Is There A Role For Dietitians In Obesity Management?

Over the past 30 years, I have actively been involved in nutrition research – conducting numerous carefully controlled dietary studies ranging from the impact of electrolytes on blood pressure and renal function, to the impact of micro and macronutrients on insulin resistance and metabolism, to the role of genetic factors in response to nutrient intake. In all of this, dietitians have always been key players in my research team helping with the design and execution of these studies.

In my clinical work, I have regularly depended on the tremendous expertise of dietitians in the care of my patients with hypertension, chronic kidney disease, dyslipidemia, and type 2 diabetes – in virtually all of these conditions, dietitians have helped my patients on a wide range of treatments ranging from medications to chronic hemodialysis improve their diets, thereby significantly improving control of their underlying diseases or averting complications.

I have practiced medicine long enough to remember the days of prescribing low-salt diets before the modern era of anti-hypertensive medications, dietary lipid management before the introduction of statins, and worrying about glycosuria well-before most people considered type 2 diabetes to be an actual “disease” and not just a “risk factor” of questionable significance that happens to old people.

Thus, it is with a bit of wonder that I sense an increasing reluctance of some dietitians (at least in Canada) to fully embrace the important role that they could play in obesity management. At times, in recent conversations, I was surprised (and concerned) that more than a few (younger?) dietitians are not only uncomfortable with addressing obesity in their clients, they are in fact ambivilant (if not frankly hostile) to the very idea that obesity is a disease or that dietary interventions to support weight loss have a role to play in obesity management.

This, of course does not apply to the many excellent and skilled dietitians working in the many bariatric centres and obesity clinics, without who many of the successful outcomes in medical and surgical treatment of this chronic disease would hardly be possible.

Rather, ambivalence towards nutritional obesity management appears to emanate from folks who clearly do not (yet) have a sound understanding of the complex psycho-neurobiology of obesity or the mode of action and effectiveness of evidence-based obesity treatments that include medications and surgery.

Indeed, I cannot but wonder about these dietitians’ qualifications to actually contribute to the care of patients struggling with obesity. Imagine having your patient with diabetes being counselled by a dietitian who has never heard of insulin or glucagon, has only a vague idea of how SGLT2 agonists, DPP IV inhibitors, or GLP-1 analogues work, and firmly believes that typ2 diabetes can be fully controlled or even “cured” if patients only followed “healthy eating” tips. Imagine having your cholesterol managed by dietitians who don’t “believe” in cholesterol or statins, or your hypertension managed by dietitians who believe that some variation in blood pressure levels is acceptable and that simply reducing your salt intake and perhaps following the DASH diet is all you need to get off those terrible anti-hypertension meds.

This is unfortunate. Not only is there room for dietary interventions in obesity management, but, as in other chronic diseases, dietitians can (and should) be a key partner in the therapeutic management of people living with this chronic disease.

However, to be effective, dietitians need to first of all be comfortable with the very notion that obesity is a chronic disease. In the same way that any dietitian who does not “believe” in hypertention or type 2 diabetes should probably best stay away from counseling clients with these conditions, I would be wary of any dietary advice regarding managing my obesity from a dietition who does not “believe” in this disease.

Next, I would also expect any dietitian attempting to counsel patients for their obesity to have a robust understanding of the complex psycho-neuro biology of obesity, be aware of their own biases and misconceptions about people living with obesity, and be fully informed and aware of current evidence-based obesity treatments, including medications and surgery.

I would expect no less of a dietitian working with my patients living with hypertension or chronic kidney failure. Simply trying to get people living with obesity to follow a healthy balanced diet is not enough – different people living with obesity require different dietary approaches – approaches that change from patient to patient dependent on patient preferences, responses, circumstances, expectations, severity of disease, as well as concomitant use of medications and surgery.

I know that dietitians can do this when managing patients with a host of other chronic diseases – why some of them struggle to similarly serve clients with obesity, is frankly beyond me.

As we will soon see in the new Clinical Practice Guideline for Obesity Treatment in Adults to be released in 2020, there is strong and robust evidence to support nutritional interventions and dietary management of people living with obesity (in adjunct to, not instead of, medical and surgical management). But is it up to the dietetic profession to fully embrace this role and prepare its members for it by ensuring that their members fully understand and appreciate the emerging science of this complex chronic disease.

Edmonton, AB