Is There A Role For Dietitians In Obesity Management?
Tuesday, November 12, 2019Over 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.
@DrSharma
Edmonton, AB
Tuesday, November 12, 2019
I’m a Dietitian stuck between both sides of the debate. I’ve seen the psychosocial and physiological effects first-hand and agree that it is incredibly complex and that helping people does require multiple approaches, which can include a variety of treatments, depending on the client. For some, promoting a balanced diet may be all they need. For others, they may need more.
My colleagues that take issue with obesity management have a valid argument, and although I don’t agree with all of their views, I see and experience their concerns daily as a clinician. The first is that weight bias still exists, and although obesity research has uncovered so much good, the “fight against obesity” still feels like a fight against the obese (in the eyes of our clients). Obesity as a disease, still feels like we are telling clients that they are diseased because they have obesity. I know that we are fighting weight bias on both sides of this battle, but we have a long way to go before bias stops hurting our clients.
Second: the non-diet approach. The first line of defense for most MDs is to tell their client to lose weight. We see those people. We see them go on a weight loss diet, then gain it all back. This happens over and over and over again. Dietitians are becoming angry because we are seeing this approach tried and recommended again and again and clients feel like they are failures, again and again. Diets only work for as long as you diet. Alternatively, we can recommend a balanced diet, which for the most part doesn’t produce large effects on the scale, which doesn’t really inspire the client NOR their MD.
I hope this explains how frustrated and inadequate RDs feel in treating obesity, and why many are distancing themselves from obesity management and the visious cycle induced by society and the medical community.
Tuesday, November 12, 2019
Excuse me, sir, but I think you misunderstood the goal of our profession. We, as dietitians, for the most part, aim for “health at any size” and utilizing “intuitive eating” in a way that helps people to adjust their dietary habits to meet a sustainable dietary pattern. We do not aim to implement a ‘quick fix’, or a diet that enables someone to lose weight quickly then gain almost double their losses back due to obscene restrictions. We understand weight loss, and that it requires behaviour change, and that not everyone you wish to lose weight will subscribe to that behaviour change as it requires a certain level of dedication that not everyone can commit to depending on their mental health and previous emotional associations with food. This requires psychological, social, environmental, medical and dietary intervention (excuse me if I am forgetting any), to make progress. As dietitians, we do not subscribe to a “one size fits all” motive, but we certainly appreciate health and helping patients and clients works at their pace to achieve a healthy lifestyle. Diets do not work long term- in some networks it would be considered a success when less restrictive long term goals are implemented.
On another note, our profession requires the us to complete an annual competency program, to that effect, I assure you that many dietitians are up to date with the research on dieting trends and weight loss methods, as you are.
I am appalled that another healthcare professional would slander our profession. If you have concerns, or questions, please ask.
Wednesday, November 13, 2019
Excellent comment. A book worthy of reading on this topic is Body of Truth by Harriet Brown, How Science, History and Culture Drive Our Obsession with Weight and What We Can Do About It. Very eye opening really. There is a chapter on Money Motivation and Medical Machine does highlight the business of obesity. Your name is highlighted in the chapter, Dr Sharma along with other high profile researchers. Am not claiming to have any authority in the area at all as much of my work is now far from obesity and hard targeted to diabetes care but I can assure you I am sensitive to my patients needs regardless of their size and circumstances. It is all a great opportunity for discussion. Dietitians are more and more being singled out for a deficit to this problem and I don’t see it as being positive in any way. I know many excellent dietitians that go above and beyond in trying to understand the complexity of the problem.
Tuesday, November 12, 2019
I think this has a lot to do with the HAES movement. It also has to do with the numerous studies that show that diets over the long run don’t generally produce lasting weight loss. This makes a lot of dietitians hesitant to recommend dietary solutions to their clients when there isn’t the evidence base to back it up. Layer that with the HAES movement and dietitians feel unsure of where to go.
Tuesday, November 12, 2019
Your right, in our clinic the family docs are all fully trained, sensitive and knowledgeable about obesity management. They carve time in their 15min appointments to address the complexities of weight management and they do so with compassion. Oh and they come right out of medical school ready to go on this subject! We should cease funding and fire RDs immediately because their profession has some division on a highly complex issue of care — and mostly because doctors can clearly do it all on their own.
Come on!
Dont throw the baby out with the bath water. The tone in this article is negative and elitist.
Tuesday, November 12, 2019
Wow! I experienced this myself! I went to our hospital to see a dietitian to discuss a weight reduction strategy of eating. She said “we don’t really do that anymore”. We tend to encourage clean eating instead.
Tuesday, November 12, 2019
The dieticians I worked with at the clinic are so helpful in my journey to become more healthy. They really take into account my cravings and binge tendencies and work with me to integrate those foods into my “diet/food plan”. In this way, I avoid the feeling of being denied my favourite foods because I eat them mindfully and work them into my daily eating and no longer crave and binge like I used to. Thank you to everyone on your team!
Tuesday, November 12, 2019
I’m a Dietitian who works in Obesity Management in Australia. From an international perspective one of the barriers that may be impacting my American and Canadian colleagues practice in this area may be the International Dietetics and Nutritional Terminology that is used to provide the standardized language for Nutrition Care (used in electronic medical record coding). The IDNT diagnoses regarding Obesity are overly simple, not person centered ( in my opinion) and fail to capture the complex physiology, sociology and psychology that are part of this chronic disease. The diagnoses are slightly better for other chronic diseases such as HT and T2D which may explain your observed differences between these areas of practice compared to obesity.
Tuesday, November 12, 2019
I’m a 77 yr old woman with no heart disease, no diabetes, familial hypercholesterolemia and no interest in a dietician *doesn’t* understand that there is NO role for statins in cholesterol lowering or preventative medicine. Thanks for making it clear, with this essay, exactly how pharma conflicted is your brand of medical care. I’d be dead of statin side effects if I had listened to the likes of you. As it is, I am 20 yrs away from my last statin forced on me by physician threats, and still have not recovered muscle and vision damage.
And still have a cholesterol reading of 11 to 14. Entirely unrelated to what I eat.
Tuesday, November 12, 2019
Can it be that these dietitians just have a different approach? We don’t have a single study showing sustained weight loss after 2 years, yet we do have studies showing a reduction in blood sugar, blood pressure, cholesterol, etc with lifestyle changes WITHOUT weight loss. Because, like you said, weight and health are complex. It’s not that we don’t want patient to lose weight, but for certain patient, putting patients on a calorie-deficient plan may cause more harm than good by putting them at risk for disordered eating or eating disorders. So sometimes it’s a question of pros and cons when it comes to weight loss.
So my three questions for you:
1. Knowing that weight loss doesn’t work, it is still ethical to promote it?
2. Can we improve health markers through lifestyle changes without losing weight?
3. What does an ambivalence towards weight loss have to do with our knowledge (or lack thereof according to your article) about medications?
Tuesday, November 12, 2019
I have few questions for you:
1. Does having a different approach make you an unqualified dietitian?
2. What does an ambivalence towards weight loss have to do with our knowledge (or lack thereof according to your article) of medications?
3. Is it ethical to promote weight loss when we know most people who lose weight gain it back? We don’t have a single study showing sustained weight loss past 2 years. Even the LOOK AHEAD trial stopped after 8 years because there was no difference in terms of health between the 2 groups, with the intervention group showing only a 6 lbs weight loss after 8 years. Diets or lifestyle changes geared towards weight loss aren’t without risk (disordered eating and eating disorders)
4. We have studies showing improvements in markers of health (blood sugar, cholesterol, blood pressure, etc.) through lifestyle changes WITHOUT weight loss. Wouldn’t it be better to focus on that since there are fewer (if any) risks?
Tuesday, November 12, 2019
As far as I know, no dietary approach has ever been proven to cure/reverse/manage obesity. All science (that I am aware of) shows that dietary approaches are unhelpful for long-term weight reduction. Why would you want dieticians to push that to your patients?
Sunday, November 17, 2019
Good point, Valerie. The reason current approaches to weight management do not work is because they address the symptom, not the cause. The science you need to be aware of is linoleic acid and arachidonic acid research. I suggest you Google these phrases: Youtube omega-6 apocalypse, Youtube Michael Eades omega-6, Anna Haug arachidonic acid, Annadie Krygsman metabolic syndrome, Olaf Adam arachidonic acid.
On a personal note, I have been perusing nutrition comment and research for 42 years. It took almost that long to get things sorted. Meanwhile, I experienced problems with varicose veins and gingivitis. (Google – varicose veins linoleic acid and David Brown Kassam) I am now healthier than I was 25 years ago when I first noticed a deterioration in my health.
Wednesday, November 20, 2019
Thanks for your input, David.
I have heard of the Omega-6 hypothesis before. However, as far as I know, there is no data at all indicating that a low Omega-6 diet in humans could reverse or prevent obesity.
So, for now, I’ll put it in the “maybe” category, along with the sugar hypothesis, the saturated-fat hypothesis, the acellular-carbs hypothesis, the hyperpalatability hypothesis, the circadian-misalignment hypothesis, the hormone-disruptors hypothesis, etc.
Tuesday, November 12, 2019
But … there is literally not a single weight loss program that can show long-term (5+ years) sustainability. The most likely outcome is regain, and often plus even more. The end result is repeated, chronic weight cycling, which is highly damaging. So at what point does the medical field recognize that prescribing weight loss is unethical because not only does it not work, it actually exacerbates the problem?
Wednesday, November 13, 2019
While I agree this is a complex area, I am one of those dietitians that disagrees that obesity is a disease. Yes, a risk factor in some diseases and a possible symptom of other diseases, but not a disease in and of itself. Not all overweight and obese people are unwell, so it is a mis-classification to call it a disease.
Yes, there’s evidence that being in the higher weight categories is a risk factor for chronic disease such as diabetes but so is for example, being indigenous and we would never classify ‘indigenous’ as a disease!
BMI is unscientific and improperly validated. Therefore, the word obesity itself has limited clinical significance and can also be stigmatising.
You’ve said it’s ‘frankly beyond you’ why some dietitians would be hesitant to prescribe weight loss interventions (including weight loss surgery- which carries huge risks). So if you don’t understand, why not come and talk to one of us, rather than assuming it’s because we have put it in the ‘too hard basket’ or have limited understanding of human metabolism.
But since you’re wondering, here’s some insight into why I personally have decided to learn how to treat the person and their symptoms with a weight neutral, non-diet approach. Health practitioners usually abide by ‘first do no harm’. If you are to look at the available evidence on weight loss interventions you will see that between 95-98% of interventions lead to weight regain in the medium to long term. No harm right? At least we tried? Well, no, because a significant portion of people regain more weight than they initially lost as a result of the body trying to compensate for a period of caloric restriction, thus putting them at greater risk of chronic disease than before. Indeed, many people have dieted themselves to heavier weights rather than eating their way there. Also, dieting (intentional weight loss) behaviours often lead to eating disorders and weight loss surgery leads to higher rates of depression and suicide. Do the risks of prescriptive weight loss (considering long-term treatment rates) outweigh the benefits? That’s the real question. So, we are simply trying to learn from the evidence and find a new and safer way to improve health outcomes.
I’m sorry if this is blunt, but I found the tone of this article quite patronising. If you want to have other allied health professionals on board in the future, it would help to scrutinise your language before posting. You’ve indicated that young dietitians are the worst culprits for ‘denying obesity is a disease’ as if this makes sense because they are inexperienced. Young dietitians are passionate, recently educated and are open-minded and receptive to research. We are competent as are our older peers (for whom I have the deepest respect). If you wish to learn more about what I am talking about in regards to how we should be very mindful with prescribing weight loss, I would recommend ‘unpacking weight science’ a great source of information from a highly respected Australian dietitian and member of the DAA.
Wednesday, November 13, 2019
As a dietitian working with eating disorders and metabolic syndrome I can see where some confusion lies. When I see clients I want them to realize that health does not ALWAYS depend on weight. I’ve seen thin and large bodies with diabetes.
Weight plays a role, food intake plays a role and exercise plays a role – but so does sleep, mood, medications, genetics, biological sex, hormonal changes, other diagnosis’ and age.
Is it really the weight that needs to be lost? Or is it healthier actions for the things that we CAN control like stress, sleep, mood, oral intake and exercise? That is what I like to focus on. Someone restricting food and losing weight will still remain unhealthy as their body is not getting the nutrients that it needs and it will not be sustainable long term. There is evidence to show this time and time again that diets fail.
So, that being said, I don’t focus on weight loss as the primary goal because this leads to frustration or defeat if clients are starting to make healthy habits and see no ‘success’ because their weight stays the same. I encourage them to see the success in their lab work or energy levels or mood. This helps give the client more control and long term…more success. It also helps immensely with body image issues and mental health issues.
Someone who is changing their eating and exercise habits, taking time to focus on their mental health and still don’t lose weight shouldn’t be disregarded. With the changes they have made they are still healthier people and have decreased their risk of chronic disease despite no weight changes.
I believe that we need to look at this issue as not just a physical one but also a mental one – as emotional eating is a huge culprit. This is what we need to address when it comes to people’s relationship with food. Weight loss may come with this type of nutrition therapy but it can never be guaranteed.
It’s not all about the weight
Thursday, November 14, 2019
Never in my 16 years of practice as a dietitian have I felt this professionally insulted. Dietitians, in my humble opinion, are some of the brightest, hard-working, and compassionate group of professionals. We have put our time in, and then some, with upwards of 6+ years of schooling, a year long internship (usually unpaid), Board exams, continuing education requirements, and salaries below many other allied health professionals. We are collectively a smart group of practitioners who cover a very diverse field and knowledge base, and provide incredibly valuable care on the multidisciplinary team. We become dietitians because we genuinely care about keeping our clients and patients nourished, and hopefully thriving in whatever life they live in.
Since when was it a crime to have a difference of opinion and different practice perspectives? How many times do we go to a second, third doctor for another opinion. I saw 2 different physical therapists for the same issue and they had very different perspectives on what was going on and how to treat it.
To assume any RD is uneducated and unqualified when they choose to practice in a way that is different than you think it should be, well, that feels downright professionally disrespectful.
Tuesday, November 19, 2019
My post was neither intended to insult anyone nor to call out any specific member of your profession. If you read my post carefully, you should see that I have nothing but the utmost respect for your profession and for the role that dietitians have to play in helping clients living with obesity manage their chronic disease. The purely rhetorical question in the heading is just that – purely rhetorical. It only takes a cursory look at my website to find countless posts where I have called out my own colleagues regarding their biases and lack of knowledge. You will also find countless posts on the issue of defining obesity (health is not measure on a scale or by BMI) and arguments for a more patient-centred and compassionate care. No one has accused anyone of a “crime” and no one has suggested that dietitians are anything else but highly educated health professionals (which is exactly why a few (I imagine no more than a handful of your colleagues) have given by pause to wonder).
Thursday, November 21, 2019
Dr. Sharma,
Re: the last sentence of your reply, above – and yet, these are your exact words:
“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.”
I hope it’s a bit more clear now why many dietitians across Canada and beyond are feeling that your words have cast doubt to the public on our understanding of scientific principles (i.e. evidence-based practice) and qualifications (in your words, as above).
It’s entirely possibly for two experts to read the same body of research on a subject and come to two (partially or fully) opposing conclusions, and thus, practice with a difference in professional opinion. It is my feeling that the words you’ve chosen to express yourself with in this post have denied healthcare providers who hold a difference of opinion from your own the ability to do so respectfully, without having their credibility questioned. Frankly, this is disappointing and disheartening. Respectfully, if you have sensed hostility from your dietetic colleagues, consider the factors that may contribute to such a response, such as the wording and delivery of the message in addition to its content.
I think starting uncomfortable conversations between and within professions can often be incredibly important, but like the care we provide to our patients, we must always weigh the potential risks with the benefits. Collaboration almost certainly will suffer when respect and trust has been damaged in a relationship. I hope to see you address some of these thoughts moving forward.
Kindly,
Sara
Friday, November 15, 2019
My Master’s Thesis, which I completed back in 2007, was entitled: “British Columbia dietitians’ perspectives on their experiences with weight loss counseling for children and adolescents”. Using grounded theory methodology, I interviewed local dietitians about their weight loss counselling experiences. My results demonstrated that, “Largely, conversations with dietitian informants reflected frustration, doubt and conflict regarding what they should and could be doing with their clients when it came to weight management. They attributed this distress to four primary issues including their experience of inadequate time and resources to do their work effectively, their perception of the client’s readiness to make behavioural change, their perception that, as dietitians, they lacked the appropriate counselling skills to be helpful to their clients and finally, their uncertainty about how to best deal with the complex problem of obesity. These experiences impacted informants and influenced the various ways they tried to address their distress while continuing to work in this area of practice”. I concluded that “Informant dietitians are feeling unsupported in their work, inadequately trained to support their clients, and uncertain how their profession should best proceed in the treatment of childhood and adolescent obesity. This has tremendous practice, education and research implications for the dietetics profession.” After reading your strongly worded article Dr. Sharma, I can only infer that the situation has not changed significantly over the ensuing decade. However, you do these ardent and well-intentioned professionals a disservice when you blame them for a situation that is as complex and nuanced as obesity itself.
Tuesday, November 19, 2019
Thank you Dr. Sharma for writing this thought provoking blog post.
As a Registered Dietitian of 40 years who is currently working in Primary Care with a focus on assisting individuals living with obesity I thought I would share my perspective.
I have had the privilege of working in various areas of nutrition and dietetics and working through the stages from novice to expert. For example, I had the opportunity to work in the area of nutrition support and was very fortunate to be in a supportive environment at a large teaching hospital. I had wonderful mentors and also devoted time to learning experiences both formal and informal to enhance my abilities to assist individuals on nutrition support. Eventually I became certified in this area.
Six years ago I was very fortunate to start working in primary care. Very quickly I realized that I needed to enhance my skills related to assisting individuals living with obesity. My journey has been different from previous novice to expert experiences. For example, I work with wonderful professionals, but I do not have a mentor. The path to becoming certified in this area six years ago was not that clear to me. The burden of weight stigma and the failure of diet culture has had a very detrimental effect on making progress in developing effective strategies to assist individuals living with obesity.
Taking courses related to motivational interviewing, behavior change, and cognitive behavior therapy have been incredibly helpful to my journey. Taking time to learn about the neuro-cognitive influences on eating behaviours and body weight management has been enlightening. When I share with individuals living with obesity this type of information you can almost see them relax a bit and think, “Wow, its not all about willpower. Maybe this time I can do this”.
Using a non-diet approach in the framework of the above mentioned strategies, and focusing on habit change, I have had the privilege of taking a journey of obesity management with a number of individuals who have had success managing conditions such as fatty liver, diabetes and hypertension.
My challenge to those who are reading this who are struggling with how to assist those they work with who are living with obesity is to make a learning plan to gain the knowledge about the biology of obesity, to learn counseling skills that are effective in this setting and ultimately to find the balance between the various treatments available to treat obesity that suit each individual.
On a system level we need to make it easier for dietitians to access the learning tools and information that they need to achieve this goal.
Wednesday, November 20, 2019
Weight is being used as a proxy measure for health (debate on accuracy aside). I question the usefulness of focusing on the weight itself, if I’m assuming correctly that the next part of the conversation with any health care provider were to focus on health behaviours eg. balanced eating, physical activity, stress, sleep, etoh consumption etc. to improve health outcomes. Why spend the 10 minutes talking about numbers (which sounds like even Obesity Canada has been shifting towards adding more context to) and not spend that time on the source of what actually improves health outcomes? Dietitians are very well trained to see the larger picture – everything mentioned above, as well as the impact of oppressive social ideologies that hit most people in the face as soon as they walk out of our offices (which trap people into the unhelpful cycle of dieting and weight cycling).
Here’s a scenario that we commonly see – busy working parent, skips meals, too busy to mindfully eat, mind often on autopilot, vulnerable to ultra-processed foods for convenience (not for taste/enjoyment, but purely survival), struggles with eating to cope with emotion at night when kids are in bed because that’s the only way many of us have learned to comfort/nurture ourselves. Enter the discussion about their weight and the advice they should lose weight. If a provider spends the majority of their time talking about the numbers, then what do they leave the office with? Many patients are on pharmacotherapy, decide to go for surgery and go on extreme diets that they google or are told to google, but at the end of the day, none of these are sustainable because everything mentioned above – IS STILL GOING TO BE THERE.
All health care providers have an altruistic drive to want the best health for our patients. Though, we need to do a better job of helping people gain skills to navigate and negotiate everyday life and health.
Not focusing on WEIGHT DOES NOT mean that Dietitians do not focus on HEALTH. Whether it’s focusing on what balanced eating looks like, the different nutrition recommendations that help address LDL, BG, HTN etc. AND learning new ways of coping with emotions, mindful eating practices, honing in on being able to recognize hunger/satiety cues, having our choices match intentions, helping to create personal boundaries against body shaming etc.
Listen to us. We have wisdom. Especially since we have the opportunity to get a much fuller picture in the HOUR we spend talking about lifestyle with patients.
Friday, November 22, 2019
The excessive focus on weight loss pre Bariatric surgery just worsens the disordered eating patterns (meal skipping, night eating etc) that patients have developed from lifelong dieting, and post surgery the weight/BMI focus can lead to the pursuit of the perfect number on the scale and increasingly restrictive ways of eating, leading to rebound cravings, overeating and weight gain (and increased risk of eating disorders). Integrating HAES pre surgery can heal patients relationship to eating and build a stronger foundation for healthy eating habits, and post surgery, it can prevent backsliding into the dieting mentality, weight gain and eating disorders
Friday, November 22, 2019
HEAS and Weight management need not be mutually exclusive, they can work together. The excessive focus on weight loss pre Bariatric surgery just worsens the disordered eating patterns (meal skipping, night eating etc) that patients have developed from lifelong dieting, and post surgery the weight/BMI focus can lead to the pursuit of the perfect number on the scale and increasingly restrictive ways of eating, leading to rebound cravings, overeating and weight gain (and increased risk of eating disorders). Integrating HAES pre surgery can heal patients relationship to eating and build a stronger foundation for healthy eating habits, and post surgery, it can prevent backsliding into the dieting mentality, weight gain and eating disorders
Sunday, November 24, 2019
Fully agree, there is in fact plenty of evidence, including a study from our centre showing that pre-surgical weight loss (at least as a means of ensuring patient “compliance”) does not predict outcomes post-surgery.
Tuesday, November 26, 2019
Wow. I just read Dr. Sharma’s blog post and I applaud him for this. I have been a dietitian for nearly 30 years and have seen a change in the “culture” in which dietitians support (or don’t support in most cases) individuals who struggle with obesity. We are experiencing an obesity epidemic like no other and as nutrition experts we need to be at the forefront to address this. Obesity and diabetes are becoming the “new tobacco” in cancer risk as well. There’s no denying this growing problem. Dietitians need to be part of the solution and get their heads out of the sand!
Tuesday, November 26, 2019
I want to also add that as dietitians we need to stop recommending low fat, high carb diets that drive up insulin levels. We have a growing incidence of metabolically-driven diseases which can all be linked back to hyperinsulinemia and insulin-resistance which are at the core of obesity and most chronic diseases. We see this even in normal-BMI individuals (i.e. those that are “metabolically-obese” even though they do not appear obese). Look at all the low carb weight loss clinics throughout the country that are showing great results! Why are RDs not getting more involved in this movement??
Tuesday, November 26, 2019
It is troubling that a physician and obesity researcher would offer such a public and subjective appraisal of colleagues and partners in care based solely on anecdotal experience. The lack of evidence to support your inflammatory comments is shocking, particularly given that you are a member of a regulated health profession whose members are expected to demonstrate professionalism and ethical conduct at all times. Sections 31 and 32 of the Canadian Medical Association’s Code of Ethics and Professionalism for Physicians calls doctors to, “Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners, and members of the health care team, and engage in respectful communications in all media.” These ethical and professional tenants were violated here and that’s unfortunate. Research supports the benefits to patients that come from interprofessional team practice. This post does not reflect that reality and creates barriers between health professionals. Shameful!
Wednesday, November 27, 2019
Not sure what exactly was violated, perhaps you may wish to carefully reread the post – this was not meant a criticism of dietitians or their expertise – it was merely discussing a recent observation that was brought to my attention by several dietitians from across Canada, who voiced specific concerns regarding on-going discussions within the RD community.
Monday, December 9, 2019
I like this article. I don’t agree with it, but I think you brought up many points that ought to be addressed.
I think the issue with this topic has more to do with multiple misunderstandings from both parties and varying definitions of the word obesity. Now, I will say that HAES is made up of some people who carry lifelong trauma regarding their body size (for valid reasons i.e. being placed on diets at the age of 5). These folks often feel triggered by words like obesity and weight loss and need to find spaces where they are not always looked at as a disease. This has lead to many disagreements in the healthcare world and what I feel is a weight loss vs. HAES debate. That is not where I am coming from today.
There is an unfortunate misunderstanding that Heath at Every Size is synonymous to healthy at every size. Part of the Health at Every Size movement focuses on not pathologizing people’s weights and body sizes. Why would we want to do this? Because pathologizing someone based on body size alone is at the very least contributing to poor mental health and on a bigger scale it contributes to weight stigma. What this means is rather than focusing on weight, some dietitians focus on other factors. When we take the focus away from weight, we can address underlining issues that may contribute to overall health. This means we do not have a weight loss agenda. This does not mean we are simply focusing on healthy plate. This also does not mean that these folks will not lose weight. This is very individual and quite frankly, will look different for each person. But as a Health At Every Size dietitian, what I can say is we will address underling issues such as their relationship with food, trauma related to weight (often stemming from childhood), and other determinants of health such as lack of access to healthy foods.
How many fellow RD’s have received weight loss referrals for clients based solely on BMI >30 with no other comorbidities? We have witnessed folks being classified as being obese (and thus diseased and needing to change body size in the name of health) based on BMI alone. And how many of these folks have successfully lost weight (with or without a dietitian) numerous times in their lifetime? (I will go ahead and assume the answer is a lot!!)
In my experience, the perceived hostility that Dietitians carry is more towards the weight stigma that the obesity classification has brought with it. WHO defines obesity as follows:
“Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in metres). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight. Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer. Once considered a problem only in high income countries, overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings.”
Within the last decade BMI has been criticized for its many limitations including not being able to accurately predict lean mass vs. fat mass. There are many other criticism of BMI but I will not get into them because I believe the definition that you are using in his article is based on a more dynamic definition of obesity which measures more than weight over height squared. Unfortunately, in my experience many doctors are still only using BMI to classify folks as obese (regardless of comorbidities) and these folks are often getting messages that are similar to “stop eating refined carbs and exercise more”. We cannot deny that there is an underlining assumption in today’s society that obesity is associated with laziness and gluttony. Not saying everyone has these assumptions but in the healthcare world (and society at large) there is a negative connotation towards obesity and fatness. This, I believe is where the hostility and the reluctance towards the deititans role in obesity management came from. We have the first hand experience seeing that people in the “obese” category are humans just as concerned about their health as folks who are “normal weight”.
Aside from that, the diet industry found a way to exploit weight loss. As a dietitian, I have seen so many diets being sold based on unsound scientific studies (small sample sizes, no follow up studies, short duration etc…). These diets unfortunately often seep into the healthcare world and are recommended to obese folks in the name of health (gluten free, Atkins, Keto to name a few). Dietitians have seen basic weight loss diets fail clients time and time again. Why? Because many of these people have other underling issues (stress, lack of sleep, trauma etc) that calorie restrictive diets do not address.
Adipose tissue related inflammation put folks at risk for many chronic diseases such as heart disease, hypertension and diabetes. I am not denying this. And despite the multitudes of weight bias research or poorly designed weight loss studies I know there are some high quality studies that demonstrate a positive impact of weight loss on many biomarkers. The issue that I have (and many other dietitians as well) has to do with the way the message is delivered to folks. Our issue is with the stigma that has come with years of assuming that obesity (based on BMI alone) is associated with disease and associated with unhealthy behaviours. It’s the minimizing of each unique experience and disregarding the other aspects of health that may be contributing to overall quality of life.
In my opinion, this debate is too dogmatic. It’s turned into us vs. them. We have to remember that at the end of the day we all have the same agenda and that is to help folks live a healthier life.
Monday, December 16, 2019
Thank you for taking the time to send in this thoughtful comment – I believe you have hit the nail on the head by pointing out the the discussion is too dogmatic (probably on both sides). Hopefully, the ongoing dialogue will let both sides be more appreciative of the need to respect both perspectives – neither one is all right or all wrong for everyone concerned.