Coaching Matters

     On a regular basis I see patients who range in age from toddlers to seniors, and for a variety of health and nutrition reasons.  A repeating theme in appointments lately has been "negative food relationships".  It worries me.....  to say the least. What is it that we are doing in our society and among our family/peer groups to cause such disordered eating and what can be done to reverse the negative effects?
      One morning I had a sixty-something year old female in for follow up and we were working together to determine what drives her negative food relationship and how it manifests. She has been on the brink of undergoing gastric bypass surgery with the hopes that it will "solve her problems".   This is a woman who has been "dieting all [her] adult life".  A woman who has a family who though well-intentioned, tends to offer dieting advice during nearly every encounter.  A woman who says "I love food but I just can't control how I eat sometimes".  A woman who is probably her own biggest critic and who feels that she has failed over and over again in her weight loss goals.  A woman who admitted, "My worth is directly related to my weight, even though I know it shouldn't be."  There is a great deal of work going into helping her let go of the guilt associated with her dieting failures.  Also, helping her recognize queues such as hunger and understanding that her body telling her she is hungry is a GOOD thing, not something she should be ashamed of and try to hide.  Along with this type of coaching,  help in formulating strategies for discussing her diet changes with family and friends, planning for holiday and family parties, dining out, menu planning and grocery shopping are essential.  This person has been inundated with so much conflicting and not-so-great diet advice for several decades.
      A few appointments later that same day, I had a teen-aged  female with Type 1 Diabetes and Obesity in for follow up.  Again, the negative food relationship found it's way into our discussion.  The added barrier in the adolescent patient is the desire to go against the grain and the satisfaction found in being stubborn when mom suggests food or exercise ideas.   My younger patient is also different from the first patient mentioned because first and foremost, there are parents involved here. Parents who want what is best for their child, but who may be misguided and pushing too hard.  Therefore, modeling good coaching behavior on the part of the dietitian is key.  Providing good nutrition education is just as important in these sessions as reinforcing the importance of staying focused on the behavior goals set in the appointments.  There is absolutely no room for the food police and that needs to be stressed with caregivers at every encounter.
     In both of these examples there is a loss of  normal eating, negative self-body image, and low self-esteem in general and I have a multitude of other patients (mostly female) with these same issues.  If negative comments, thoughts, and repeated diet failures is the root cause in many of these problems, then it stands to argue that positive comments, reinforcing normal eating queues, and small but repeated behavioral successes might be the cure. It's a slow process and one that is patient-centered.  It requires the Coach to be louder than all the other voices coming from family, friends, and the internet. The ultimate goal being the same for all:  To help people find their own way to better health, self-satisfaction, and true enjoyment of food.
   

Worth the Wait

When I was studying to be a dietitian, the role of the RD in patient care was specific. Follow the diet prescription, be quick, move on. The problem with that approach of course, is that it is ineffective. Not only does it do nothing for the patient, but it does nothing for the career stability of the dietitian.  In recent years, I've had the good fortune of being able to slow down and see patients outside of the acute care facilities. I've been been able to hone active listening and motivational interviewing skills to help patients realize their own path to behavior change and improved outcomes.  Thankfully, since more insurance plans are paying for Nutrition Therapy services with unlimited visits, I can make a modest income and be an effective health educator.
      Follow up visits really are the key to a patient's success. Multiple visits help dietitians to help their patients find THEIR way to successful behavior change. Multiple visits help dietitians avoid the "putting patients on a diet" trap and instead lead them to a life of intuitive eating and lifelong behavior change. Multiple visits with a dietitian helps the patient by reinforcing good nutrition information, continuously evaluating appropriateness and success of goals, reducing patient's self-doubt, and breaking down barriers to behavior change. It is unrealistic to believe that Nutrition Therapy can be effective in one visit. Just as it is unrealistic to expect physical therapy and mental health therapies to be effective in one visit. It is important to the field of dietetics but also to health care in general that more value be placed on Nutrition Therapy by the public, doctors, nurses, insurance companies, etc.  

      Yesterday was a great day to do what I do!  During their follow up appointments yesterday,  two of my patients described behaviors that were clearly intuitive eating behaviors.  One patient has taken years to get there and one is three visits in. These were beautiful moments for me because that is exactly what I'd hoped to see in them! Of course, they want weight loss and better blood sugar and lipid outcomes, which they are achieving.  But in order for this success to be long term, the THINKING part of eating has to change.  The work these two patients have put into improving their health has gotten them to a more healthful state of mind which in turn is giving them the physical outcomes they'd hoped for. These patients have placed their trust in me to help get them there. This goes beyond counting calories, carbohydrate and fat grams.  This goes beyond label reading.  This goes WAY beyond the concepts of "I cheated on my diet yesterday" or "I was so good yesterday because I didn't eat any ice cream." Instead what I heard was, "There has been a chocolate cake sitting in my refrigerator this whole week and I haven't even touched it."  When I asked why,  he stated, "I don't know.  I guess it's because I know I have permission to eat it, and I guess I decided that I really don't want it right now. I can have it another day."  Can we all say BREAK THROUGH?  The second patient I mentioned also had his own break through moment.  "I don't know if I've ever actually felt hunger my whole life.  I just ate whenever and usually ended up overeating.  Now, I actually feel hungry when it's meal time.  Not overly hungry, but I know it's meal time.  It's a whole new thing."  Some breakthroughs happen sooner than others, but if you have a patient willing to take the steps to get there, no matter how slow, then it's absolutely worth the wait.  It's why I do what I do.
       Dietitians/Nutritionists have great opportunities to help people overcome bad feelings about food and normalize their eating behavior, without them "dieting" per se.  I might go as far as to say that dietitians/nutritionists are obligated to terminate the word "diet"' from what we do so we can stop being lumped into all the fad,  ineffective, expensive, impractical, short-term weight loss programs out there.  Hmmmm....I've always resisted using my Nutritionist title vs. my Dietitian title, but I may start embracing  "Nutritionist" from here on out.