Trust Versus Control in Nutrition Practice

by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist

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Consider what you want for the people with whom you work. Do you want them to feel relaxed and positive about eating and feeding and accepting of and loyal to their body? That would be the trust paradigm, embodied by the Satter Eating Competence Model (ecSatter) and the Satter Feeding Dynamics Model (fdSatter). Or do you want them to worry about good/food-bad-food, stress about what to eat and not eat, anguish over the bathroom scale, and feel bad about their body? That would be the prevailing control paradigm.

It seems an obvious choice, but it is not so obvious at all, because negative feelings about food, eating, and weight are the norm in our control-paradigm-based culture. Guilt and negativity about eating and weight are the soup we swim in. We are so surrounded and influenced by those eating attitudes and behaviors that they are invisible to us and seem normal. Most people try to go along with those conventional expectations in the name of health—or feel guilty when they don’t.

Consequences of the control paradigm

Consider the young woman whose pregnancy was being spoiled by being told not to diet but to gain only so much weight. Consider the young man who would—and could—only eat at certain fast-food restaurants because that is where his parents fed him in order to get him to eat. Consider the septuagenarian who once again seeks help with weight loss because she has been told that if she doesn’t lose weight she will die. Consider the young woman who worries so much about what to eat that she spends hours in the grocery store reading food labels and cannot join her friends when they eat out. Consider the middle-aged father whose on-again, off- again high-protein, low-carbohydrate dieting for his up-and-down weight creates no end of misery for him and disrupts family meals. Consider the university student who is so overwhelmed by the amount and variety of food in the school cafeteria that she doesn’t know where to start with feeding herself. These are all people who are handicapped by our culture’s good-bad approach to food.

Achievable feeding goals

What are the implications for feeding children? Ellyn Satter’s Child of Mine opens by saying “Instead of telling you what and/or how much your child should eat, I emphasize raising your child to have positive eating attitudes and behaviors: To enjoy food, eating, and family meals, be comfortable around unfamiliar food, and eat as much or little as they need to grow in the way that is right for them. Those goals let feeding be enjoyable, confident, and relaxed and free parents from the maddening and impossible expectations of getting their child to eat certain foods and grow in certain ways.” Parents raise their child to have positive eating attitudes and behaviors by following the Satter Division of Responsibility in Feeding (sDOR).

Achieving feeding goals allows achieving nutritional goals. Validation testing with sDOR.2-6y showed that children of parents who scored high in sDOR.2-6y had lower nutrition risk. The parents showed lower restriction and pressure on children’s eating, higher parent Eating Competence, lower cognitive restraint with parent eating, and higher parent quality of life indicators (sleep, stress, psychosocial functioning).¹ Parent reports of following sDOR were supported by video observation.²

Unachievable goals

After over 50 years of trying to eat and weigh according to the Dietary Guidelines, by 2020 we as a US population have only achieved a score of about 60 out of a 100 percent on the Healthy Eating Index, a measure of nutritional quality.³ One of the goals of the Dietary Guidelines is to prevent “obesity,” but as a nation we are getting fatter and fatter.⁴ I have nothing against being fat: It is the rapidly accelerating fatness that concerns me. It means something is out of whack: Most times that something is restrained eating and yo-yo dieting.

The Dietary Guidelines were created to prevent degenerative disease. They don’t work. Metanalysis of randomized trials showed no support for recommendations to increase dietary fruits and vegetables and restrict or modify dietary saturated fat.^{5, 6} Large-scale research found no decrease in diabetes, cardiovascular disease, cancer,⁷ or early death^{7, 8} from following the high-fruit-and-vegetable, low-fat dietary recommendations of the Dietary Guidelines.

Contrast those findings with the rapidly accumulating evidence summarized on the annotated web page, “The Satter Eating Competence Model: Evidence for the Satter approach to eating.”⁹ Eating Competent adults have better diets, lower BMIs, superior metabolic profiles, and more- positive quality of life indicators. They show lower eating-disorder-related symptomology, are more active, do better with low-income food resource management, and are more likely to follow sDOR. Rather than striving to eat certain foods in certain amounts and weigh within certain limits, Competent Eaters and the professionals who advise them focus on instilling positive eating attitudes and behaviors.

Consider normal eating

Good-food-bad-food thinking is normative, but is it normal? From the ecSatter perspective, normal would be cooperating with, rather than attempting to ignore and overrule, the utility and effectiveness of the body’s biological, psychological, and social processes: hunger and the drive to survive, appetite and the need for pleasure, the social reward of sharing food, and the biological propensity to maintain preferred and stable body weight.

Google What is normal eating. This popular handout makes the rounds of refrigerator doors, office bulletin boards, and social media sites. In the context of today’s conflict and negativity about eating, this Eating-Competence-consistent definition offers good news for beleaguered eaters. Normal eating is Competent Eating. People who are Eating Competent are mindful, and that mindfulness makes all the difference between order and chaos. Competent Eaters:
• Have positive eating attitudes: They feel good about food and eating.
• Attend to context management: They have regular meals, tune in while they eat, and provide themselves with repeated neutral exposure to a variety of food.
• Do well with food acceptance: They are relaxed about unfamiliar food and gradually increase the variety they eat.
• Depend on internal regulation: They rely on their internal regulators of hunger, appetite, and satiety to guide how much to eat.¹⁰

How does the trust paradigm address food selection?

The fundamental point about emphasizing positive eating attitudes and behaviors rather than what or how much to eat is easy to read past and also a mind-bender, so bear with me while I belabor it. Consider the word paradigm: A way of a way of perceiving, thinking, and doing. A paradigm shift is a change to a completely different way of perceiving, thinking, and doing.  Emphasizing attitudes and behaviors rather than eat-this-don’t-eat-that is a paradigm shift. It is either one or the other: Following ecSatter and fdSatter leaves absolutely no leeway for saying what and how much to eat. Eat-this-not-that guidelines prioritize eating nutrient-dense foods and achieving certain BMIs and leave no leeway for hunger and appetite. In fact, hunger and appetite are considered enemies of adherence.

Here is how nutrition and food selection issues play out in the control versus the trust paradigm:

Establishing a positive tension

ecSatter and fdSatter establish and maintain a positive tension between structure and predictability on the one hand and permission to eat on the other. Becoming Eating Competent (sBEC) is a parallel to the Satter Division of Responsibility in Feeding (sDOR): Parents do the what, when, and where of feeding; children do the how much and whether of eating. With sBEC, adults do the what, when, and where of feeding themselves; then, when they sit down to eat, adults trust themselves to eat what and how much is appealing to them at that moment.  According to the handout, The Joy of Eating: Becoming Eationg Competent (sBEC), that positive tension is:
• Feed yourself faithfully
• Give yourself permission to eat

Discipline and permission draw on both the external and the internal: maintaining structured and reliable access to personally rewarding food and trusting the body’s powerful and resilient drive to maintain itself and to keep its systems in balance. The internal contradiction that is the essence of ecSatter—discipline and permission—works by giving order and stability. As individuals persist with feeding themselves faithfully and giving themselves permission to eat, eating falls more and more into place as being positive, relaxed, and nurturing.

Some people are stuck

Some people cannot approach eating with any kind of equanimity. They have simply been too mistreated around eating—by themselves and/or other people—and their internal conflict is too great. They try to escape their good-food-bad-food predicament either by being extremely rigid with food selection or throwing away all controls; feeling deprived on the one hand or guilty on the other. When they attempt to give themselves permission to eat, they are overwhelmed by negative self-talk about their weight. When they sit down to eat or deal directly with food, they are flooded with negative memories that overwhelm their ability to tune in to eating.

The How to Eat intervention, taught in the Treating the Dieting Casualty VISION Workshop, treats people who are stuck with eating. How to Eat uses cognitive and behavioral techniques to help patients resolve and manage their conflict and anxiety about eating.

The take-home message

The trust paradigm works by defining eating and feeding goals in the way that they can be achieved: by developing positive eating attitudes and behaviors. Those feeding/eating goals can be accomplished by establishing and maintaining a positive tension between structure and predictability on the one hand and permission to eat on the other. Growing out of that positive tension, both adults and children can feel good about food and eating, enjoy family meals, be comfortable around unfamiliar food, and can eat as much or little as they want.