DIETARY ADHERENCE: CHECK YOURSELF BEFORE YOU CHECK YOUR CLIENT – Part 2

In the first instalment of this series I discussed what adherence is and the importance of goal setting, knowledge and motivation in understanding and enhancing dietary compliance.

The next three components of the ‘Dietary Adherence Framework’ consist of a roadblock (the environment) and two antecedents of habit formation (implementation intentions and discipline/routine).

In the previous article (Part 1 of this series) I suggested, “It is common for new clients to retrieve information (usually misinformation) regarding nutrition from sources they think are reliable, leading them to thinking they are well-informed about a certain topic, when in fact they are ill-informed”. I think it is worth diving into this phrase a litter deeper as influencing the way your clients think can not only have a short-term impact on their goals, but also have a long-lasting impact on their fitness journey. Let’s face it, most people would rather be told by others what to think and believe as opposed to thinking for themselves – this is why the media is so powerful and why most clients hire a coach. In many cases, this mental shortcut that literally conserves brain energycan be a double-edged sword; Edge 1– you listen to the right people who will provide you with valid, reliable information and persuade you to think for yourself, and Edge 2– you listen to the wrong people who provide you with misinformation. Many clients will have experienced the wrath of Edge 2 throughout their fitness journey, and as an evidence-based coach it is your job to ensure they have a shield to use the next time they encounter the unfortunate edge of the sword. Usually, clients who carry these preconceived ideaswill need their thought patterns manipulated over time and delicacy in this case is important. Attacking the client’s point of view, laughing at the idiocy (or supposed idiocy) of their ideas or degrading the individual they got their information from is a response I have witnessed from coaches all too often – both in person and online. I myself have been guilty – and still do fall guilty – of the above from time to time. However, although I may slip up here and there, I endeavour to use the following rules to manufacture my response or rebuttal.

These are ‘Rapoport‘s rules of constructive argument and debate’which can be explored further through a simple google search or in Daniel Dennett’s book, Intuition Pumps and Other Tools for Thinking:

1. You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.”
2. You should list any points of agreement (especially if they are not matters of general or widespread agreement).
3. You should mention anything you have learned from your target.
4. Only then are you permitted to say so much as a word of rebuttal or criticism.

Along with this strategic method of constructive criticism, respecting that the client probably holds this particular idea (or construct) as a personal truthis important. This is all they have ever known and probably wouldn’t appreciate you tearing it like you would a piece of paper – with a full tear enervating their emotional state. How would you feel if someone attacked your religion or other personal beliefs? If we can explain the distinction between a personal truth and an objective truththe client will have a chance at conceptualising the fact that their thoughts were somewhat incorrect or at least lacking robust evidence.

Personal truth– A construct that an individual deems to be true even in the face of contradicting/opposing evidence. Truth may not be the right word to use here, but deep down the individual is under the impression they are correct; thus, their constructs are true to them. For e.g. ‘pasta makes me gain weight’ or ‘the earth is flat’ or ‘aliens exist’.

Objective truth– A phenomenon that is confirmed to be true, usually through a scientific consensus, and is true no matter what anyone believes to be true. These objective truths stand their ground in the realms of science and time, allowing us to make predictions about certain concepts. For e.g. Pasta is a source of carbohydrate containing 4 calories per gram, if carbohydrate is overconsumed and a calorie surplus is created, weight gain will occur. In this case, ‘calorie surplus = weight gain’ (calorie balance nuance is unnecessary in this example) is an objective truth that opposes the idea of pasta directly leading to weight gain.

If we can help our clients appreciate the validity and reliability of an objective truth, they will soon come to respect science and the role of an evidence-based coach. Upon gathering information in the future, the clients who understand and respect the difference between these truths (personal and objective) will perennially ponder the credibility of the information distributor and will experience a prefrontal workout – as they assiduously determine the worthiness of the information. 

First up, environment.

4. Environment

The environment, which can be defined as “the surroundings or conditions in which a person, animal, or plant lives or operates” is an underestimated influencer of food intakeand is a roadblock to many other important dietary adherence factors like ‘habit formation’. Habits will not be engrained and thus behaviour will not be changed if the environment is not conducive to this change. 

Long stands the discussion of nature (genetic influence) versus nurture (environmental influence), or more accurately, nature and nurture, as stating that this is an ‘either/or’ situation with the use of ‘versus’ is a false dichotomy. Both factors play a role in an individual’s upbringing and trait development, including propensity to consume food, and both must be paid respect to. Much research has been conducted in the realm of genetic heritability of certain traits, but this research is limited in its application to dietary adherence. Some research suggests that appetite, satiety and enjoyment of food are determined by genetic factors in children to a higher degree than food preferences, and the same traits have been shown to be related to genetic pathways linked to weight gain. Considering psychological traits are highly heritable, this is not surprising and there is most definitely a link between genetics and an individual’s propensity to overfeed or underfeed and gain weight or lose weight. The strength of this link (heritability) is unclear and nonetheless, not modifiable. 

Although your genetics can prompt you into moulding a specific environment as you get older*, the environment is something that we, as adults can control (for the most part). 

The environment is analogous to a car. Genetics creates the car for us, but we drive it. Its drivability has set limitations, and certain road signs may point to genetically programmed directions, but our hands grip the steering wheel tightly, and we choose the way to go. 

Your environment, including but not limited to the food in your house, people around you, proximity to fast food restaurants, weekly food budget and social events can all drastically affect dietary adherence. This is why addressing your client’s environment and making the appropriate adjustments is critical – no matter how hard you work on other components of the framework, your client’s environment, if not suitable to a change will inhibit adherence, period.

*Example:An individual who has a genetic predisposition to be highly intellectual (for arguments sake, intellectual ability in this case as measured via an IQ test) will be prompted to purchase and read more books throughout their life and thus the environment further influences their genetic propensity for a relatively high intellectual ability.

Here are some characteristics of our environment (in the western world), in relation to dietary adherence:

• The current food system, a major contributor to the obesity epidemic, involves increased production and marketing of inexpensive, highly processed foods with supernormal appetitive properties.
• Many foods on the market are typically more calorically dense and far less healthy than unprocessed foods such as fruits, vegetables, and fish.
• Many people do not prepare meals at home, and more food is consumed in restaurants.
• Occupations have become more sedentary and suburban sprawl necessitates vehicular transportation rather than walking to work or school.
• Rapid weight loss programs that lack sustainability and education are highly advertised.
• Diets that eliminate certain foods are prevalent and many people think that elimination is necessary – this dietary dogma is exacerbated through documentaries and the media.

I see the above characteristics as roadblocks, this is why I have highlighted ‘Environment’ red in my framework. If clients can’t drive around these roadblocks, they will not progress to the next component of the framework. From here, it should be quite clear what needs to be changed and manipulated to ensure your clients environment is conducive to their goals. See below for some environmental changes that I (try to) implement with my clients, as part of their adherence plan.

In closing, as a coach it is up to you to deal with environment modification on a case to case basis. Each client will present with a unique environment and will need individualised strategies, the above are just some examples that should be further tailored to the client. 

5. Implementation Intentions

As mentioned earlier, motivation is important initially and intermittently throughout a client’s fitness journey – but what happens when motivation fades away? As coaches, we need to understand that our clients aren’t going to be perennially motivatedand we need to have a plan in place to safeguard form drops in motivation. Now this doesn’t mean that we should tell our clients not to rely on motivation or that motivation isn’t important – remember that your clients aren’t you. You may not need motivation to get yourself to the gym 6 x per week, but the attributes that you possess, whether genetically manifested or built over time may not be represented in your clients – remember, each of our cars is different. Putting motivation up against intentions (as in, another versus scenario) is in my opinion, another false dichotomy. Both motivation and intentions are going to be important throughout anyone’s fitness journey. Although motivation shouldn’t be the sole driver of your adherence overtime, it is always going to be hanging around in the background – sometimes giving you a boost to complement other attributes and other times not helping much at all. I don’t see motivation as an on and off switch, but rather like a dimmer switch that is regulated by many ‘prompting’ factors – sensory information, emotions, life events etc. To ensure adherence is paramount, we need to help our clients create intentions that will be concrete contributors to their success with motivation being more of a spontaneous but prompted contributor.

Let me set the scene.

1. Client shows up to consultation. We speak about nutrition and set up a plan.
2. Client says they are going to go shopping after the consultation and do their meal prep.
3. Client shows up to their first session two days later: 
   Me,“Did you go shopping and do all your meal prep for the week?”
   Client,“No.”

I’m sure we have all dealt with this identical scenario before. The reason clients are so likely to fall through with their intentions is because motivation drops in the hours post-consultation and there was never any structure regarding their intention! This is where the ‘implementation’ in implementation intentions is crucial. Implementation intentions is the process of devising a specific plan for when and where you will perform a certain intention/habit. A large body of research demonstrates that implementation intentions are effective for acquiring new habitsand people are just more likely to follow through if there is a specific plan in place. Instead of simply telling ourselves that we will go shopping, to increase our chances of partaking in this intention, we need to specify when and where we will go shopping – potentially even specifying the products that we will purchase. This is how we evolve an intention, into an implementation intention.

As adapted form James Clear’sbook, Atomic Habits, using the following structure is a simple way to apply this strategy to any intention or habit. I have added the ‘OTHER’ component for exercise and nutrition related intentions that require additional information.

I will [BEHAVIOR] at [TIME] in [LOCATION] and [OTHER]

Example: I will TRAIN at 3.30PM in JPS HEALTH & FITNESS and FINISH MY UPPER BODY WORKOUT.

Do not underestimate the power of implementation intentions which can work for several intentions including but not limited to training, shopping, meal prep, eating, cardio, reading, relaxing, doing work, making calls etc. The key here is to work with your client’s environment*, the environment that based on the previous section, needs to be conducive to their goals. This is what creates the foundation for ‘habit formation’ which will be touched on in the next part of this article series.

*Example:Environmental change = no highly processed foods stored at home. Implementation Intention = I will go shoppingat 9am every Sundayat Colesand will not purchase highly processed foods.

The research in this area is robust, and trust me, you don’t want your clients – particularly your general population clients – making intended plans with no structure. 

Why?

The human brain has evolved to value immediate rewards more highly than future rewards. For example, after work, most clients would rather sit on the couch (an immediate reward) as opposed to get up and go to the gym to complete their training program (future reward). In saying this, clients will be more inclined to actually train after work if they drive straight to the gym as opposed to going home. This is a time inconsistent*decision that is based on what the client deems as immediately favourable. Another fascinating but consequential phenomenon regarding the brain – that prompts clients to hastily choose the immediate reward – is its ability to negotiate with different time points of itself– thus establishing meta-knowledge about the short- and long-term ‘centres’ (opposing teams in your brain) involved in the making of a certain decision. This is known as a ‘Ulysses Contract’. I highly recommend watching this linked video by neuroscientist David Eagleman where he succinctly outlines the myth of Ulysses. Put simply, your brain can easily be seduced by the power of now,and thus, intentions easily disregarded. 

Sit back and watch the theatre curtains part.

Your client is at work and one of their colleagues approaches them with their favourite flavoured donut. Certain parts of their brain desire an immediate rush of glucose, whilst other centres in their brain care about their current dietary goals; the former being concerned about short-term gain and the latter concerned about the long-term plan. The battle between the two ‘centres’ (or teams) in your client’s brain tips towards the emotional (and usually irrational) side and they make a contract with their future self, “I’ll eat the donut…but I promise I’ll run it off tomorrow morning, my coach will respect the compromise”. They end up eating the donut. 

Curtains close.

That was a freely made decision that bound your client into the future, otherwise known as a Ulysses Contract. This experience sounds familiar, right?

*Time Inconsistency:This is a concept that is highly prominent in economics and suggests that people are not always consistent with their decisions – they generally discount the future. Consider, for example, the following question:

(a) Which do you prefer, to be given $100 right now or $110 a week from now?
(b) Which do you prefer, to be given $100 fifty-two weeks from now or $110 fifty-three weeks from now?

To be time-consistent with your decision, you must make the same choice for question (a) as for (b). Most people tend to choose $100 today and $110 fifty-three weeks later. Thus, there is a time-inconsistency in the decision and right now holds the highest value. Emotional brain centres are highly active upon choosing immediate rewards and this can lead to impulsive behaviour. When people delay gratification, and opt for a longer-term reward, lateral areas of the neocortex involved in higher cognition and deliberation are more active – these areas also consume more brain energy, making the emotional decision an energy favourable one. To put this in context, if a client doesn’t have an implementation intention to do their meal prep, and they find themselves on the couch watching Netflix, they are less likely to delay gratification and watch Netflix later – meal prep will be discounted.

What is important here is that we put strategies in place tosafeguard our clients from constantly making negotiations with their future self– this happens a lot more than you think, and you probably do it too, unwittingly. If there is no implementation intention put into place, your client is more likely to tell themselves that they will do ‘it’ tomorrow instead, but tomorrow never comes around. Using specific implementation strategiessuccessfully and repetitively will also help the client delay gratificationwhich is a great predictor of ‘success’ in life and will be touched on in the ‘Habit Formation’ section.

Start thinking about ways you can incorporate implementation intentions with your clients. Here are some strategies that could be used but you need to be willing to think for yourself:

• Setting an alarm (e.g. It is time to go to the gym at JPS Health & Fitness and train lower body)
• Note on fridge (e.g. I will go shopping every Sunday at 9am at Coles and purchase the following ingredients)
• Note in diary (e.g. I will go for a walk at 5.30pm around the lake to achieve my 10000-step target)
• Note on computer screen (e.g. I will tell people I am dieting when I am offered food at work to ensure I stay on track with my diet)
• Tell friend to meet at the gym/schedule a walk with a friend

6. Discipline & Routine

The human brain can travel into the future (via the Ulysses contract) – but how do we ensure this hack doesn’t interfere with our dietary goals? Discipline.

Implementation intentions are the first step to building discipline. Discipline is the act of obeying “a code of behaviour” – whether it comes with a large or minor mental energy cost. Ultimately, we want to be able to exert discipline with a negligible energy cost. An example of this type of discipline is being able to say ‘no’ to the donut without having to think about it. Being able to get off the couch as soon your alarm goes off…without having to think about it. The latter is momentous. You see, the brain has two main systems (or teams) – the rational system, and the emotional one. The rational one is involved during higher-order operations that require more cognitive processing, whilst the emotional one monitors your internal state – such as your level of hunger – and ranks your possible next actions in the world and their potential effects on your mood state, i.e. will eating the donut make me feel good or bad? You can calculate algebraic equations without your emotional system, but it’s very hard to say no to the donut without it. Emotional decisions are also fast, energy favourable decisions, and thus require very little mental energy. The emotional system (via the amygdala) has the ability to receive sensory information before it reaches the rational system and trigger a hasty decision– much like a ‘shot from the hip’. Pulling the gun out of its holster, raising it to shoulder height and taking aim would be a more calculated, accurate decision that requires engagement of the rational system. 

This is dangerous.

This easy, energy efficient route also uses less will power. Will power is like a universal gas tank – universal, because anydecision that requires mental energy (thinking) will drain it. The same tank is used for decisions that involve food and decisions that involve what you’re going to wear on a Saturday night. Research shows that the rational system (via the dorsolateral prefrontal cortex) becomes active when dieters choose the healthier food options in front of them, thus burning through mental energy and depleting the gas tank. Yes, will power is something that we can deplete, and this shouldn’t be taken lightly*.

*A prisoner’s fate can be influenced by hunger. A 2011 study found that prisoners chances of parole rose to 65% after the parole board enjoyed a food break. Conversely, prisoners seen towards the end of a long session only had a 20% chance of a favourable outcome, being parole. The more cases the judges had to make decisions about, the more energy depleted their brains became and the more likely they were to make a fast, energy favourable decision. Even judges, who are striving to limit the interference of their bias are imprisoned in human biology. For more Incognito by David Eagleman.  

Let me ask you a question. If you wanted to conserve your car’s fuel what would you do? Drive less, right? In the case of conserving will power, making less decisionsneeds to be your first point of call! Ever heard of the term ‘decision fatigue’? The more decisions you make on a daily basis the more you deplete your gas tank, resulting in fatigue and the inability to subsequently engage the rational system and make calculated decisions. The result; a full tub of ‘Ben & Jerrys’ ice cream devoured after a long hard day of decision making.

Discipline and routine go hand in hand. A set routine as opposed to no routine requires less discipline and thus will power to undertake. Repetition and routine are tenacious in the hunt for habit formation. When our brain is exposed to the same tasks repetitively, it rewires its own circuitry until it can accomplish the task with maximum efficiency, i.e. in the most automatised and energy favourable way possible.

Automatisation and energy efficiency are of chief importance for humans. They permit fast decision making with a minor energy cost. They allow us to engage our rational system without depleting too much of our will power. We become better at rationalising decisions because our brain is quieter. These two qualities can separate great athletes from the average ones – great athletes can run on ‘autopilot’ and are often said to seemingly see the game in “slow motion”. The more times we can get our clients to repeat their daily or weekly routine, the easier it will be for them to build habits. Help your client’s practice repetition through routine. A routine that revolves around their work and moulds into their lifestyle but is also malleable and allows for some flexibility.  

Combine low-energy discipline with routine, and you have habit formation.