“Now I Can Do Better”: A Study of Obese Women's Experiences following a Nonprescriptive Nutritional Intervention

Participants

Participants were enrolled in the Health and Wellness in Obesity Study, a community development program offered at the largest university in Brazil. Participants were recruited via media advertisement. Interested individuals attended a lecture that introduced the objectives and procedures of the intervention. Eligible participants met the following criteria: (a) female, (b) aged 25–50 years, (c) a BMI higher than 30 kg/m², (d) literate, (e) not suffering from diabetes mellitus, (f) not engaged in other nutritional treatment or physical training programs, (g) not using any weight-loss medication, and (h) not being pregnant. Thirty participants were recruited and 14 completed the entire intervention (53.3% of the original sample dropped out of the intervention before its conclusion). Participants' reasons for dropouts are explained in Table 1.

OPEN IN VIEWER

Table 1.

Dropout reasons from a nonprescriptive intervention program (n = 16), São Paulo, Brazil, 2013.

	PROPORTION (%)
Moved to another city	12.4
Time unavailability	18.8
Pregnancy	6.3
Familial issues	25
Health issues	31.2
Travel	6.3

The participants gave informed consent verified by signature, and all procedures were in accordance with the Helsinki Declaration as revised in 2008. The project was approved by the Ethics Committee of the Federal University of Sao Paulo. This trial was registered at clinicaltrials.gov as NCT02102061.

Study Design

An action research method employing a qualitative and exploratory approach was used. The theoretical framework used was based on the HAES® philosophy and on the paradigm of nonprescriptive intervention. Action research progresses through cycles in which actions that aim to make specific changes to a given scenario are taken; it uses a reflexive method to track the evolution of the scenario from the perspective of those involved. ¹⁶ The present study was thus characterized by an ongoing process involving implementation of separate focus groups (December 2012, April 2013, July 2013). Reflexivity was achieved by the maintenance of an ongoing exchange of ideas between professionals and participants. The study was dialectic, since the perspectives of the participants, expressed in the focus groups, guided the course of the intervention.

Before commencing the intervention, 60 hours of interdisciplinary meetings were conducted between physical education, philosophy, and nutrition professionals, who discussed the principles of nonprescriptive interventions and how to apply them. Additionally, the nutritional therapists were provided with 30 hours of training in nutritional counseling principles and techniques. The duration of the intervention was 1 year. It aimed to improve participants' quality of health and life, based on the idea that obese individuals may experience health and wellness, and live fully, independent of any weight loss. Independence of aims from weight loss and nonprescriptivity ensured that the intervention coincided with the HAES® philosophy, and the professionals involved were committed to HAES® principles. The intervention lasted 1 year and consisted of a physical activity program, philosophical workshops, and individual nutritional sessions. Blood tests and anthropometric assessments were taken quarterly, questionnaires and scales were self-administered, and focus groups were conducted.

Data Collection and Analysis

For comparing characteristics among participants who completed or dropped out of the study, we used independent samples T test.

An experienced anthropologist conducted three focus groups during the intervention. In addition, an observer recorded participants' expressions, gestures, and other nonverbal behavior. Considering that the activities and concepts of the intervention were gradually developed along its course, it was not appropriate to follow a standard guiding questionnaire for all the focus groups; hence, each focus group was guided by a separate questionnaire. Questionnaires were constructed collectively by all professionals involved in the intervention. The questionnaires were not pretested because they were specific to the characteristics of participants.

Although the focus group discussions covered issues relevant to all areas of the intervention, the present paper examines only those related to experiences of the nonprescriptive nutritional intervention. The focus groups explored participants' experience of participating in the intervention; their beliefs regarding about and attitudes toward the HAES® paradigm; and their experience of the techniques used, the eating changes they made, and the nature of the therapeutic process.

Liamputtong ¹⁷ argued that groups with fewer than four people might lose group characteristics, whereby active and interesting discussion will be difficult to maintain. On the other hand, groups with more than eight people are difficult for a coordinator to manage. Therefore, it was intended that 7 or 8 women would participate in each focus group; however, to account for possible attrition of participants, 10 were invited to each group. All three focus groups were attended on separate occasions by 12 different women: 2 participated in three of the focus groups, 5 in two, and 5 in one focus group. Each session lasted from 80 to 100 minutes. The sessions were audio-recorded and transcribed verbatim immediately following their conclusion. The data collected in the focus groups were returned to the participants at the end of the intervention.

The Collective Subject Discourse (CSD) technique was used for data analysis. It allows for the organization of qualitative data obtained by discursive means. ¹⁸ CSD uses methodological figures, expressed by the central idea and key expressions (ECH). ECHs are verbatim quotations of the most important ideas in a dialog. Once selected, each ECH is given a name, and that name is the central idea. The central idea describes its ECH synthetically and accurately. Later, central ideas that are similar or complementary are identified and their corresponding ECHs are gathered into a summarizing discourse, which is the CSD. ¹⁸ This technique aims to reconstruct, from parts of individual discourses, as many summarizing discourses are needed to express a given representation of a phenomenon. ¹⁸ Analysis was performed by an experienced researcher and was independently revised by another experienced researcher; the data were then discussed until a final consensus was reached. Nine CSDs were produced.

The tables resulting from the CSD analysis were analyzed. During this process, meaningful elements of each utterance were identified and reflected on. Meaningful elements were organized on interpretative axes such that similar elements were represented on a single axis. Axes were not predetermined, but rather identified during the CSD process. The interpretive axes are presented in the Results and Discussion section.

Conflicts and Perceptions

This interpretative axis analyzed participants' conflicts and perceptions about the nutritional intervention proposed in this study. Barberia et al ¹⁹ assessed the attitudes of overweight and obese women toward nutritional interventions. Some of the participants in that study reported that they had started a certain diet due to the encouragement of their family and friends, whereas others did so because they felt pressure to conform to external opinions related to acceptable body image. Participants in a nonprescriptive intervention initially expected to lose weight, although weight loss was usually not required for the sake of the participant's health. ¹¹ The first focus group of the present study analyzed participants' impressions of the nonprescriptive intervention. Participants expected the intervention to aim to reduce bodyweight and were distrustful when they discovered that it did not (central idea 1B). However, central idea 1A (the body is beyond the lean ideal) identified well with the proposed intervention.

The same focus group explored participants' attitudes toward participating in the intervention for several months. Some participants stated that a conventional diet “would have never worked out” (central idea 2A), whereas others described changing focus from weight loss to other areas of better health (eg, participants' focus shifted from weight loss to what they ate and to their health and body generally), although these remarks still reflected a degree of concern with the conventionally ideal body (central idea 2B). Kirk et al ²⁰ aimed to examine the experiences of individuals living with obesity. All participants in that study had tried to manage their weight with limited or no success. Consequently, the participants blamed their obesity on themselves and expressed feeling ashamed and embarrassed because of their inability to control their weight. These feelings devastatingly affected participants' self-esteem and willingness to attempt novel weight managements. Further, participants felt discouraged regarding their ability to make future changes. The discourse found in our study, that a diet “would have never worked out” (central idea 2A), seems to change the process described by Kirk et al. ²⁰ Similarly to Chapman, ²¹ the nonprescriptive approach used in the present study made participants more attentive to their diet (central idea 2B) and increased their interest in their health (central idea 2C). Over the course of the intervention, participants in the present study seemed to show an increased interest in health versus losing weight alone.

Central idea 2D indicated that some participants were frustrated by the modest weight loss they achieved. This central idea suggests that, despite the intervention, these participants still held diet-focused and weight-loss–focused attitudes (such as the belief that weight might be changed any time), ²² which prevented them from valuing achievements made in areas other than weight loss. It may be that the intervention's duration was insufficient to effect the replacement of typical weight-loss-focused thoughts and expectations with those of a new paradigm.

Herriot et al ²³ qualitatively evaluated the experiences of individuals who participated in weight-loss programs. Participants valued the rapid weight loss the programs brought about and the convenience of following a set diet. In the present study, a duality between the different approaches permeated the discourses. On one hand, there was an acceptance of the nonprescriptive approach (central idea 2A and 8A) and a certain rejection of diets (central ideas 2A, 1A, and 8A); on the other, the desire of some participants for dieting remained (central idea 2D), illustrated by their belief that they would have adapted to a prescriptive intervention. Participants reported wanting or needing some additional form of behavioral control despite indicating that they approved of the intervention and had benefited from it (central idea 8B). This may reflect expectations that the intervention would provide a simple way for participants to manage their diet or a belief that external diet control would make the task of handling food choices less stressful. These observations agree with those of Herriot et al, ²³ whose participants held the belief that diets provided ease and convenience. It is important to note, however, that the convenience and stress reduction effected by prescriptive diets is largely the consequence of the fact that individuals who adopt a prescriptive diet do not make their own food choices, which is neither sustainable nor ethical. ¹⁰ Although weight loss was not the goal of this intervention, the participants who focused on gains beyond weight loss seemed to be more empowered to maintain or even reduce their body weight. The results of the present study indicate that orienting the intervention toward goals other than weight loss resulted neither in weight gain among participants nor in the neglect of health concerns. Contrary to Kirk et al, ²⁰ it appears that the intervention stimulated participants to find ways to take care of themselves independent of weight changes. Leske et al ¹¹ suggested that personality traits may influence individuals' choice of a particular intervention; however, there is little information to be had–-including from the present study–-explaining which traits are important to this process, and how they affect it. This presents an opportunity for future studies to advance in this understanding. This needs to be evaluated in future studies. Understanding the role of beliefs and expectations will enable professionals to propose interventions suited to the individual, which will increase the benefit the intervention is able to confer.

Gaining Motivation, Perspectives, and Positions

This section addresses the influence of the intervention on participants' behavior. One such factor was the motivational aspect. Herriot et al ²³ observed that a desire for weight loss and for the good opinion of friends and family motivated individuals to adhere to prescriptive diets. In contrast, participants in the present study indicated an increasing motivation to continue with the intervention that was related to an increase in their self-confidence and well-being, as noted in the following statements: “I haven't seen a big difference in the scale number, but I've realized that I feel more motivated to continue” (central idea 2B) and “I've been changing my habits and I've realized that this is a matter of health. My pants are fitting, I feel better about walking and now I can do better” (central idea 2C). The excerpt “now I can do better” suggests that the intervention motivated participants by improving their confidence in their ability to change various aspects of their lives.

Another point refers to a new perspective acquired. The participants in the present study reported that they could realize when they were hungry and when they had a desire to eat (central idea 5B) and that were therefore able to respond to hunger in a considered way rather than reacting to it impulsively. Moreover, participants' improved ability to recognize hunger was connected to an important attitudinal change: participants indicated relinquishing the all or nothing thinking characteristic of people following a prescriptive diet in favor of a view that considered occasional moments of excess normal and acceptable (central idea 2B). Chapman ²¹ identified feelings of failure as important to an individual's choice to abandon a given attempt at weight management. In contrast to this result, participants in the present study indicated that they were able to get back into their routines quickly after a lapse, rather than feeling as if they had blown it–-a difference which may be due to the more accepting attitude the intervention aimed to foster. Finally, our findings revealed different positions among participants. A qualitative study revealed that overweight people coped with stressful situations by responding negatively to considerations about their physical condition or by agreeing with negative considerations in order to be better accepted. ²⁴ In contrast, when our participants said, “I eat as much as I want” (central idea 2A), they showed an opposite response to what was expected because of their overweight–- to reduce their intake. Their responses also showed a position of equality with people who had different body weights–-“I'm just like anybody else” (central idea 2A)–-suggesting that they did not change their behavior based on external expectations nor were they complacent about it. It seems that the approach helped them to position and strengthen themselves against the stigmas and stereotypes of being obese.

These results indicate that the intervention-related changes to participants' attitudes and beliefs had a beneficial impact on participants' motivation. Permanent changes in the motivational makeup of participants may allow the benefits of the intervention to persist indefinitely.

Becoming Autonomous Eaters

Throughout the intervention, participants reported dietary changes related to their eating consumption, structure, behavior, and attitudes. (According to Alvarenga et al, ²⁷ food consumption refers to the food intake; eating structure refers to planning, type, and regularity of meals; eating behavior refers to actions related to eating; and eating attitudes refer to beliefs, thoughts, feelings, and behaviors concerning food, as well as the individual's relationship with food). In the first focus group, the changes reported reflected an increased concern with food quality, which was reflected in a decreased consumption of highly processed products and a corresponding increase in consumption of natural, less processed and whole grain foods and better quality fat (central ideas 5A, 7B, and 7C). As emerged from central idea 5A, an increased concern among participants with dietary planning and nutritional balance was observed. Participants reported improved awareness of hunger and satiety cues and indicated that this resulted in more conscious food choices (central idea 5B). Improved awareness of appetitive cues, together with improved meal planning (specifically involving consumption of small, frequent meals), was suggested by participants to explain the observed reduction in the quantity of food consumed (central idea 5C). Participants also reported changes in food-related attitudes and emotions (central idea 3A). Importantly, some difficulties participants emphasized in the first focus group, such as managing more frequent meals, time spent eating, or food intake volume (central ideas 5D and 5E), appeared to have been overcome by the time the second focus group was held. They said they could manage their meals via fractionating, which was reflected in the food quantity. They also expressed that there were changes in the food quality, such as the incorporation of whole grain products and the increased consumption of fruits and legumes (central ideas 7B and 7C). A novel change was related to a decrease of the restrictive behavior (central ideas 6A and 7D). These effects were still more apparent in the third focus group: participants again reported a decrease in the overall quantity of food consumed, along with an improved ability to plan and consume more frequent meals, and an improved ability to manage emotional eating (central ideas 9A, 9B, and 9C). None of the difficulties initially reported by participants were reported in the third focus group, suggesting that the reported improvements were the consequence of permanent changes. Importantly, participants indicated that changes to the consumed quantity of food and management ability they reported reflected internal changes to their desires and motivations and that they regarded the changes as positive. This is markedly different to the typical attitude of dieting individuals, according to which the requirements of the diet are viewed as negative and temporary.

According to Satter's ²⁵ model of eating competence, competent eaters are positive, confident, comfortable, and flexible with regard to their eating practices. The present article agrees with this model; however the phrase autonomous eaters will be used in place of competent eaters, since the term competent may connote moral judgment.

The participants of the present study became more autonomous eaters, contradicting the assumption that without vigilance and food restriction, obese individuals will make poor nutritional choices and overeat. This supports the view that hunger and satiety cues, when properly attended to, can be trusted to assist in food selection. ²⁵ Participants indicated increased positivity across a wide variety of food-related scenarios and improved comfort when exposed to a large amount of available food (central ideas 6B, 6C, and 8A). Further, participants reported an improved ability to manage the influence of their emotions on their food choices (central ideas 3A, 5B, and 9C) and an improved awareness of their eating habits (central ideas 3A, 5A, and 6B). Finally, participants stressed the importance of properly handling social situations (central ideas 8A and 6C) and that they could manage what they like to eat (central ideas 6A and 7D), showing that they had acquired flexibility and confidence.

Overall, participants indicated improved abilities to manage a wide variety of situations and to plan and modify their eating autonomously. This suggested that the nutritional intervention implemented by the present study had increased their independence. The observed decrease in participants' dependence on external behavioral controls suggests that behavioral changes will be more concrete and sustainable in the long term.

Acquiring Tools

Food diary records corroborated participants' reports of increased autonomy and improved nutritional choices (central idea 8A). ²⁶ In addition, participants reported improved awareness of emotional eating and nibbling (eg, continuously eating small amounts at a time), which aided the development of tools and strategies to manage these issues, like reflecting and planning before eating (central idea 3A). Some participants reported that the food diary tool was exhausting and not sustainable indefinitely, although they recognized the importance and gains that resulted from it (central idea 3D).

Burke et al ²⁷ reported that individuals who had difficulty in maintaining a food diary were less organized, lacked social support outside the intervention, and did not appear to plan their eating in advance. ²⁷ By contrast, participants in the present study reported that after some time, diet management strategies like attending to eating habits and planning ahead became routine (central ideas 3A and 3D) and that once these strategies were consolidated into behavioral habits, maintaining the food diary became tiresome. Importantly, even participants who did not maintain their food diary regularly reported that the diary encouraged them to make better food choices (central idea 3C). Unlike the results of Burke et al, ²⁷ these results indicate that the participants of the present study benefited from keeping a food diary and used it to make dietary changes. It may be that the diary is interesting, and therefore not tiresome, until attention and planning are consolidated, and that use of the diary should thereafter be decreased in lieu of the application of other self-monitoring strategies, with an allowance made for the resumption of the food diary if necessary. Continual maintenance may all the same be necessary for some individuals, since as reported in central idea 3C, some participants were less careful about their eating when they did not maintain the food record.

The food record seemed to have allowed our participants to properly manage a wide variety of situations and to take an active, central, and independent role during the intervention. The nutritional therapists involved in administering the intervention were thus facilitators and guides in the process of change, with the agents of change being the participants themselves. The food record was also involved in the observed change in dysfunctional eating attitudes (central idea 3A); such a change, according to Alvarenga et al, ²⁸ predicts a better outcome in treatments. Considering the importance of the food record as an instrument of beneficial change, the paucity of studies addressing it is surprising.

Other tools aided management of other food contexts. Central ideas 6B and 6C describe participants' experiences of situations–-typically social in nature–-with high food availability. Individuals who are dieting often attempt to avoid or minimize eating before such occasions to minimize the impact of an anticipated high food intake. Characteristically, this attempt will fail, and the individual will then attempt further restrictions after the fact to compensate for their overconsumption. Participants in the present study were encouraged to not attempt to change their eating patterns, either before or after a social situation, and were instead advised to eat as normally as possible. Accordingly, participants did not report or describe attempting restrictive behavior in situations of high food availability and importantly were able to quickly and easily return to good eating habits thereafter (central idea 6C). Regarding the consumption of confectionery, nutritional therapists proposed tools and strategies intended to cause participants to consume them carefully and consciously; the positive effect of these measures was reflected in participants' increased enjoyment of those foods (central idea 6B). Overall, the strategies implemented by the intervention were effective in helping participants to manage properly a wide variety of eating contexts.

The Meetings between Nutritional Therapists and Participants

In the present study, the nutritional therapists helped participants to understand their eating in better ways, make food choices according to new criteria, and manage stress without turning toward food for refuge. The nutritional therapists used food-planning and goal-setting techniques to help participants achieve these aims. This approach contrasts with that which was analyzed by Hancock et al ²⁹ in their investigation of participants' impressions of prescriptive and nonprescriptive interventions. Some participants in that study expressed the view that since their input was not sought when prescriptive advice was given, the advice they were offered was not relevant to them. Others felt incapable of achieving the results they had expected due to insufficient support from the intervention.

In the present intervention, the open-ended nature of the goal-setting process helped participants to choose a course of action and, in so doing, to choose the amount of effort they would expend. This collaborative and inclusive approach fostered self-confidence, which led to participants making more comprehensive and sophisticated plans. Some participants reported feelings of satisfaction when meeting their goals (central idea 4B), while others expressed frustration with their inability to meet their goals, but importantly, both positive and negative reports reflected participants' identification with the goals they were aiming to achieve (central idea 4C). This identification with the program's goals underlines the central role participants' input played throughout the intervention and may partly explain participants' frustration when they were unable to achieve their goals. Contrary to Hancock et al, ²⁹ this finding suggests that nonprescriptive intervention processes helped participants take responsibility, thereby resulting in their agreeing consensually to plans they saw as appropriate and relevant. If the participants did not feel responsible, they would not have expressed their frustration toward not achieving the goals.

Moreover, some characteristics of the nutritional therapists seemed to have aided participants in adhering to the treatment protocol: participants praised the therapists' listening skills, patience, empathy, and understanding (central ideas 4A and 4B). The statement “we talk about everything” (central idea 4A and 4B) suggests that the participants felt accepted by the nutritional therapists. Hence, the therapeutic component of the present intervention may also have assisted in participants' improvement (central ideas 4A and 4B).

Interestingly, some statements recorded earlier in the intervention reflected negative expectations among participants concerning the nutritionists, imagining them as slimming agents (central idea 1B) or determiners of food choices (central idea 1A). Given participants were unacquainted with the nutritional therapists prior to beginning the program, these preconceptions likely reflect the ubiquitous social and professional emphasis on weight loss and reduction of calorie consumption in connection with nutrition. Extant research offers reasons why such preconceptions might exist: Barr et al ³⁰ found that 88% of nutritionists believed it to be part of their practice to encourage their patients to lose weight, and Chapman et al ³¹ found that many nutritionists were comfortable with their role as educators, but not as counselors. Harvey et al ³² assessed the attitudes of 187 nutritionists toward overweight and obese individuals. The nutritionists assessed generally saw obese individuals as less successful professionally and less able to relate to other people and generally did not believe overweight or obese individuals could lead a normal life. Kirk et al ²⁰ found that some healthcare professionals felt ill equipped to offer the support that obese individuals require and were skeptical about the weight-loss programs they had to offer. The poorly empathetic and relationally weak nutritional care ³³ received by overweight and obese individuals is likely a reflection of these feelings and attitudes. Even if it is not, the low quality of care received by obese and overweight individuals makes it likely that the participants of the present study perceived the intervention as different from others they may have experienced. This may explain participants' comments on nutritional therapists as akin to psychologists–-because of the nutritionists' commitment to HAES® principles, the additional counseling training they received before the intervention commenced, and the support they received while the intervention was ongoing; their attitudes toward the participants was likely more positive than is generally the case.

The present study aimed to understand obese women's experiences of a nonprescriptive nutritional intervention. A qualitative methodology allowed detailed data describing the participants' perspective to be collected and made possible the analysis of the effects of this type of approach and its elements on the participants. There is a dearth of published quantitative studies that provide an in-depth perspective on nonprescriptive programs, and those qualitative studies that have been published do not describe the personal experiences of participants encountering a nonprescriptive paradigm and its elements. The present study and its results help to fill this gap in the literature of nutritional intervention.

Strategies for ensuring analytical rigor were employed throughout the processes of data collection and analysis. First, each focus group was recorded, transcribed, analyzed, and discussed immediately after its conduction. This allowed the identification of critical ideas and gaps in the discussion, which were immediately corrected in the following focus group. This interaction between data collection and analysis is essential to attain reliability and validity in the data. ³⁴

Congruence was sought between the research question and the components of the method (eg, planning each focus group according to a given stage of the intervention); sample size was chosen to allow the collection of sufficient data to analyze all aspects of the phenomenon under investigation. Lastly, data saturation was obtained. According to Morse et al, ³⁴ data are saturated when they indicate “aspects of the developing analysis that are initially less than obvious”. Accordingly, the results showed a variety of attitudes and points of view, allowing a more sophisticated picture of participants' opinions to emerge than that of participants simply accepting or rejecting the intervention. Additionally, ideas raised in the focus groups were replicated and confirmed when the collected data were returned to the participants at the end of the intervention.

Study Limitations

Sample size was reduced by attrition (53.3% of the original sample dropped out the intervention before its conclusion), though participants who dropped out gave reasons external to the intervention. Hence, the small sample size constitutes one of the main limitations of the present study, despite the final sample's sufficiency for in-depth data collection. In addition, although the focus group moderator endeavored to provide a welcoming environment, the collective nature of the focus group as an investigative tool may have caused some participants to feel uncomfortable expressing their opinion on certain topics or providing in-depth explanation of their point of view. On the other hand, observer notes indicated that the focus groups were characterized by expressive participation of the participants and the discussion of a wide variety of ideas, suggesting that participants did indeed feel comfortable expressing their opinions. While participants were initially randomly selected, sampling after attrition may have been somewhat self-selective–-it is possible that participants who were more engaged with the program and who felt that they were benefiting from the intervention participated more often in the focus groups or stayed involved in the study when others dropped out. To increase attendance and minimize attrition, participants were reminded about the focus groups through phone calls, messages, emails, and face-to-face conversations.

Implications for Research and Practice

More work needs to be done to investigate individual experiences of non-prescriptive interventions. Qualitative inquiries that include critical or extreme cases in their samples (eg, participants who adhered best and worst to the intervention protocol or participants who had most or least success according to changes in the parameters evaluated) may help to understand why people adapt differently to nonprescriptive interventions and how the strategies and tools applied in the intervention affect some subjects and cause the best and worst outcomes within it. The global effect of nonprescriptive interventions on individuals' daily lives and the local effect of interventions on food choices present good opportunities for in-depth ethnography. Given the observed effectiveness of the food diary, the relationship between different types of individuals and the food diary needs further analysis, since it is clear that different participants experience the use of this tool differently, but it is not clear why. The nature and extent of the benefit of the food diary, as well as the extent to which it represents or resembles an external behavioral control, also merits investigation.

It is interesting that nutritionists prefer not to prescribe a specific diet to their clients or patients. Instead, self-monitoring skills may help individuals to assess their eating habits and attitudes toward food. Together with goal-setting and meal-planning skills, the ability to self-monitor helps participants play a central, active, and independent role during their treatment and to assume responsibility for their decisions, unlike in the case of prescribed diets. It could also be interesting to explore the expectations, experiences, and perceptions characteristic of the most prominent discourses presented here, as well as the techniques and characteristics of this paradigm, while acknowledging the uniqueness of each patient. For instance, further analysis of hunger and satiety cues, responses to food-related external stimuli, and food neutralization (the de-dichotomization of food as good or bad) will open opportunities to help obese individuals better manage their eating.