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Applying a philosophy of nutrition education to weight control
VIEWPOINT Applying a Philosophy of Nutrition Education to Weight Control ELLEN
S.
PARHAM
Department of Human and Family Resources, Northern Illinois University, DeKalb, Illinois 60115 Nutrition education programs aimed at weight control are long overdue for a major overhaul. Any critical reading of the literature reveals that our best efforts produce significant weight losses for only a few individuals and that, for most of these individuals, these losses are not sustained. However, it is not these "failures" that prompt me to call for a rethinking of weight control strategy. Given the realities of bioenergetics and of our contemporary social environment, this limited ability of individuals to achieve long-term weight changes may be inevitable. It is our apparent inability to face these truths and to incorporate them into our programming philosophy that concerns me. By this we do harm, harm to our clients who suffer diminished self esteem and may be drawn to more and more extreme measures of weight control, and harm to ourselves and to our profession. Achterberg and Trenkner (1) have provided the groundwork for developing a working philosophy of nutrition education. I will follow the framework of their major ideas to point out examples of applications appropriate to weight control. The term "weight control" will usually refer to efforts by overweight people to lose weight, to maintain weight loss, or to avoid further weight gain. However, many of the ideas are applicable to weight control in the broadest sense. The reader should not exclude applications of these ideas to nutrition education programs targeting anorexia nervosa and bulimia. In collecting these ideas, I have drawn upon my personal experiences as an overweight nutrition educator, my professional experiences involving six years ofleading a weight control gJ,"oup, and more than twenty years of research into factors affecting weight change. Also represented are t~e ideas and experiences of many graduate students and of a number of nutrition educators in northern Illinois who meet annually to exchange ideas about weight control programming.
PATERNALISTIC APPROACHES IN WEIGHT CONTROL PROGRAMMING It is easy to discover examples of paternalism in weight control programming. Some of the traditional, but still widely used techniques fit Achterberg and Trenkner's description of a paternalistic approach as one where the expert professional assumes full responsibility for all patient-oriented decisions. Think how often we launch our programs by referring to our official charts or formulas to determine goal weights. We distribute diet plans based on our own decisions as to the number of calories required daily or to the proper pattern of meals. Some programs emphasize following their diet exactly, labeling even the slightest deviation as "not legal." These practices reduce the long range effectiveness of our programs, but we often continue them because they seem efficient. However, they are relatively benign compared with some more subtle paternalistic approaches. One such approach involves the automatic assumption that every overweight person can achieve slenderness and should proceed forthwith to pursue this goal. We usually find it easy to support this assumption, because society imposes such severe penalties for deviation from an "ideal" weight and because of the much quoted association of obesity with risks to health. The fact of the matter is that these risks are variable, depending upon the person's age, sex, and genetic makeup (2). Furthermore, we need to remember that good health is not an end in itself, but a means toward achieving the end of improved quality of life. Another serious shortcoming of paternalistic approaches to weight control is the failure to be honest about the difficulties of weight loss maintenance. It is easy to brainwash ourselves into believing that anyone who follows our expert advice can become slender forever. Those who do not are "deviant." Sooner or later patients must venture away from our care. If we have created false expectations, we have probably done more harm than good. Regrettably, before we leave the discussion of paternalism in weight control, it is necessary to comment upon
Address correspondence to: Ellen S. Parham, Department of Human and Family Resources, Northern Illinois University, DeKalb, IL 60115. 0022-3182/90/2204-0194$02.00/0 © 1990 SOCIETY FOR NUTRITION EDUCATION
194
J. ofNutr. Educ. Vol. 22, No.4
the influence of profit motives. The frantic desire of Americans to be thin creates a huge market for any program or product that promises help. Competitiveness in this market demands the guarantee of quick success. The suggestion of alternative goals or treatments may limit program enrollment. Certainly, any honest discussion of long-term difficulties in weight loss maintenance will be labeled as unduly discouraging. It is a very real challenge to find ways to deliver helpful programming in such an atmosphere without succumbing to paternalism.
MORALISTIC APPROACHES IN WEIGHT CONTROL PROGRAMMING The good old Puritan ethic that leads to moralistic nutrition education approaches works overtime when it comes to weight control issues. Allon (2) eloquently pointed out that in the contemporary United States, fatness is stigmatized not only as a disease and as an aesthetic affront, but also as a sin and a crime. Punishment for the sins of gluttony and sloth can take the form of ostracism or ridicule or, if the guilty party agrees to rehabilitation, deprivation offood and endurance of painful exercise. Do any of these situations sound familiar? -The leader who brags about telling participants who are not losing weight at the expected rate that they would be better off to drop out of the program. -The participant who starts her account of the week by saying that she wasn't very good and continues to describe how she devoted herself to a neighboring family struggling to cope with the unexpected death of the mother. Somehow there wasn't much time for exercise and the rich foods brought in by neighbors were too available. And so she was bad. -The woman who had complained to her family physician for years about her indigestion and diarrhea. He always reminded her that she was overweight and if she wouldn't eat so much, her digestion would be fine. Finally, she was diagnosed by a specialist as having a gluten intolerance. Although her health is better today, she is still overweight and is embarassed to see her family doctor for her regular checkup. The list could go On and on. Obviously there is a strong moralistic overtone to contemporary weight control programming. Our judgment is most harsh when we apply it to members of our own profession. We tell one another, "Unless you can be a model of good nutrition, you should leave the profession. We must practice what we preach." Certainly, if our approach to nutrition education is preaching, this is appropriate advice. However, when we preach or use other moralistic approaches, we totally ignore genetic and other factors that make weight control more difficult for some people than for others. The Wooleys have given us a timely reminder (3) that effort is not
August 1990
195
always enough: "Obese people seemingly do little out of the ordinary to cause them to be fat and once they are fat, only the most extraordinary behavior will allow them to become thin." Achterberg and Trenkner (1) point out that moralistic approaches assume that any problem is soluble by the application of will power and hard work, and view the role of the change agent as that of providing information and motivation. If these are, in truth, the only elements missing for successful weight control, the very concept of an overweight nutritionist would be a contradiction in terms. Overweight people are usually quite willing to accept blame for their fatness and for their failure in weight loss programs. Several of my graduate students explored this phenomenon by doing a random telephone survey inquiring as to people's reasons for dropping out of various self-improvement programs. In programs other than weight loss, reasons for dropping out were equally divided among dissatisfaction with the program, dissatisfaction with self, and external factors, such as a change in work schedule. However, among those people who had been in weight loss programs, dissatisfaction with themselves was the most frequently given explanation for abandoning the effort.
IDENTIFYING A MORE EFFECTIVE MODEL Achterberg and Trenkner (1) recommend the compensatory model, in which individuals are viewed as responsible for the solution to their problem but not necessarily for the occurrence of the problem. They suggest that this model is most appropriate for most circumstances involving individual behavior change. Because the compensatory model can involve a provider-client partnership characterized by active participation, it has the potential to empower the client. Is this the model upon which we should base our overhaul of weight control programming? Will it work with the special characteristics of weight control? Obesity is characterized by a multiple etiology, some of the contributing factors being within an individual's control and some beyond. In addition, some of the factors that tend to perpetuate obesity are responses to the fatness rather than causes of the initial excessive gain. Generally, I find that it is not useful to try to assign responsibility for the occurrence of the problem of obesity. The contributing factors are usually so numerous and the interactions among them so intricate that it is impossible to sort them out. In any case, solutions do not usually consist of just undoing contributing factors. For example, it has not been shown that eating fast is a universal characteristic of obese people, but slowing the pace of eating helps many people to control the amount eaten. Furthermore, focusing upon responsibility for the devel-
196
Parham / Weight Control
opment of the weight problem translates quite easily into guilt for many people; as discussed above, guilt feelings are more likely to deter, rather than to assist in pursuing solutions. A model that focuses upon solution rather than upon guilt or blame for occurrence of the weight problem is most appropriate in establishing a program for weight control. Another fundamental characteristic is that weight control involves changing numerous and extremely complex behaviors. These behaviors are highly individualized. The model of choice will involve treating participants as unique individuals, rather than as beings whose performance can be predicted by mathematical formulas. Behavior changes slowly and the changes must be sustained or even accelerated for years, probably for the rest of the individual's life. Responsible programming must have a long-term focus. Short-term weight losses frequently have little significance in long-term weight control (5). Because no health care system can afford to provide never-ending programs, the successful model must empower the client to take over the long-term responsibility for the maintenance of appropriate weight control behavior. Although no nutrition education programs can guarantee success, the outcome of the treatment of obesity is especially difficult to predict. This uncertainty means that weight control goals have to be highly individualized and must be repeatedly redefined. The model must have the flexibility to allow this. Although there are probably people who lose weight and keep it off without professional help, nutrition educators are more likely to work intensely with persons who have a history of many unsuccessful attempts and who are characterized by low self-esteem and anticipation of failure. If these individuals are to take responsibility for their own weight control, these feelings of inadequacy must be replaced by confidence and a sense of control. The model must lend itself to approaches that help the participants learn to use their own personal resources and to obtain help from outside resources when needed. The compensatory model provides for a partnership between provider and client in which each is an active participant. This can be an ideal system for providing some of the missing resources without developing dependence upon the provider. Achterberg and Trenkner describe four phases of this partnership process. Effective nutrition educators are already implementing programs utilizing these phases. There is not the space here to examine each of these phases, but a few comments on the first phase will illustrate how this partnership can work in weight control. In this phase, the change agent helps the client to build up motivating power. Most clients in weight control programs have a strong desire to lose weight, but this desire does not always translate into useful and sustained motivation. I visualize desire as a nice, soft, pink, wispy
cloud, whereas useful motivation is more like the force of steam under pressure. The desire can be converted into useful motivation, but the conversion is inhibited by the remoteness of the goal, by competition from other priorities, and by barriers, including conflicting motivations. It is the client's own needs and values that determine the motivation, but the educator can help by showing the client how to break down the pursuit of a remote goal, such as "slenderness," into a series of more concrete and short term objectives. The partnership involves the client identifying his/her own desires, values and goals, and selecting the first steps, while the leader contributes understanding of the process and helps by raising questions and refocusing attention when necessary. Thus, the leader does not really motivate the client but, instead, helps the client develop the power to harness and sustain hislher own motivation. Achterberg and Trenkner (1) advance a platform of thought that they recommend as a basis for a philosophical perspective for nutrition education. Let us examine the appropriateness of these perspectives to weight control. The first perspective is that life is open-ended, nothing is absolute, and change is always possible. I think of a woman I knew in a weight control program. She attended the entire four-month series, but accomplished little toward her stated goal of weight loss. I was rather surprised when she was back in the next series and making real progress. She explained that during the first series she had been so preoccupied with a death in the family that coming to meetings was all she could manage. She thought of herself as lying fallow, gathering strength for a later effort. Fortunately, the program avoided moralistic tones that would have labeled her a failure during the first series. Unfortunately, change is not always for the better. The efforts that paid off at one time may not be equally successful at a later date. The effects of aging, and possibly the effects of yo-yo dieting, are such that it becomes more difficult over time to establish a negative calorie balance. On the other hand, these negative effects may be counterbalanced by improvements in social support or other behavioral factors. So, the advice given by Achterberg and Trenkner, that we should never permanently give up hope on anyone group or individual, is very applicable in weight control programming. The second suggested plank in the AchterbergiTrenkner platform is that humans are free agents, unique individuals, capable of purposeful action and moral responsibility. In this regard we must examine our usually automatic assumption that every overweight individual can and should lose weight. There are many valid alternatives to a goal of achieving absolute slenderness: lose just enough weight to relieve a health problem or to fit into ordinary-size clothes, increase fitness and flexibility through exercise, achieve a sense of control over eating, increase self esteem, improve nutritive adequacy, de-
J. ofNutr. Educ. Vol. 22, No.4
velop a family life-style that will reduce the risk of obesity for the children, and others. We can help people by vebalizing that alternative goals are acceptable and by encouraging them to consider their own values, as well as the benefits and costs of achievement of each objective. Finally Achterberg and Trenkner remind us that life is difficult. Anyone who has worked with weight control programming or dealt with a personal weight problem can attest to the applicability of this thought. The truth is that once an individual is overweight, it requires a lifetime of effort tQ avoid staying that way. Weight loss is not easy, but maintenance is even more difficult. It's rather like the problem of heating your house in a cold climate. During the winter you can run your furnace at one low level all the time or you can tum it down sometimes and up at other times, but you still have to run it. You can make a constant effort at weight control or you can make intermittent efforts, but you will have to make some kind of effort. You can insulate your house and use other measures to reduce heat loss, but still you will have to do some heating. You can change your living habits and ways of thinking about food and exercise, and thereby reduce the amount of effort required for weight loss maintenance, but we have no evidence that you can ever expect to reach a state where you don't have to continue to work at it. My colleagues and I have studied attitudes toward the weight control process as expressed by dietitians, dieters, fitness instructors (6), and as reported in women's magazines articles on weight control (7, 8). Generally, our finding is a failure on the part of many weight control programs and magazine articles to be honest about the difficulties of weight loss maintenance. Sure, everyone says that there is no easy answer, but the general tone of optimism belies the extent of the difficulty. This leaves the participants unprepared for what lies ahead. When they encounter the almost inevitable weight regains, the tendency is to feel shame. This leads to reduced self esteem, again reducing the chances of any sustained achievement. How to be honest without being unduly discouraging is one of the major challenges of weight control programming. The recognition of alternative goals for overweight individuals is one possibility. Another is to rec-
August 1990
197
ognize that clients with a long history of weight control efforts have already experienced the difficulties of weight loss maintenance. Talking about these difficulties honestly will validate their experiences. I like to talk about the fact that weight control exacts a cost - in some cases, that cost in terms of time, attention, and sacrifice is very high. Each individual has to discover for herself what price he/she is willing and able to pay. Yes, there is much about contemporary weight control programming that is due for an overhaul. Many talented and dedicated nutrition educators have worked hard to develop programs that utilize the current research base on weight control and avoid the pitfalls of some of the more traditional approaches. We should learn from the example of these educators. We will find that the best of the programs are built upon the compensatory model that is not only characterized by the active participation of both leader and client, but also encompasses the truths that life is open-ended, humans are free agents, and life is difficult. 0
REFERENCES 1 Achterberg, C. and L.L. Trenkner. Developing a working philosophy of nutrition education. Journal of Nutrition Education 22:189193,1990. 2 Ernsberger, P. and P. Haskew. Rethinking obesity: An alternative view of its health implications. Journal of Obesity and Weight Regulation 6:57-137, 1987. 3 Allon, N. The stigma of overweight in everyday life. In Obesity in Perspective, vol 2, part 2, C.A. Bray, ed. Washington, D.C.: U.S. Cov. Printing Office, 1973, pp. 83--102. 4 Wooley, S.C. and O.W. Wooley. Obesity and women. I. A closer look at the facts. Women's Studies International Quarterly 2:69-79, 1979. 5 Parham, E.E. The context of weight changes: Factors associated with weight changes in adult women. Journal of the American Dietetic Association 88: 1539-1544, 1988. 6 Parham, E.S., M.J. Flynn, V.L. Frigo, and A.H. Perkins. Weight control: Attitudes and opinions of dieters and change agents. Accepted for publication by the Journal of Home Economics. 7 Parham, E.S., V.L. Frigo, and A.H. Perkins. Weight control as depicted in popular magazines. Journal ofNutrition Education 14:153156,1982. 8 Parham, E.S., S.L. King, M.L. Bedell, and S. Martersteck. Weight control content of women's magazines: Bias and accuracy. International Journal of Obesity 10:19-28, 1986.
S.
PARHAM
Department of Human and Family Resources, Northern Illinois University, DeKalb, Illinois 60115 Nutrition education programs aimed at weight control are long overdue for a major overhaul. Any critical reading of the literature reveals that our best efforts produce significant weight losses for only a few individuals and that, for most of these individuals, these losses are not sustained. However, it is not these "failures" that prompt me to call for a rethinking of weight control strategy. Given the realities of bioenergetics and of our contemporary social environment, this limited ability of individuals to achieve long-term weight changes may be inevitable. It is our apparent inability to face these truths and to incorporate them into our programming philosophy that concerns me. By this we do harm, harm to our clients who suffer diminished self esteem and may be drawn to more and more extreme measures of weight control, and harm to ourselves and to our profession. Achterberg and Trenkner (1) have provided the groundwork for developing a working philosophy of nutrition education. I will follow the framework of their major ideas to point out examples of applications appropriate to weight control. The term "weight control" will usually refer to efforts by overweight people to lose weight, to maintain weight loss, or to avoid further weight gain. However, many of the ideas are applicable to weight control in the broadest sense. The reader should not exclude applications of these ideas to nutrition education programs targeting anorexia nervosa and bulimia. In collecting these ideas, I have drawn upon my personal experiences as an overweight nutrition educator, my professional experiences involving six years ofleading a weight control gJ,"oup, and more than twenty years of research into factors affecting weight change. Also represented are t~e ideas and experiences of many graduate students and of a number of nutrition educators in northern Illinois who meet annually to exchange ideas about weight control programming.
PATERNALISTIC APPROACHES IN WEIGHT CONTROL PROGRAMMING It is easy to discover examples of paternalism in weight control programming. Some of the traditional, but still widely used techniques fit Achterberg and Trenkner's description of a paternalistic approach as one where the expert professional assumes full responsibility for all patient-oriented decisions. Think how often we launch our programs by referring to our official charts or formulas to determine goal weights. We distribute diet plans based on our own decisions as to the number of calories required daily or to the proper pattern of meals. Some programs emphasize following their diet exactly, labeling even the slightest deviation as "not legal." These practices reduce the long range effectiveness of our programs, but we often continue them because they seem efficient. However, they are relatively benign compared with some more subtle paternalistic approaches. One such approach involves the automatic assumption that every overweight person can achieve slenderness and should proceed forthwith to pursue this goal. We usually find it easy to support this assumption, because society imposes such severe penalties for deviation from an "ideal" weight and because of the much quoted association of obesity with risks to health. The fact of the matter is that these risks are variable, depending upon the person's age, sex, and genetic makeup (2). Furthermore, we need to remember that good health is not an end in itself, but a means toward achieving the end of improved quality of life. Another serious shortcoming of paternalistic approaches to weight control is the failure to be honest about the difficulties of weight loss maintenance. It is easy to brainwash ourselves into believing that anyone who follows our expert advice can become slender forever. Those who do not are "deviant." Sooner or later patients must venture away from our care. If we have created false expectations, we have probably done more harm than good. Regrettably, before we leave the discussion of paternalism in weight control, it is necessary to comment upon
Address correspondence to: Ellen S. Parham, Department of Human and Family Resources, Northern Illinois University, DeKalb, IL 60115. 0022-3182/90/2204-0194$02.00/0 © 1990 SOCIETY FOR NUTRITION EDUCATION
194
J. ofNutr. Educ. Vol. 22, No.4
the influence of profit motives. The frantic desire of Americans to be thin creates a huge market for any program or product that promises help. Competitiveness in this market demands the guarantee of quick success. The suggestion of alternative goals or treatments may limit program enrollment. Certainly, any honest discussion of long-term difficulties in weight loss maintenance will be labeled as unduly discouraging. It is a very real challenge to find ways to deliver helpful programming in such an atmosphere without succumbing to paternalism.
MORALISTIC APPROACHES IN WEIGHT CONTROL PROGRAMMING The good old Puritan ethic that leads to moralistic nutrition education approaches works overtime when it comes to weight control issues. Allon (2) eloquently pointed out that in the contemporary United States, fatness is stigmatized not only as a disease and as an aesthetic affront, but also as a sin and a crime. Punishment for the sins of gluttony and sloth can take the form of ostracism or ridicule or, if the guilty party agrees to rehabilitation, deprivation offood and endurance of painful exercise. Do any of these situations sound familiar? -The leader who brags about telling participants who are not losing weight at the expected rate that they would be better off to drop out of the program. -The participant who starts her account of the week by saying that she wasn't very good and continues to describe how she devoted herself to a neighboring family struggling to cope with the unexpected death of the mother. Somehow there wasn't much time for exercise and the rich foods brought in by neighbors were too available. And so she was bad. -The woman who had complained to her family physician for years about her indigestion and diarrhea. He always reminded her that she was overweight and if she wouldn't eat so much, her digestion would be fine. Finally, she was diagnosed by a specialist as having a gluten intolerance. Although her health is better today, she is still overweight and is embarassed to see her family doctor for her regular checkup. The list could go On and on. Obviously there is a strong moralistic overtone to contemporary weight control programming. Our judgment is most harsh when we apply it to members of our own profession. We tell one another, "Unless you can be a model of good nutrition, you should leave the profession. We must practice what we preach." Certainly, if our approach to nutrition education is preaching, this is appropriate advice. However, when we preach or use other moralistic approaches, we totally ignore genetic and other factors that make weight control more difficult for some people than for others. The Wooleys have given us a timely reminder (3) that effort is not
August 1990
195
always enough: "Obese people seemingly do little out of the ordinary to cause them to be fat and once they are fat, only the most extraordinary behavior will allow them to become thin." Achterberg and Trenkner (1) point out that moralistic approaches assume that any problem is soluble by the application of will power and hard work, and view the role of the change agent as that of providing information and motivation. If these are, in truth, the only elements missing for successful weight control, the very concept of an overweight nutritionist would be a contradiction in terms. Overweight people are usually quite willing to accept blame for their fatness and for their failure in weight loss programs. Several of my graduate students explored this phenomenon by doing a random telephone survey inquiring as to people's reasons for dropping out of various self-improvement programs. In programs other than weight loss, reasons for dropping out were equally divided among dissatisfaction with the program, dissatisfaction with self, and external factors, such as a change in work schedule. However, among those people who had been in weight loss programs, dissatisfaction with themselves was the most frequently given explanation for abandoning the effort.
IDENTIFYING A MORE EFFECTIVE MODEL Achterberg and Trenkner (1) recommend the compensatory model, in which individuals are viewed as responsible for the solution to their problem but not necessarily for the occurrence of the problem. They suggest that this model is most appropriate for most circumstances involving individual behavior change. Because the compensatory model can involve a provider-client partnership characterized by active participation, it has the potential to empower the client. Is this the model upon which we should base our overhaul of weight control programming? Will it work with the special characteristics of weight control? Obesity is characterized by a multiple etiology, some of the contributing factors being within an individual's control and some beyond. In addition, some of the factors that tend to perpetuate obesity are responses to the fatness rather than causes of the initial excessive gain. Generally, I find that it is not useful to try to assign responsibility for the occurrence of the problem of obesity. The contributing factors are usually so numerous and the interactions among them so intricate that it is impossible to sort them out. In any case, solutions do not usually consist of just undoing contributing factors. For example, it has not been shown that eating fast is a universal characteristic of obese people, but slowing the pace of eating helps many people to control the amount eaten. Furthermore, focusing upon responsibility for the devel-
196
Parham / Weight Control
opment of the weight problem translates quite easily into guilt for many people; as discussed above, guilt feelings are more likely to deter, rather than to assist in pursuing solutions. A model that focuses upon solution rather than upon guilt or blame for occurrence of the weight problem is most appropriate in establishing a program for weight control. Another fundamental characteristic is that weight control involves changing numerous and extremely complex behaviors. These behaviors are highly individualized. The model of choice will involve treating participants as unique individuals, rather than as beings whose performance can be predicted by mathematical formulas. Behavior changes slowly and the changes must be sustained or even accelerated for years, probably for the rest of the individual's life. Responsible programming must have a long-term focus. Short-term weight losses frequently have little significance in long-term weight control (5). Because no health care system can afford to provide never-ending programs, the successful model must empower the client to take over the long-term responsibility for the maintenance of appropriate weight control behavior. Although no nutrition education programs can guarantee success, the outcome of the treatment of obesity is especially difficult to predict. This uncertainty means that weight control goals have to be highly individualized and must be repeatedly redefined. The model must have the flexibility to allow this. Although there are probably people who lose weight and keep it off without professional help, nutrition educators are more likely to work intensely with persons who have a history of many unsuccessful attempts and who are characterized by low self-esteem and anticipation of failure. If these individuals are to take responsibility for their own weight control, these feelings of inadequacy must be replaced by confidence and a sense of control. The model must lend itself to approaches that help the participants learn to use their own personal resources and to obtain help from outside resources when needed. The compensatory model provides for a partnership between provider and client in which each is an active participant. This can be an ideal system for providing some of the missing resources without developing dependence upon the provider. Achterberg and Trenkner describe four phases of this partnership process. Effective nutrition educators are already implementing programs utilizing these phases. There is not the space here to examine each of these phases, but a few comments on the first phase will illustrate how this partnership can work in weight control. In this phase, the change agent helps the client to build up motivating power. Most clients in weight control programs have a strong desire to lose weight, but this desire does not always translate into useful and sustained motivation. I visualize desire as a nice, soft, pink, wispy
cloud, whereas useful motivation is more like the force of steam under pressure. The desire can be converted into useful motivation, but the conversion is inhibited by the remoteness of the goal, by competition from other priorities, and by barriers, including conflicting motivations. It is the client's own needs and values that determine the motivation, but the educator can help by showing the client how to break down the pursuit of a remote goal, such as "slenderness," into a series of more concrete and short term objectives. The partnership involves the client identifying his/her own desires, values and goals, and selecting the first steps, while the leader contributes understanding of the process and helps by raising questions and refocusing attention when necessary. Thus, the leader does not really motivate the client but, instead, helps the client develop the power to harness and sustain hislher own motivation. Achterberg and Trenkner (1) advance a platform of thought that they recommend as a basis for a philosophical perspective for nutrition education. Let us examine the appropriateness of these perspectives to weight control. The first perspective is that life is open-ended, nothing is absolute, and change is always possible. I think of a woman I knew in a weight control program. She attended the entire four-month series, but accomplished little toward her stated goal of weight loss. I was rather surprised when she was back in the next series and making real progress. She explained that during the first series she had been so preoccupied with a death in the family that coming to meetings was all she could manage. She thought of herself as lying fallow, gathering strength for a later effort. Fortunately, the program avoided moralistic tones that would have labeled her a failure during the first series. Unfortunately, change is not always for the better. The efforts that paid off at one time may not be equally successful at a later date. The effects of aging, and possibly the effects of yo-yo dieting, are such that it becomes more difficult over time to establish a negative calorie balance. On the other hand, these negative effects may be counterbalanced by improvements in social support or other behavioral factors. So, the advice given by Achterberg and Trenkner, that we should never permanently give up hope on anyone group or individual, is very applicable in weight control programming. The second suggested plank in the AchterbergiTrenkner platform is that humans are free agents, unique individuals, capable of purposeful action and moral responsibility. In this regard we must examine our usually automatic assumption that every overweight individual can and should lose weight. There are many valid alternatives to a goal of achieving absolute slenderness: lose just enough weight to relieve a health problem or to fit into ordinary-size clothes, increase fitness and flexibility through exercise, achieve a sense of control over eating, increase self esteem, improve nutritive adequacy, de-
J. ofNutr. Educ. Vol. 22, No.4
velop a family life-style that will reduce the risk of obesity for the children, and others. We can help people by vebalizing that alternative goals are acceptable and by encouraging them to consider their own values, as well as the benefits and costs of achievement of each objective. Finally Achterberg and Trenkner remind us that life is difficult. Anyone who has worked with weight control programming or dealt with a personal weight problem can attest to the applicability of this thought. The truth is that once an individual is overweight, it requires a lifetime of effort tQ avoid staying that way. Weight loss is not easy, but maintenance is even more difficult. It's rather like the problem of heating your house in a cold climate. During the winter you can run your furnace at one low level all the time or you can tum it down sometimes and up at other times, but you still have to run it. You can make a constant effort at weight control or you can make intermittent efforts, but you will have to make some kind of effort. You can insulate your house and use other measures to reduce heat loss, but still you will have to do some heating. You can change your living habits and ways of thinking about food and exercise, and thereby reduce the amount of effort required for weight loss maintenance, but we have no evidence that you can ever expect to reach a state where you don't have to continue to work at it. My colleagues and I have studied attitudes toward the weight control process as expressed by dietitians, dieters, fitness instructors (6), and as reported in women's magazines articles on weight control (7, 8). Generally, our finding is a failure on the part of many weight control programs and magazine articles to be honest about the difficulties of weight loss maintenance. Sure, everyone says that there is no easy answer, but the general tone of optimism belies the extent of the difficulty. This leaves the participants unprepared for what lies ahead. When they encounter the almost inevitable weight regains, the tendency is to feel shame. This leads to reduced self esteem, again reducing the chances of any sustained achievement. How to be honest without being unduly discouraging is one of the major challenges of weight control programming. The recognition of alternative goals for overweight individuals is one possibility. Another is to rec-
August 1990
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ognize that clients with a long history of weight control efforts have already experienced the difficulties of weight loss maintenance. Talking about these difficulties honestly will validate their experiences. I like to talk about the fact that weight control exacts a cost - in some cases, that cost in terms of time, attention, and sacrifice is very high. Each individual has to discover for herself what price he/she is willing and able to pay. Yes, there is much about contemporary weight control programming that is due for an overhaul. Many talented and dedicated nutrition educators have worked hard to develop programs that utilize the current research base on weight control and avoid the pitfalls of some of the more traditional approaches. We should learn from the example of these educators. We will find that the best of the programs are built upon the compensatory model that is not only characterized by the active participation of both leader and client, but also encompasses the truths that life is open-ended, humans are free agents, and life is difficult. 0
REFERENCES 1 Achterberg, C. and L.L. Trenkner. Developing a working philosophy of nutrition education. Journal of Nutrition Education 22:189193,1990. 2 Ernsberger, P. and P. Haskew. Rethinking obesity: An alternative view of its health implications. Journal of Obesity and Weight Regulation 6:57-137, 1987. 3 Allon, N. The stigma of overweight in everyday life. In Obesity in Perspective, vol 2, part 2, C.A. Bray, ed. Washington, D.C.: U.S. Cov. Printing Office, 1973, pp. 83--102. 4 Wooley, S.C. and O.W. Wooley. Obesity and women. I. A closer look at the facts. Women's Studies International Quarterly 2:69-79, 1979. 5 Parham, E.E. The context of weight changes: Factors associated with weight changes in adult women. Journal of the American Dietetic Association 88: 1539-1544, 1988. 6 Parham, E.S., M.J. Flynn, V.L. Frigo, and A.H. Perkins. Weight control: Attitudes and opinions of dieters and change agents. Accepted for publication by the Journal of Home Economics. 7 Parham, E.S., V.L. Frigo, and A.H. Perkins. Weight control as depicted in popular magazines. Journal ofNutrition Education 14:153156,1982. 8 Parham, E.S., S.L. King, M.L. Bedell, and S. Martersteck. Weight control content of women's magazines: Bias and accuracy. International Journal of Obesity 10:19-28, 1986.