How the “what-the-hell” effect may impact patient success

By Emily Hulse, MS, RD | Fact-checked by MDLinx staff
Published February 20, 2023

Key Takeaways

  • Patients who create strict, unattainable goals may fall victim to the “what-the-hell” effect of overindulgence and consequent shame cycling.

  • Setting attainable goals with personalized strategies may help patients find success in their health outcomes.

  • Medical providers have influence on patients’ self-efficacy and ability to achieve desired health goals.

A patient walks into your office and vows to stop eating fast food, exercise five days a week, and drink eight or more glasses of water per day. But, a few weeks later, they return feeling shame and frustration for not meeting a single goal. They claim they tried their hardest, but were tempted and fell victim to circumstances pushing them to resort to old habits.

The cycle may continue for years and years with restrictive, challenging rules and vows followed by bouts of overconsumption and indulgence, as well as shame and guilt. This cycle refers to the “what-the-hell” effect that many patients face. 

One 2019 study analyzed this concept in action by comparing unrestrained and restrained eaters. It found that unrestrained eaters—those not dieting, restricting, or otherwise following rules related to their nutrition—ate less overall than individuals trying to restrain, restrict, and regulate their food intake.[]

This example shows a common theme among individuals trying to change their nutrition, physical fitness, finances, and other areas of their life. When excessive restraint and regulation set the stage, overindulgence and counter-regulatory behaviors can stand in the way of success.

Associated behaviors

Nutrition is a common area where the “what-the-hell” effect comes into play. While many Americans are working toward weight loss, approximately 80 percent of weight lost through diet will be regained within five years of starting a diet.[] There are certainly multiple reasons behind weight gain despite restriction, but the “what-the-hell” effect may be one of the largest contributors. 

Kristin Draayer, MS, RD of Nutrition by Kristin explains that “This effect can have negative consequences, such as loss of control over eating, and feelings of guilt and shame. These negative emotions can further reinforce the cycle of breaking food rules, overeating, and restriction.”

"Negative emotions can further reinforce the cycle of breaking food rules, overeating, and restriction."

Kristin Draayer

As a result of this cycle, patients can get farther and farther from their health goals and begin to feel discouraged, isolated, and frustrated.

Another area “what-the-hell” may seriously affect is alcohol consumption. According to the Centers for Disease Control and Prevention, one in six adults will binge drink.[] Binge drinking is associated with severe consequences such as unintentional injuries, sexually transmitted diseases, chronic diseases, and more. Patients who binge drink may similarly restrict and avoid alcohol but later over consume alcohol, leading to shame, guilt, and serious consequences. 

Think of common scenarios: a college football tailgate, all-expenses paid cruise, or bachelor/bachelorette trip. These experiences all set the stage for binge-drinking as the “what- the-hell” effect is in full force. 

Fortunately, this pattern can be managed and providers have opportunities to help their patients achieve sustainable habits that benefit their health long term.

How can you help?

Adequate goal setting techniques and strategies can help patients overcome the “what-the-hell” effect.

A 2019 systematic review found that medical providers play an integral role in promoting self-efficacy for patients to make choices that best support their goals and needs for chronic conditions.[]

One way to address this cycle of overindulgence and shame is to focus on adding positive behaviors, rather than removing negative ones. According to researchers Benjamin Gardner and Amanda L. Rebar, when prioritizing high-value goals and outcomes patients may be more likely to initiate the goal and maintain the subsequent desired habit.[]

For example, rather than ask a patient to reduce the amount of sugar-sweetened beverages consumed daily, consider asking your patient to increase water intake daily. Additionally, provide tools for success, such as suggesting a refillable water bottle, a water-drinking phone application to track progress, or even ask patients to set alarms on their phone to remember to drink. 

Kristin Draayer, MS, RD concludes, “So what can we do about it? Give ourselves unconditional permission to eat all foods. When certain foods are off-limits or deemed “bad,” it leads to stronger cravings, loss of control around food, or feelings of guilt and shame around eating.” 

In nutrition, new movements such as intuitive eating aim to work around the “what-the-hell” effect by providing similar frameworks to Kristin’s insight.

Ultimately, working with patients to achieve attainable goals, giving permission to find balance, and celebrating all wins can help patients overcome this effect and establish long term, beneficial habits.

What this means for you

You may recognize the “what-the-hell” effect in patients who set unattainable goals and fall short time and time again. This patient perspective isn’t unchangeable, and practitioners with confidence in goal setting, problem-solving, and empathy can help their patients overcome this mindset shift. Through smaller, sustainable changes patients can overcome their shame to create positive and longstanding health-related habits.

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