Once upon a time That s how a story

Once upon a time…. That's how a story always begins, isn't? So, once upon a time, when I had just finished studying, it was twenty years ago, I was sure I was going to succeed to help people lose weight, help them to be thin. I was full of ambitions and passion and step by step my clinic became the largest one in Israel. True, my patients lost weight, but they also regained it. My patients were confused and I felt helpless. I couldn't understand what I had done wrong. Slowly I realized that something was not as I thought it might be and maybe I didn't really know how to make people thinner. I also understood that probably weight is not an outcome of willpower.

At that point – 12 years ago - I attended a workshop in Philadelphia, which was part of a convention of eating disorder. At the middle of the workshop we were asked to get up and dance. To my great surprise, everybody, including a group of extremely obese people, did it. I was the only one who remained sitting, although I was the thinnest person there. That was a turning point in my professional perspective. I realized that you can't weigh your self-esteem. Step by step, without even noticing, I started leading my patients to get off the diet roller coaster. By then I felt that I could not continue selling the “thinness dream”. So I retired from my position as president of the dietitians association in Israel in order to act according to my beliefs.

It was not easy because, although people knew that diets were a failure, they continued looking for the magic that would allow them to achieve the fantasy. They were ready to pay a fortune in order to get it. I, as a dietitian who did not sell those dreams anymore, started to lose patients and money and to receive much negative criticism. It wasn't easy but the way back was already closed. I couldn't save my patients from their bodies. At that time I understood that the diet game was ruled by the political and economic side of what was called "the obesity epidemic". I discovered that the facts about the consequences of obesity were just a small part of the whole picture and maybe we don't have to be thin to be healthy.

So, as I said before, once upon a time… I was a "real" dietitian who helped her patients to become thin, I was part of the diet industry - but not anymore. Now I am looking to help people get off the diet race, stop gambling on the next diet, stop being occupied and ruled by the diet language of eating. I try helping them to realize that real people come in all sizes and that real happiness in life does not rely on weight, counting calories and thinness. That's why I opened the eating dialog – school for fat studies. One of the school's main purposes is helping the professionals who work with obesity and eating behavior to think, see and behave differently with their patients and make the shift from the weight-centered approaches to the healthcentered approaches, meaning making a shift from the diet language of eating to the intuitive language of eating.

This process is based on the ACT dimensions with its main component – the acceptance. Accepting the sad fact that I don’t know how to help people to lose weight and keep it off, and I can't help people be thin as they want. But the worst thing that I have to accept is that, being part of the diet roller coaster makes us heavier than before and less healthy, both physically and emotionally. And from that point I have to look for the real value of life and move toward it. So in this workshop I will try to make you understand be part of this process.

“Eating Dialog” "Eating Dialog” An academic program for physicians and dietitians using ACT to make the shift from the diet paradigm which focuses on weight to the HAES paradigm which focuses on well being. Ayelet Kalter RD. MSc. The founder & director of the Eating Dialog Study & Therapy Center. The founder & coordinator of the "Eating Dialog – School for Fat studies” in Ariel University Center. The HAES leader in Israel. www. eatingdialog. com

Words for thought v I would be happy and healthy if I just lost 5 pounds… v I could feel great if I didn’t eat the pizza… v I could be thin if I had a strong willpower… v I would not go to the party unless I managed to get into the black dress… v I don’t have…. if I had…. I would be happy. . . v If I succeed to get rid of…. I would surely be happy…

Obesity v One of four Americans is suffering from obesity. v Obesity kills 400, 000 people every year. v Obesity causes coronary heart disease, cancer, diabetes, blood pressure… v Obesity costs around 100 billion dollar a year. v Global epidemic. v In 1980, 30% of America’s population were defined as overweight. Today 60% are defined as overweight v Our children are going to be the first generation in the modern world whose life will be shorter than their parents. Eric Oliver –” the fat politics” 2005

What do we feel? Fear of eating Fear of food Fear of being fat Fear of binge eating Fear of loss of control

"In Amsterdam some Buddhist guru taught me that in order to get rid of pains, you have to stop nourishing and feeding them. The diet he gave me consisted of two kinds of water, green and mineral. He also warned me against hospitalization, even if I felt weak. This is the strongest indication that fear wants to gain control”, explained the guru, "and the best way is to ignore its alarm sirens. Look at it in a philosophical way. Do we water weeds? And that is the whole theory". (Yael Israel, "The taste of life", Carmel Publishing House).

What happens when we are ruled by fear? Fight War against obesity - diet industry. War against fat people - fat discrimination. The thinness race.

The diet trap shir story

The situation today 120 million Americans are: Enslaved by the diet roller coaster (yo-yo cycle). Enslaved by the diet paradigm. Enslaved by the diet language of eating.

Weight centered approaches The main objectives underlying the diet paradigm (life style change, losing weight without dieting…): v Obesity is an illness. v You have to lose weight and get to the right weight according to the BMI in order to be healthy. v Everyone can lose weight, keep it off and achieve the ideal weight. v Weight reduction is an outcome of willpower. v By modifying our behavior - eating healthy food and exercising - we can reach our healthy weight. Avenell, A Journal of Human Nutrition and Dietetics, 17, 317 - 335 2004 Bronwell KD. The LEARN program for weight control. 7 th edn. American Health: Dallas, TX 1997. J Hum Nutr Diet. 2004; 17(6): 503 -12

Eating v Thinking patterns – dictate and create the language in which we think and according to which we behave. v Thinking patterns – tell us what, how much, when and how to eat as well as what we will feel before and after eating. v Hence, the complex dialog with the food resides in the need for physical and emotional nourishment, which starts when we come into the world and ends when we leave it. This dialog is a language – the language of eating.

The diet language is an outcome of the diet paradigm. v The diet language embodies rigidity, strictness, dichotomy, guilt, restrictions, avoidance and punishments. v The diet language is based on control. v The diet language takes away our freedom to eat what, when, where and how much we need and want. v The diet language takes away the joy of eating.

I won't go to the restaurant because I wouldn’t resist eating. Today I will feast tomorrow I will diet. How many calories do I have to eat? The diet language How many calories I burned in one hour running? I am fat so I can’t get out and meet people Just today… I have no willpower What do I have to eat? All - nothing Good - bad I am not allowed to eat the cake.

Although we all use the diet language as the solution for the obesity problem or maybe because we all use the diet language :

v 95% of the people who lost weight regained it in 5 years. v Our eating behavior is defective – binge eating, loss of control, ignoring hunger and satiety, being afraid of enjoyment, eating unhealthy food – we are afraid to eat. v Fat discrimination. v Social processes that are the result of the medicalization and the mystification of obesity and eating – harm our well-being. v Increase of disorder eating and eating disorder. v Abuse on the background of body hatred and low self-esteem. v America is heavier than it used to be. Mann, T. , et al. , Medicare's Search for Effective Obesity Treatments: Diets Are Not the Answer, Am Psychol, 2007. 62(3): p. 220 -33.

Although we continue being enslaved by the diet paradigm as individuals, as professionals and as therapists. We suffer from being overweight, eating in an unhealthy way and hating our bodies.

Words for thought: v Everything can cause suffering. v Everything can be a sufficient reason for suffering but none of them is a necessary reason. v Suffering by itself is not the issue but rather clinging to it.

The happiness trap More suffering Natural pain More control More avoidance More clinging Dr. Russ Harris

v Many reasons for the human suffering and psychopathology exist in our language, in the translation we give it and in the difficulties to make changes and become more flexible. v We cling to special tools and continue using them although they are inefficient and useless to us. Hayes, S. C. , Luoma, J. B. , Bond, F. W. , Masuda, A. , & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy 44, 1 -25

What do we cling to? v The stories we have been told about the obesity epidemic. v The wish to be thin and the fear of being fat. v The diet paradigm in all its forms - the thinness race. (Lir story)

A monk asked: "What is the essence of all the essences"? Joshu answered: "How long have you been preoccupied with this issue of essence? " The monk said: "I have been engaged with the issue of essence for a very long time". Joshu said: "Fortunately he has met me. This fool is almost entirely 'threadbare'". (The Joshu Zen Book).

Maybe what we create as the solution (controlling eating, controlling weight, avoiding eating…) has actually become the problem?

Can it be different?

The treatment is not about getting rid of the obesity, nor is it about teaching clients new elegant ways to control their weight, help them be thin. It is acceptance and mindfulness approach to obesity, operates from a different perspective, which says: ”Obesity is part of living rather than a cause of not living”. ACT for Anxiety disorders Eifert and Forsyth 2005 Raincoast Book Canada

This will allow the clients to avoid controlling their body and their eating, and help them eat normally and live a full life in every shape and size.

Acceptance and Commitment Therapy ACT The third wave of the CBT Therapeutic tool for creating psychological flexibility, helping the clients and the students make the shift from one approach to the other.

What is Acceptance & Commitment Therapy? Acceptance and Commitment Therapy (ACT) gets its name from one of its core messages: to accept what is out of your personal control, while committing to an action that will improve your quality of life. v. Hayes, S. C. , Luoma, J. B. , Bond, F. W. , Masuda, A. , & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behavior Research and Therapy 44, 1 -25. v. ACT for Anxiety disorders Eifert and Forsyth 2005 Raincoast Book Canada v. Hayes, S. C. & Smith, S. (2005). Get out of your mind and into your life: The new Acceptance and Commitment Therapy. Oakland, CA: New Harbinger.

ACT MODEL Committed Action The observing Values self Psychological Flexibility Cognitive defusion Being present Acceptance Mindfulness skills

Mindful skills - 4 categories The mind = The thinking self + The observer self v Thinking self – the part that is always thinking; the part that is responsible for all your thoughts, beliefs, memories, judgments, fantasies etc… v Observing self – the part of your mind that is able to be aware of whatever you are thinking or feeling or doing at any moment. Hayes, S. C. & Smith, S. (2005). Get out of your mind and into your life: The new Acceptance and Commitment Therapy. Oakland, CA: New Harbinger. Luoma, J. , Kohlenberg, B. S. , Bunting, K. , & Hayes, S. C. (2005). ACT and self-stigma in substance abuse: A pilot study. Paper presented at the Annual Meeting of the Association of Behavior Analysis, Chicago.

Acceptance: making room for painful feelings, urges and sensations, and allowing them to come and go without a struggle. Contact with the present moment: engaging fully with your here-and-now experience, with an attitude of openness and curiosity. Defusion: distancing from, and letting go of, unhelpful thoughts, beliefs and memories. Hayes, S. C. & Smith, S. (2005). Get out of your mind and into your life: The new Acceptance and Commitment Therapy. Oakland, CA: New Harbinger. Luoma, J. , Kohlenberg, B. S. , Bunting, K. , & Hayes, S. C. (2005). ACT and self-stigma in substance abuse: A pilot study. Paper presented at the Annual Meeting of the Association of Behavior Analysis, Chicago.

Mindful v Paying attention in a particular way: on purpose, on the present moment, and non-judgmentally. v Bringing one’s complete attention to the present experience on a moment-to-moment basis. v Paying attention with openness, curiosity, and flexibility.

Mindfulness v Is not an obesity control strategy that tries to control our eating. v It is not for evaluating or judging our eating. v It is for seeing it, describing it, looking at it.

Worksheet no. 1 The observation worksheet Notice yourself noticing Push the ‘observer self’ plug

Autobiography in five chapters - Portia nelson I walk down the street. There is a deep hole in the sidewalk. I fall in. I am lost… I am helpless. It is not my fault. It takes forever to find a way out. I walk down the same street. There is a deep hole in the sidewalk. I pretended I don't see it. I fall in again. I can't believe I am in the same place But it is not my fault It still takes a long time to get out

I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in…it's a habit. My eyes are open. I know where I am. It is my fault. I get out immediately. I walk down the same street. There is a deep hole in the sidewalk. I walk around. I walk down another street.

Worksheet no. 2 Evaluating the workability and cost of various strategies you have used in order to cope with weight issues and to reduce suffering.

Acceptance is v Knowing what you can’t change. v Having the courage to change what you can. v Developing the wisdom to know the difference. v Allowing change.

Accept that… v The diet obsession increases the obesity prevalence and causes emotional and health problems. v There is an empowerment of the obesity problem ruled by political and economic interests. v There is a natural diversity in weight and shape among the population – real people come in all sizes. v We don’t have to be thin to be healthy. v We all have our own set-point. v Losing 5 -10% its enough for attaining our well-being. v We don’t know how to help people lose weight and keep it off.

But we do know how to: Stop the obesity process. Lose 5 -10% and keep it off. And most importantly Eat healthy, be active and live a meaningful life in every shape and size.

Worksheet no. 3 Acceptance is not giving up. BUT It is letting go of ineffective and unworkable change agenda to open the door fundamental change to occur. What do you have to accept personally?

What do I have to accept? v Weight is not an outcome of willpower. v Avoidance of certain foods empowers loss of control and binge eating. v Being part of the diet cycle…(yo-yo) – cause us harm. v Winning the thinness race is like winning the lottery. v Diet – every diet - makes us fatter. v Using the scale is harmful. v We can’t weigh our happiness. v Life is here and now. Not in the future not when you are thin. v Normal eating is following internal codes according to your own hunger and satiety.

Worksheet no. 4 Getting hooked “Hooked by thoughts” – means getting caught up in our thoughts which exert a strong influence over our actions. v In what situations does your mind manage to hook you? v What sort of things does it say in order to hook you? v How do you manage to unhook yourself? (based on Russ Hurries worksheet)

Defuse Looking at thoughts rather than from thoughts Russ Hurris

“Eating Dialog” Cognitive Defusion learning to step back and detach from unhelpful thoughts, feelings, behaviors… Identify value of life Well-being Committed action

From control strategy to freedom of choice From weight-centered approach with its diet language of eating to the health-centered approach with its intuitive language of eating.

Mindful eating Intuitive eating arie stoty

Letting go of: Mindfulness Mindful skills Observation Acceptance Being present Cognitive defusion Experiential avoidance techniques that belong to the diet language Hunger and satiety Emotional hunger Physical hunger

Physical hunger Mindful Skills Observation Acceptance Being present Cognitive defusion Identify the hunger Identify its level Identify the food that will satisfy you

Emotional hunger Feel hunger v. Experiential Mindful avoidance skills v. Cognitive fusion Identify the emotional hunger Identify the emotion Expansion Mindless eating Binge eating Low self esteem Increase obesity Acceptance Cognitive defusion Value of life – well being

Emotional eating Committed action - Choice Mindful skills Eat the feeling Mindful eating No guilt No damage to the self No loss of control No binge eating Being with the feeling Feeling Normal eating

Emotional hunger

Epilog

“Eating Dialog” "Eating Dialog - School for “fat studies” From the weight-centered approaches to the health-centered approaches. Ayelet Kalter RD. MSc. The founder & director of the Eating Dialog Study & Therapy Center in Tel Aviv. The founder & coordinator of the "Eating Dialog - School for fat studies” in Ariel University Center. The HAES leader in Israel. www. eatingdialog. com

“Eating Dialog” The objectives of the program v To promote new social and professional discourse designed to abandon the boundaries of the diet paradigm. The discourse enhances the critical, political, social, and economic point of view. Thus, it facilitates the shift from the bio-medical model to the bio-psycho-social model. v To lead the professionals to think, see and behave differently regarding issues that deal with weight, shape, body and eating so they can make the shift from the weight-centered approaches to the health-centered approaches. v To promote society in general and individuals in particular toward their well-being in every shape and size.

“Eating Dialog” The school model Weight-centered approaches The diet eating language ACT* Health-centered approaches (HAES) The intuitive eating language ACCEPTANCE COMMITMENT THERAPY*

“Eating Dialog” The outcome of the process The process is individual and experiential and takes place first and foremost within oneself. v The students are going through a process of training and change so that they can actualize, teach, treat and behave through the health-centered approaches. v The students become leaders and a role model, both socially and professionally.

In the future “Eating Dialog” Eating Dialog School for fat studies General public clinic individual & group therapy Food industry programs and enrichment Media, politics, public sector various activities Focused training for specific professional groups Health 3 -year program for medical staff Education counselors, teachers and principals

“Eating Dialog” Before you embark on any path ask the question: Does this path have a heart? If the answer is “no”, you will know it, and then you must choose another path. ” (Carlos Castaneda = The Teachings of Don Juan)

Thank you!