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Obesity Education for Dietitians



There is no doubt that dietitians are the health professionals most often looked to for advise on weight management.

It may therefore come as a surprise to many readers that although dietitians have vast knowledge about healthy eating and the dietary management of a wide range of diseases like diabetes, kidney disease, celiac disease and many others, most dietitians interestingly do not have specific training in treating obesity (the same can sadly be also said for the vast majority of doctors, nurses, exercise physiologists, or any other health profession you can think of).

No one is more acutely aware of this lack of expertise than the dietitians themselves, especially as they are so often called upon for dietary advise by people trying to manage their weight.

As anyone working in this field quickly recognizes (and regular readers of these pages will know this by now), eating or ingestive behaviour is only one part of the energy balance equation and even there, the many socio-psycho-biological factors that determine caloric intake are anything but simple.

I am therefore particularly pleased that the Dietitians of Canada have partnered with the Canadian Obesity Network to co-host the first pan-Canadian Learning Retreat on the Principles & Practice of Interdisciplinary Obesity Management for Dietitians, that is currently being held in Winnipeg.

The aim of the retreat is of course not to teach dietitians about counseling clients on healthy eating or even about nutritive approaches to weight losst. Rather, the retreat focusses on all of the other topics that dietitians need to know about in order to fully understand and appreciate the many factors that are essential for effective obesity management.

It is therefore not surprising that there is a lot of room on the program for the discussion of topics like weight bias, psychosocial factors, mental health, neurobiology of hunger and satiety, exercise physiology, body composition, and of course medical and surgical management of obesity.

Judging by the enthusiasm of the attendees, it appears that such a learning opportunity has been long overdue and I am certainly hopeful that events like this will help ensure that patients struggling with excess weight will have an increasing number of dietitians to turn to, who have been specifically trained in obesity management.

AMS
Winnipeg, Manitoba

15 Comments

  1. All of the topics are useful.

    However, dietitians also need to RESEARCH and find the best food plans for losing weight, including use of supplements, scheduling eating, monitoring blood work routinely, eating enough protein ( with specific types of exercise so protein is utilized to preserve muscle, exercises from another professional).

    One of the impediments to weight loss is that diets recommended BY DIETITIANS don’t work, like “follow the canada food guide but eat less.” or “have milk in your coffee instead of cream”” – not bad advice, just totally inadequate to treat obesity.

    Bariatric surgery patients are able to lose weight because they eat a very low calorie diet that is specifically designed for weight loss, supplemented, scheduled, precise balances of carb-protein etc. , and are monitored by blood work etc.

    There needs to be more research so that a person going to a dietitian for weight loss will get a plan based on the optimum food plan for maximizing weight loss while maintaining health.

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  2. Hi Arya,

    Even if dietitians don’t have specific training on obesity reduction, it appears that they can significantly reduce the obesity rate in a region. I am in the process of writing up some results on the relationship between the obesity rate of Canadian cities and the number of dietitians in that city. The key finding so far is: A 1% increase in the number of dietitians in a city leads to a 2-3% reduction in the obesity rate (technically BMI>27). Next week I may post some initial results on our blog (www.canadianagrifood.ca) and I’ll definitely link to the paper once it’s completed. (Also, not to be excessively wonkish, but causality is well-established (IV estimates) so our conclusions are robust.)

    Regards,
    Brandon

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  3. Hi Dr Arya,
    Thanks again to bring to our attention the complexity of weight problematic.

    And to add to the complexity of this topic we have to keep in mind the systemic approach of healthy “lifestyle”.

    We have to realized only a certain percentage of Canadians have access to dietician. If you don’t have health problem, the “patient” became a “consumer” by paying from his pocket the amount of its consultation whit someone, because it is not automatically provided by our [each provincial] health system.

    And as Adam Drewnowski, remind us [for several years now]; how people eat is intimately related to the constraints and opportunities they face everyday:

    *** Drewnowski, A. (2009). Obesity, diets, and social inequalities. Nutrition Reviews, 67(s1), S36-S39.
    *** Darmon, N. et Drewnowski, A. (2008). Does social class predict diet quality? Am J Clin Nutr, 87(5), 1107-1117.
    *** Drewnowski, A. et Darmon, N. (2005). Food Choices and Diet Costs: an Economic Analysis. J. Nutr., 135(4), 900-904.

    Thanks,
    Nathalie

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  4. Great idea! Will this information be available somewhere afterwards for Dietitians unable to attend?

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  5. This is wonderful news. There’s hardly been a day over the last ten years when I haven’t read or seen in the news a dietician saying that to lose weight people just need to get up off the sofa and make better food choices. As an overweight person who says “no” to themself a thousand times a day and still doesn’t lose weight, the implied message that I’m just not trying hard enough is neither helpful or healthy. I look forward to hearing that dieticians have a better understanding of the causes of obesity.

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  6. To moderator – on another topic – Dr Sharma, any comments on:

    Globe and Mail , today, Mar 5, Life section, page L4

    STUDY> OBESITY Bacteria may drive appetite (Washington, Associated Press)

    Journal SCIENCE, Dr Andrew Gewirtz “The reason [people are] eating more may be an increased appetite resulting from changes in intestinal bacteria.”

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  7. I agree, however, one comment included the use of supplements! I would suggest that the news is filled with reports of fragmented, synthetic and/or isolated vitamins, multi or otherwise could be detrimental. Vitamins should be recommended with a great deal of caution, perhaps only prescribed by a doctor when neccessary for a particular disease or purpose. The news is consistently recommending raw whole food supplements, organic or otherwise be used and is more beneficial.

    Bill Moe

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  8. We’ve seen the Alarming Statistics: Hypertension, Glucose intolerance and orthopaedic complications. Social Acceptance, Body Image and Self-Esteem issues.

    Yet working 9-5 is a thing-of-the-past and busy families still make poor food choices.
    When people are hungry and reaching for the first available meal, important alternatives to “fake” fast food have to provide cost-effective “real” food and save time.

    Meal Assembly businesses fit this situation. They’ve been around a decade and deserve a good look before we resort to drastic surgery. Nutritionists need to team up with these facilities and doctors need to recommend them, where appropriate.

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  9. As a dietitian who just attending this excellent conference, I would like to add a comment. I was impressed with the depth of knowledge and passion I observed in my fellow conference delegates. I do not believe that Dr. Sharma intended to imply that dietitians are not knowledgeable about weight management. Depending on our client’s interests and motivation as well as the amount of time we get with them, we have the tips and tricks, sample menus and meal plans based on specific calorie amounts for guidance, we know how to work with food journals, etc. We are linked to the current research by our professional organizations.

    Like any health professional, there is a lot that can be learned from other disciplines, and in weight management this is especially important such as in motivational interviewing. At the end of the conference after all the experts had presented, the delegates voted about 40% of the material as being new.

    Dietitians could give clients 900 kcal meal plans like many of the diet programs do, but they are not sustainable (Dr. Sharma used the analogy of an elastic band to describe weight lost on diets – the further you stretch the band the faster back it will spring), and people who lose weigh rapidly and gain it right back after stopping the diet have lower metabolisms and more of a sense of failure than before the dieting.

    The bottom line is that weight loss is never easy and a more realistic and achievable goal is often prevention of further weight gain. I felt inspired after this conference by how hard colleagues in my profession are striving to support the health of their clients. Dietitians do have more of a background in the many factors influencing weight than the diet industry. However the diet industry is much larger than the group of dietitians, and they will continue to aggressively advertise their promises of drastic (albeit unsustainable) weight loss to draw people in.

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  10. Brandon < the number of dietitians in a city leads to a 2-3% reduction in the obesity rate>

    This is great news, and I must say after attending the Retreat that I have rarely seen a more enthusiastic and committed crowd. I am absolutely confident that dietitians can make a huge difference and I do hope that others who attended the four days will post on their experience (thank you Anonymous for your post).

    AMS

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  11. I also had the opportunity to attend the conference and have come out of it knowing that I will be approaching my patients and my practice quite differently when I return to work on Monday. As an avid reader of Dr. Sharma’s blog and other great nutrition blogs, I have always known that obesity is a multi-faceted issue, but the conference really helped to bring all these factors together and presented ideas on how to address those in my practice. As a new dietitian who is also the only dietitian on staff where I work, I also appreciated meeting my more experienced colleagues working in different areas in obesity to hear about what they do in their practice.

    To address the first two Anonymous comments – It appears that your experience with dietitians has been limited to the media. Unfortunately when speaking to the media, dietitians have to make comments that would apply to as many people as possible; this message is then filtered through the health reporters and editors who may simplify the message even more to make it more easily digested by the public. This leaves us with not a lot of things that we can say. If you have the opportunity, I urge you to seek out a dietitian in your area for one-on-one consultations – you will then see that dietitians do have the knowledge to make practical recommendations based on the latest nutrition research AND your individual needs.

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  12. 1st yr RD,

    My dietitian was in a hospital. I was referred by a doctor. I lost 18 pounds, and then stayed about the same for a few more months. That was considered good enough.

    I was still 107 pounds over the recommended weight for someone my height.

    Ironically, if I had GAINED even more weight, gotten sick with problems caused by obesity, and had bariatric SURGERY,
    THEN I would have been put on an extreme diet.

    If I could lose weight on an extreme diet after I got fatter, sicker, and stressed by surgery, why can’t I be on an effective, aggressive, medically monitored diet treatment now, while I’m comparatively healthy?

    When I was DIETING, I got only a weigh-in and no other medical monitoring, so I suppose the dieting approach had to be conservative.
    If patients who were dieting got aggressive low calorie diet plans and real medical monitoring to detect and deal with side effects, we could aim for substantial weight loss just like a surgery patient.

    Looking back, I don’t think the dietitian understood what that weight meant to me.
    107 lbs. Imagine picking up 5 20-lb sacks of potatoes. Imagine that weight strapped onto your body, to be carried around all day, every day. It is crippling. Getting rid of that weight is worth dealing with some side effects along the way.

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  13. This is a really good read for me, Must admit that you are one of the best bloggers I ever saw.Thanks for posting this informative article.keep blogging.

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  14. Anonymous 1:

    During the retreat one of the things that I learned was that for many people with obesity it is NOT realistic to expect them to lose weight to what is considered a “normal weight for their height”. Your weight loss of 18 lb and then subsequent maintenance WOULD be considered a success from a health standpoint because you are avoiding the comorbidities that would come with gaining more weight.

    The “extreme diet” that comes with bariatric surgery is not primarily for weight loss; it is there more to help the patient meet all their nutrient needs given the fact that their stomach can only hold a fraction of what it used to and the malabsorption issues that come with those types of surgeries.

    Obesity is a condition that requires LIFELONG treatment. Commercial weight loss programs are only concerned with the LOSS part, so it’s not safe to assume that what they’re doing is “conservative”. On the other hand, dietitians are concerned about MAINTAINING weight loss (or just maintaining weight at all, if that is an issue for the patient). As the anonymous dietitian said, if we put people on an aggressive low-calorie diet, they lose weight rapidly and then gain it right back once they go off of it. But it is also unrealistic to maintain an “aggressive low-calorie” diet for life from a financial standpoint (patients will likely require expensive supplements and/or meal replacements), a staffing standpoint (for monitoring) and most importantly, a quality of life standpoint.

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  15. 1st yr RD,

    The DIETING I referred to as being “conservative” was the diet given by the hospital dietitian, not a commercial program.

    I meant to compare the difference in approach between being a bariatric surgery patient who gets medical tests and checkups and who is monitored for problems, and being a patient whose treatment is dieting according the dietitian’s program, and getting a weigh-in, but getting no other medical tests.

    A surgery patient who develops a severe nutritional deficiency would have that picked up in medical testing, and supplements would be given to correct the problem. The surgery patients survive on a tiny amount of food so they lose weight, but they have to be monitored carefully. The side effects are dangerous, but the patients are monitored, the side effects are treated, and the overall result – safe weight loss – is worth it.

    An out-patient dieting according to a dietitian’s plan, like me, who develops a severe nutritional deficiency would not have that problem picked up in testing (I had no medical tests besides weighing), and serious problems could develop. So the primary focus of the dietitian has to be avoiding any possible problems or side effects which could make the situation worse. That is what I meant by being “conservative”. The dietitian can’t lower food intake much below maintenance level because it’s too dangerous to risk deficiencies and side effects while having no way to detect them and treat them.

    The question is :
    Is it impossible for me to lose more weight by dieting, because I would get sick if I limited food to small enough quantities for me to lose weight…
    or…
    Is it impossible for me to lose more weight by dieting because the effective medical monitoring and treatment of problems and side effects associated with weight loss is unavailable to me because I’m not a surgery patient

    Anyway, on the dietitian’s plan I did lose that 18 lbs, and was left with 107 extra lbs.

    My 18lb-and-holding loss was a success as far as the medical system was concerned, because, as you point out, staffing, monitoring, supplement, etc is expensive. There is no point in spending health care dollars on a problem which isn’t really a medical problem, it’s just a 107 lb inconvenience to me. Fair enough.

    There is also no point in me spending any more time and effort meeting with a dietitian when there is no hope of any further progress. The dietitian already gave me the diet information I need to maintain weight, and it seems that more weight loss while staying “healthy” is not possible.

    You learned that “for many people with obesity it is NOT realistic to expect them to lose weight to what is considered a ‘normal weight for their height’.”

    I guess that’s me.

    I do wonder why you say “it is … unrealistic to maintain an aggressive low-calorie diet for life from … a quality of life standpoint.”

    If it were possible to achieve a satisfactory weight, I would apparently have to stay on a maintenance diet for life which would always be lower in calories than most people’s, and I may have to take supplements to get needed nutrition while eating few calories. Is that what you mean by a low quality of life – eating little food and taking supplements – or is there something else?

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