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The Ellyn Satter Institute Newsletter

Advice for an undergraduate dietitian: Practicing ecSatter

by Ellyn Satter, Registered Dietitian and Family Therapist

If you are a student dietitian, or even an experienced professional, you may struggle with regard to practicing the Satter Eating Competence Model (ecSatter)1 in a conventional world. Practicing ecSatter means your job is helping people become joyful with food, rather than teaching them what they should and shouldn’t eat. You may worry that you will be ostracized for your liberal advice, and worry that your patients will simply go out of control. You may also wonder, in fact, whether it is safer to teach modified diets, especially to people who have diseases.   

Conventional practice assumes dietary prescription is best

It isn’t easy making the transition from the control to the trust model. One of the biggest sticking points is the assumption that in clinical practice, food prescriptiveness is superior to the relaxed and positive self-trust of eating competence (EC). In my experience, it is not. In fact, prescriptive diets do more harm than good. They cost people their joy and ease in eating, engender distrust of their own well-established and well-tested foodways, and precipitate distorted eating attitudes and behaviors. I used to give those diets, I created all that negativity in my patients, and I was stimulated by my own mistakes to develop EC.

Eating competence (EC) gives better outcomes than dietary dos and don’ts

Research shows competent eaters do better in all ways. Dietary prescriptiveness can’t match that. 

In the 30 or so years since then, other EC practitioners and I have found that helping people to be positive, joyful, and reliable with eating gets better results than we ever did with dietary prescriptions. These positive results likely grow out of consistency and sustainability. EC is intrinsically rewarding, so people keep it up. The research backs up our clinical experience. Competent eaters do better nutritionally,24 do better with weight management (in that they stabilize their weights and once in a while lose a little weight if they have it to spare),3,4 have more positive eating attitudes and behaviors,4,5 and  show better health indicators (blood lipids,6 blood pressure,6 and blood sugar3). They even do better socially and emotionally.4 Research with dietary prescriptiveness, including nutrition policy, doesn’t match that.

Eating competence is a radical model, which doesn’t mean extreme or fanatic

Radical means “reduced to its simplest and most elemental form – of or relating to the root.” Being a radical thinker lets you be creative about helping people find solutions to their food and nutrition challenges, something you can’t do if you are simply handing out dietary prescriptions. Consider trusting food traditions and the social and emotional meanings of food. If you go back far enough, people in all cultures developed their foodways by trusting their bodies, being tuned in to the environment, and finding ways that work with food and with eating. Consider trusting physiology, metabolism, and the body’s homeostatic processes. You can show your patients how to put together meals that are satisfying and sustaining, reassure them about the ebb and flow of appetite, and show them how to work with their bodies rather than against them in regulating food intake. Consider food chemistry, food composition, and nutritional principles. Rather than having to go by lists of dos and don’ts, you can evaluate fatty acid profiles of “forbidden” fats,7 and discover the nutritional value in those and other foods your patients enjoy. Consider evidence-based practice. You can read and evaluate the literature, make up your own mind, and help your patients make informed decisions about the costs and benefits of adhering to nutrition prescriptions.8

To practice dietetics from the EC perspective, join with people right where they are

Do the least you can to get the desired results. Trust the process. When people achieve EC, they naturally learn and grow with food: Over time and to the best of their personal and financial ability, they increase their dietary quality. If you are positive, supportive, and cognizant of the hierarchy of food needs,9 you might discover an opening to help your patient along a bit with food selection, but be careful. If your advice precipitates shame and an on-again, off-again eating pattern, back off. It is doing harm, not good.  People do the best they can with their food, and they are not helped by being made to feel ashamed of what they eat.

You will encounter resistance from other professionals

So, dear Anonymous, it is up to you. Being a practitioner of eating competence (and feeding dynamics) is not for the faint-hearted. It takes time, energy, and courage, as your colleagues may react with resistance and suspicion. As one EC practitioner observed, “Sometimes I would just like to go back to telling people what to eat.” But let me be absolutely clear: You do have to choose. If you straddle paradigms by trying to blend dietary presciptiveness in with EC, you will confuse yourself and your patients and end up doing more harm than good.

Your patients will love your EC practice

Your patients, on the other hand, will be surprised and gratified by your kinder, gentler ways with nutrition counseling and will do well in finding their way with more realistic guidelines. Whether it is clinically or with respect to doing nutrition education, I always feel best about practicing dietetics when I help free people up to enjoy their eating. My wish for you is that you will find the same.  

References

  1. Satter EM. Eating Competence: definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav. 2007;39 (suppl):S142-S153.
  2.   Lohse B, Bailey RL, Krall JS, Wall DE, Mitchell DC. Diet quality is related to eating competence in cross-sectional sample of low-income females surveyed in Pennsylvania. Appetite. Nov 25 2011;58(2):645-650.
  3. Lohse B, Psota T, Estruch R, et al. Eating competence of elderly Spanish adults is associated with a healthy diet and a favorable cardiovascular disease risk profile. J Nutr. Jul 2010;140(7):1322-1327.
  4.   Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ. Measuring Eating Competence: psychometric properties and validity of the ecSatter Inventory. J Nutr Educ Behav. 2007;39 (suppl):S154-S166.
  5.   Krall JS, Lohse B. Interviews with low-income Pennsylvanians verify a need to enhance eating competence. J Am Diet Assoc. 2009;109:468-473.
  6.   Psota T, Lohse B, West S. Associations between eating competence and cardiovascular disease biomarkers. J Nutr Educ Behav. 2007;39 (suppl):S171-S178.
  7.   E.M. S. Appendix N, A primer on dietary fat. Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook. Madison, WI Kelcy Press; 2008:283-285.
  8.   Satter EM. Appendix D: Diet and degenerative disease: It’s not as bad as you think. Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook. Madison, WI: Kelcy Press; 2008.
  9. Satter EM. Hierarchy of food needs. J Nutr Educ Behav. 2007;39 (suppl):S187-188.

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