Focus on ‘how to eat’ more effective than diet

At UW, dietetics students learn principles for delivering effective client care that goes beyond what you put on your plate. 

Our society is obsessed with thinness, dieting, and fitness. 

At the root of this obsession is a weight-biased belief that if you are a person in a higher-weight body, you lack willpower, are lazy, or make poor lifestyle choices. 

This stigma and discrimination toward people in larger bodies is pervasive, and can also be experienced in the healthcare system, not just in cultural messaging.

Weight stigma contributes to numerous health consequences and creates significant barriers to prevention and treatment for nutrition related conditions. 

As practitioners and researchers in public health, finding solutions and approaches that are both evidence-based and effective for everyone is a goal.   

In the University of Washington Graduate Coordinated Program in Dietetics (GCPD), students and faculty are exploring how to address the prevalence of weight stigma in their field, and build a stronger understanding of how to help people attain their goals without the shame and focus on dieting. 

Dietetics peer group formed around eating competence

Over the summer of 2021, a group of students and faculty in the GCPD formed an informal peer advising group to discuss principles and topics related to eating competence, child feeding dynamics, and weight stigma/bias.

Michelle Averill and Cristen Harris, who are both core faculty in the Nutritional Sciences Program in the School of Public Health, are mentoring the group.

“Students are challenged with how to address or utilize size-inclusive or weight-neutral approaches in a weight-normative medical or public health framework that is traditionally focused on reducing obesity,” said Averill, also an associate teaching professor in environmental and occupational health sciences, and coordinates the clinical training for graduate students in her role as GCPD associate director.

“When we work with patients, keeping focus on weight loss is proven not to be effective.”

Averill, along with Harris are working to adopt the same peer support model framework which was so successful this summer as a permanent part of the GCPD program.

Harris, who is also an associate teaching professor in epidemiology, has expertise with the evidence-based Satter Eating Competence Model (ecSatter) and frequently collaborates on projects with Ellyn Satter and the Ellyn Satter Institute. 

“We have to remove the barrier of being weight-focused because it gets in the way of developing positive attitudes about food, eating, and feeding, and working towards Eating Competence,” said Harris.

Students explore weight stigma from many angles

Each of the four students collaborating with Averill and Harris this year are concurrently completing RDN training in the GCPD in combination with their chosen graduate degree program. Each is approaching the issue of weight stigma differently.

Current student projects

• Eating and drinking habits of UW students during COVID-19 – Jenn Dearden is qualitatively analyzing survey data to assess how eating and drinking behaviors of UW students changed in the context of COVID-19.
• Tik Tok’s influence on driving food culture and food choices – Kaitlin Sandberg is using a mixed methods content analysis that investigates the landscape of healthy recipes on TikTok. 
• Correlation between eating competence and gender identity – Kaitlin Benjamin is assessing correlations between Eating Competence and weight satisfaction, eating concerns, and weight-and-body related guilt-and-shame as it pertains to gender identity. 
• How Irritable Bowel Syndrome (IBS) influences eating attitudes and behaviors – Kate Evans is exploring the impacts of Irritable Bowel Syndrome (IBS) on Eating Competence and symptoms of eating disorders.

Student work from past years

Student interest in these issues is not new. In recent years, student projects have also focused on related topics.

• Weight Bias in Clinical Care: Assessment of an Interprofessional Session for Health Sciences Professionals was a master’s thesis produced by Diana Aguilera (MPH/RDN ‘21)
• Examination of Early Learning Mealtime Best Practices: Opportunities and Challenges for Specialized Responsive Feeding Practices was a master’s capstone project authored by Jessa Engelken (MPH/RDN ‘21) 
• Patient Perspectives on Nutrition Providers’ Phenotypes and Attitudes About Weight During Treatment for Atypical Anorexia Nervosa was a master’s thesis authored by Meredith Blumenthal (MS/RDN ‘20) 
• Interprofessional Perceptions of Dental Providers’ Engagement in Childhood Obesity Prevention was a master’s thesis authored by Anna Mowell (MPH/RDN ‘20) 

Not focusing on diet has been freeing for students

“In my opinion, Eating Competence is an important piece of our education as future RDs,” said Jenn Dearden, a student in the peer support group this year.

“There is often a lot of focus on what people are eating, and even why–food systems, policies, and access, for example. But the how is also key to better understanding a person’s relationship with food and is something that we need to carefully consider and examine as future RDs.”

Kaitlin Benjamin who is using the Satter Competence Inventory (ecsi 2.0) for her project on Eating Competence and gender identity is grateful to have this fresh perspective.

“​Learning about the Eating Competence Model has been a game changer for me, regarding how I plan to educate future clients, as a dietitian,” said Benjamin. 

“It releases me from the implied burden of telling people what they should or should not eat and instead allows me to simply help them become more comfortable around all foods in all contexts.” 

Principles of a size-inclusive model  

The ecSatter model, which is evidence-based and being incorporated in various ways with student work, is designed to address eating attitudes and behaviors, internal regulation of intake, food acceptance, and skills related to selecting, preparing, and planning meals. 

This size-inclusive model aligns with biopsychosocial cues and is focused on “how” to eat, rather than what and how much to eat.

Health At Every Size® principles and Intuitive Eating principles are other weight-inclusive approaches explored within program discussions. 

The main distinction between ecSatter and these approaches is that the ecSatter model emphasizes consistent opportunities to eat, an area in which nutrition and dietetic practitioners excel at strategizing with their patients and clients.

More and more studies are showing that both physical and psychological outcomes can be improved by focusing on health rather than weight per se.

Teaching size-inclusive approaches may help reduce potential weight bias among dietetic and nutrition students and/or professionals by placing the focus on health rather than weight or body mass index (BMI). 

Eating competence has been tested with adults and is associated with higher dietary quality, lower cardiovascular risk factors, lower diabetes risk factors, better sleep quality, better body image, higher physical activity levels, and stable body weight. 

“Eating competent parents are more likely to feed their children using an appropriate division of responsibility, so that children can grow up to be eating competent adults,” said Harris. 

“We don’t have a longitudinal study that tracks that yet, so this is fertile ground for future research.”

For the four second-year students working closely with Averill and Harris this past year, the collaboration has been rewarding.

“It has been so special to receive support from Michelle and Cristen. They are both very intentional in delivering their course content and have dedicated the same energy in guiding our thesis group,” said Kaitlin Sandberg.

---

By Lori Tiede

November 15, 2021