of negative self-talk. For example, you could ask, “How might the guilt you are experiencing for not reaching your goal keep you from starting up again?” By using some CBT in combination with MI, you may be

  able to tune your client into the unhelpful nature of negative self-talk and guide her to come up with positive self-talk replacements.

  CBT is the practice of changing your thoughts to create a chain reac-

  tion that ultimately changes how you feel, how you act, and the results you see (Beck, 2005). If your client is able to change her thought from “I just can’t do this,” to “I sometimes have a hard time with this,” she might be more inclined to start up again. Instead of “I feel lousy and guilty,” she could reframe the statement to, “I could try that again but with a little less of this and that and a little more of these.” The key is to help your client become aware of the negative self-talk and guide her in developing positive self-talk replacements. She will be more likely to try again and then enjoy the results of accomplishing her goal.

  You can help her make those changes by asking open-ended questions

  about her negative self-talk, reflecting her feelings, and asking permission before offering alternative positive self-talk.

  the exercise as a Punishment trap

  Many people use exercise as a way to make up for undesirable eating

  behaviors. The old adage of energy balance described as energy in = energy

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  out becomes a construct that can oversimplify the very complex variables of metabolism and appetite. However, clients often get caught up in the thought that our bodies are simple math equations; if you burn a certain number of calories, you can erase that slice of cheesecake or milkshake.

  The truth is, counting calories you consume and charting the calories you burn rarely gives you reliable results after the first 6 months (Mann et al., 2007). Over time, people end up feeling discouraged and dreading the prescribed exercise as if it were a punishment for their eating “sins.”

  Clients can benefit more from nutrition and fitness counseling that is

  free from authoritative pressure. The right to eat what’s right for your body is inalienable. No matter one’s weight, there is nothing one can eat that is deserving of punishment. When the eating culture becomes one of sins and virtue, the cornerstone of well-being begins to crumble. No matter what kind of practitioner you are, you can help your clients see their inherent value as human beings and the potential they have to flourish. Because in the end, eating right and living an active lifestyle are only tools to improve and enhance one’s ability to feel joy and live a happy life. Motivating oneself with guilt and shame rarely leads to happy and healthy living.

  Through applying MI to a session about physical activity, the focus

  is shifted away from telling clients recommended minutes and steps necessary for good health and toward eliciting intrinsic motivation and enjoyable ways to move their bodies. In today’s fast-paced world, it can be a challenge to find time to squeeze in physical activity. However, clients will go to great lengths to make time for activities that are fun and feel good. Self-discoveries of the life-enhancing properties of physical activity will result in a lifetime commitment to change.

  chAPter 15

  Put ing Motivational Interviewing

  to Work to Address Weight Concerns

  and Disordered Eating

  The scale can only give you a numerical reflection of your

  relationship with gravity. That’s it. It cannot measure beauty,

  talent, purpose, life force, possibility, strength, or love.

  —SteVe maRaBoli

  We live in a dieting culture, bombarded daily by advertisements for weight loss aids with enticing success stories plastered on magazines, websites, and social media. From boot camp-style workout regimens, to commercial diet programs, diet pills, shakes, and surgeries, the message runs deep—beauty and health are dependent on body shape and size. And yet, more often than not, these attempts at losing weight fail (Mann et al., 2007).

  The weight loss and diet control market is a $61 billion industry that

  is failing the American public (Market Data Enterprises, 2013). Weight loss programs, whether fad diets or under the guise of “lifestyle changes,” are often chosen as short-term solutions, resulting in weight loss followed by weight regain (Bacon et al., 2002; Bacon, Stern, Van Loan, & Keim, 2005; Dansinger, Gleason, Griffith, Selker, & Schaefer, 2005; Dansinger, Tatsioni, Wong, Chung, & Balk, 2007; Mann et al., 2007; Neumark-Sztainer et al., 2006; Stice, Cameron, Killen, Hayward, & Taylor, 1999).

  Weight loss programs are not

  only ineffective in the long run but

  The weight loss and diet control

  also can be physiologically and psy-

  market is a $61 billion industry

  chologically damaging (Bacon et

  that is failing the American

  al., 2002; Bacon et al., 2005; Mann

  public.

  et al., 2007; Steinhardt, Bezner, &

  Adams, 1999; Tomiyama, Ahlstrom,

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  MI to Address Weight Concerns and Disordered Eating 233

  & Mann, 2013). Moreover, an individual’s fitness level may be a better predictor of mortality than weight and body composition (Barry, Beets,

  Durstine, Liu, & Blair, 2014)

  Emerging research suggests that promoting weight loss may cause

  more harm than good (Ramos Salas, 2015; Tylka et al., 2014); however,

  health care professionals are increasingly pressured to instruct their clients to lose weight. While practitioners have good intentions, they may be inadvertently promoting weight bias, which negatively affects their larger clients (Tomiyama, 2014). In fact, clients who are told to lose weight are more likely to gain weight over time (Sutin & Terracciano, 2013).

  Weight bias can be defined as the inclination to form unreasonable judgments based on a person’s weight (Washington, 2011). According to

  the Centers for Disease Control and Prevention (Washington, 2011), weight bias is caused by the belief that stigma and shame motivates people to lose weight. Weight bias often goes unnoticed due to cultural values of thinness.

  Thin is viewed as healthy and fat is viewed as unhealthy. In reality, size is not a direct reflection of health. Given the genetic component of body size, there are many thin individuals who are aerobically unfit and eat a nutrient-poor diet and many fat individuals who are aerobically fit and eat a nutrient-rich diet. Recent research comparing mortality rates among all weight categories has uncovered

  that your overweight and obese cli-

  ents (body mass index = 25–35) may Motivating through shame and

  actually live the longest (Flegal, Kit, stigma is in direct opposition to Orpana, & Graubard, 2013; Lantz, the spirit of MI.

  Golberstein, House, & Morenoff,

  2010).

  Regardless of your clients’ weight or health status, motivating them

  through shame and stigma is in direct opposition to the spirit of MI. True acceptance is modeled through communicating absolute worth no matter

  the clients’ size or shape. The purpose of this cha
pter is to give you tools to discuss your clients’ weight and disordered eating concerns with the spirit of MI as your guiding force and with the focus of your counseling on overall health and well-being. Whether your clients are struggling with binge-eating disorder, bulimia, or general body dissatisfaction, they will benefit from counseling that aims to heal their relationship with food and fitness while enhancing body esteem.

  IntroducIng A weIght-neutrAl APProAch

  If improving health is truly the focus within a nutrition and fitness counseling session, then it is in the client’s best interest for the practitioner to focus on nutrition and fitness behaviors and not on weight. The ultimate

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  goal is for clients to make sustainable changes and mounting evidence suggests that a non-diet approach is more conducive to adopting long-term

  changes while minimizing disordered eating patterns (Tylka et al., 2014). In addition, this nonjudgmental, nonstigmatizing approach is preferred by clients, resulting in more return visits (Schaefer & Magnuson, 2014; Thomas, Lewis, Hyde, Castle, & Komesaroff, 2010).

  One such non-diet approach is the Health At Every Size® (HAES®)

  paradigm (Figure 15.1).* The HAES approach differs from traditional

  weight-focused paradigms in that clients are encouraged to tune in to hunger and fullness cues, energy levels, and cravings to guide eating and activity timing and quantity (Bacon & Aphramor, 2011; Association for Size Diversity and Health, 2014). HAES is a weight-neutral approach, meaning that the focus is not on weight, but on helping the client make healthy lifestyle changes while allowing weight to stabilize at a number that is largely genetically driven and varies widely from person to person. Historically, the word “fat” has had a negative connotation; supporters of this movement advocate reclaiming this word as a descriptive term and not as a negative judgment of character or physicality.

  Poor health and disease affects individuals of all sizes. The HAES mes-

  sage is not that all body weights are health-enhancing for all individuals.

  Not everyone is at a weight that is optimal for their health. However, that 1. Weight inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.