There are two major approaches when dealing with stress. The first is to change the environment by altering the stressor or reducing exposure to it. The ideas discussed previously are responses to the environment. The second is to change the patient’s response to the stress. The first approach is problem-focused and the second approach is emotion-focused. These two approaches are complementary rather than mutually exclusive. In Table 11.2 Quick Meals
Plan ahead by stocking your pantry and freezer with necessary ingredients for healthy, quick meals.
Ideas:
Spaghetti with bottled or canned tomato sauce Canned chili
Packaged macaroni and cheese made with skim milk and without margarine or half the margarine
Pork n’ beans with brown bread
Microwaved potato topped with cottage cheese and vegetables Frozen ravioli with bottled or canned tomato sauce
Refrigerated mashed potatoes with broccoli and salsa Fresh finger food fruits and vegetables
Stir fried chicken with frozen vegetables Soup and sandwich
Microwaved fish with salsa
Modified from Session 15, Ver. 2: 06/30/95, Women’s Health Initiative.
1604_book.fm Page 118 Tuesday, May 30, 2006 10:37 AM
Reducing Stress to Maintain Dietary Change 119
nutrition counseling both are important. However, new preliminary research described in Chapter 13 indicates that the emotion-focused approach might be more effective in maintaining weight loss. Identifying life as stressful can mask feelings that lead to overeating. Feelings do not need to be eliminated because identifying feelings can be helpful. The changes need to occur in the way a patient copes with feelings. Chapter 13 describes new untested theories related to feelings. In her book The Solution, Mellin describes stress as a smokescreen and states that identi- fying the feeling that accompanies stress and a coping strategy should be the focus [1].
Building on the objectives discussed above with the concept of prob- lem- and emotion-focused stress management, strategies to deal with stress range from being assertive in expressing eating desires to dealing in an appropriate way with emotion-driven-eating cravings. The words “no thank you” can assist the patient in asserting will when trying to avoid certain foods.
Asking the patient what methods he or she currently uses to cope with stress can result in more useful collaborative goal setting. Knowing what coping strategies have worked in the past is a good predictor of what will work in the future.
In summary, keeping points related to stress simple is important. Below are just a few ideas that cover both the environmental and emotional orientation of stress management:
Use positive self-talk.
Plan ahead.
Use time-management skills.
Find a support system.
Set feasible goals.
Be assertive.
The discussions that follow are derived from actual experiences in the Women’s Health Initiative Study [2].
11.4.1 Positive Self-Talk
Helping patients see the positive, even in slips from healthy eating, can eliminate the “all or nothing” attitude about healthy eating. The idea that perfection is the only way to success is identified as leading to erroneous expectations and eventual regression to past eating habits. Providing ideas to stop negative monologues, and replacing them with positive thoughts, can be very encouraging and provide ideas for dealing with negative situations in the future.
1604_book.fm Page 119 Tuesday, May 30, 2006 10:37 AM
120 Nutrition Counseling for Lifestyle Change
Table 11.3 provides some concepts that help in understanding positive self-talk and may allow the patient to see how to revise those internal emotion-driven thoughts in a positive direction. By identifying the coping strategies used as stressful situations occur, it is possible to turn those ideas that surface in emotional context to the positive. Often in the context of general stress it is easy to focus on the negative. Coping in a new way by using more positive self-talk can increase motivation to continue to strive for more healthful eating behaviors.
11.4.2 Planning Ahead
The concept of planning ahead is useful in preventing setbacks in healthful eating but also in providing ideas for future strategies to deal with problem situations. Planning ahead allows the patient to be in control as a stressful situation occurs. Bringing a favorite healthy dish to a reunion so that it might be the one dish chosen in the largest serving amount, is a strategy to help avoid making a reunion an eating disaster.
One of the participants in the Women’s Health Initiative stated that she found a friend to talk with and sat as far away from the food as possible. This meant that she could thoroughly enjoy the event without eating more than she intended.
Other suggestions by participants have been to suggest to a friend that they take a walk around the area in which the reunion is occurring. This adds exercise, fun conversation, and a move from an event that can be totally food-focused.
11.4.3 Time-Management Skills
Time saving techniques include the important element of organization.
Planning meals ahead can afford one time to focus on what types of foods would be appropriate. Keeping an ongoing shopping list provides a level of organization that mandates more healthy eating habits. Time-saving ingredients (pre-cut vegetable or boned skinless chicken) make the pro- cess of recipe preparation shorter. Healthy convenience foods (frozen, canned, or instant) allow for time-saving food preparation. Many patients have emphasized the importance of maintaining a quick and easy recipe file. Often pre-preparation for a meal is the first step in the time manage- ment process. Preparing part of the meal ahead of time makes actual meal preparation easier and less time-consuming. Making a double batch and freezing it for a later meal cuts down on preparation time. Often, one meal can be devised to be used for leftovers in another meal. Methods that shorten cooking time contribute to time management. These methods
1604_book.fm Page 120 Tuesday, May 30, 2006 10:37 AM
Reducing Stress to Maintain Dietary Change 121
Table 11.3Concepts Related to Self-Talk Potential Responses Self-Talk CategoriesPatient-Oriented DescriptionNegative Self-TalkPositive Self-Talk Overgeneralization Self-Abstraction Excessive Responsibility Self-Reference Catastrophizing Dichotomous Thinking Willpower Breakdown
If it is true in this case, it applies to any case that is even slightly similar. The only events that matter are failures. Slip = failure. I am responsible for all bad things. I am the center of everyone’s attention, especially when I fail. Always think the worst; it is likely to happen. Everything is one extreme or another. Willpower is absolute; once it has failed, loss of control is inevitable.
“I ate too many potato chips at the last party I attended, and I’ll probably do the same here.” “Well I blew it when I ate that piece of cheesecake. This just isn’t working for me. I might as well quit.” “I am a failure. I knew I should have avoided the cookies.” “If I didn’t eat that last doughnut at work, my coworkers wouldn’t think I’m such a failure.” “I ate a piece of coconut cream pie, now my kids will never let me hear the end of it.” “If I have one cookie, everything is lost.” “I just have no more willpower.”
“This situation is different and I have learned new skills that I can use this time.” “Normally, I don’t eat cheesecake. I only had one piece. I will be sure to eat more fruit as a snack and always have it available at home.” “This is a single mistake, not a failure. I can use it to learn how to handle future high-stress situations.” “My coworkers are supportive, I’ll ask them to help me the next time I am tempted to eat the last doughnut.” “I can explain to my kids that no foods are forbidden. I do not need to eat pie every day, and I stopped at one piece.” “One more cookie will not break my healthy eating plan.” “There are a lot of things I can do to control the amount and types of foods I eat.” Modified from WHI Manuals: Volume 4 — Dietary Modification Intervention.
1604_book.fm Page 121 Tuesday, May 30, 2006 10:37 AM
122 Nutrition Counseling for Lifestyle Change
might include stir-frying, poaching, and broiling. Using a convection oven, microwave, electric skillet, or pressure cooker can reduce cooking time.
11.4.4 Support Systems
Finding support in groups similar to those used in large-scale studies like the Women’s Health Initiative can be beneficial to dietary adherence.
Suggestions from those in like situations who attend group sessions show that adherence over time is possible in a population of women following a low-fat diet with increased fruits and vegetables and grains [2]. Group support can contribute to maintenance of dietary behaviors over long periods of time. In the article referenced above, excellent dietary adher- ence in postmenopausal women is reported for years 1 and 5.
11.4.5 Feasible Goals
Often goals that are unattainable will lead to stress and a lack of confidence in maintaining healthy eating behaviors. A major focus in setting goals should be the end result relative to outcomes. If the goals are not feasible, the motivation to continue striving for attainment is lessened. This in itself can be a stressor that leads to unhealthy eating habits.
11.4.6 Assertiveness
Learning to say “no thank you” is a most important skill when emotions are key to success. Feeling good about turning down a food that is not a favorite just to please a relative or friend is okay. It is important to let a patient know that it is okay to elicit the respect of those around him or her as decisions are made about eating.
The strategies related to reducing stress are numerous. Many have a basis in their positive effect on diet adherence in long-term randomized dietary-related trials.
REFERENCES
1. Mellin, L., The Solution, New York: Harper Collins, 1997, 158.
2. Women’s Health Initiative Study Group, Dietary adherence in the Women’s Health Initiative Dietary Modification Trial, J. Am. Diet. Assoc., 104, 654, 2004.
1604_book.fm Page 122 Tuesday, May 30, 2006 10:37 AM
123
12
ORGANIZING DATA ON DIETARY CHANGE