A few days ago I posted an article with the tongue-in-cheek rhetorical title, “Is there a role for dietitians in obesity management?”, to which, as readers should note, my clear answer (or so I thought) was “ABSOLUTELY!”.
Interestingly, the response to this post from the dietitian community was both humbling and indeed an honour. Not only did the post receive an unusually large number of lengthy and passionate comments (both here and on social media), but I also received a most thoughtful letter signed by well over 200 dietitians, suggesting I reconsider or at least clarify my post.
This overwhelming response to my post was humbling, because, I do not believe that there is anything I could possibly have written that would have elicited an even remotely similar prompt and passionate response from my own medical colleagues – clearly dietitians care strongly about what they do. Apparently, they also appear to pay attention to what I have to say – which is an honour indeed!
That said, I agree very much that some clarification is in order.
For one, as stated above, the title of the post was indeed entirely rhetorical – if I did, for even a second, have any doubts as to the important role that dietitians have in obesity management, I would probably not have bothered writing the post at all.
Secondly, I would have thought that both my opening and closing paragraphs would have made it entirely evident just how much respect I have for the professional expertise that dietitians have with regard to their discipline and their essential role in obesity management. I truly believe that it would be entirely fair to say that dietitians’ knowledge of biochemistry, disease processes, counseling techniques, client-centred care, and clinical passion are second to none (and I happily include my own colleagues in the comparator).
Furthermore, nowhere did I state or imply that my comments apply to ALL (or even the majority of) dietitians – in fact, I thought I had made it clear that the issues I raised applied to a small minority (perhaps no more than a handful?) of dietitians. (I did not single out anyone by name, as I do not believe in, nor intended, any ad hominem attacks).
In my post, I touched on a few different but related issues:
1) The unequivocal endorsement of obesity as a chronic disease.
2) Potential gaps in specific obesity training.
3) Reluctance (of at least some practitioners) to consider weight loss as a realistic (and often necessary) therapeutic option.
Apart from the fact (as I have done in countless previous posts) that I have called out members of my own (or for that matter, any) medical profession on the exact same issues, I am also fully aware that within any health profession there is a wide range of expertise, experience, and opinion on virtually any issue.
But, I do believe that each of the above-mentioned issues is of importance (not just for dietitians), and I will happily clarify my stance and thinking on each of them in subsequent posts.
As to why, if my comments apply to all health professions, I decided to single out dietitians for this particular post, the reasons are simple:
1) This specific post happened to be prompted by actual conversations over the past few months with several dietitians from across Canada, who all (independently!) raised similar concerns about what they thought was perhaps amiss amongst some (younger?) members within their profession when it comes to obesity management (again, no names!).
2) Ten years of blogging have taught me that to initiate a lively discussion with any post, it needs to be opinionated, one-sided, strongly worded, and provocative – anything less, is a waste of time (sadly, balance is boring!). If nothing else, my post certainly achieved that.
3) I truly do consider the role that dietitians have to play in obesity management of the utmost importance. Dietitians are in fact “THE” profession, that other health professionals most often look to when it comes to obesity management. With that comes immense responsibility, which I know dietitians take very seriously.
I promise that I will attempt to do my utmost to clarify and expand on the specific issues raised in my previous post in subsequent posts.
Hopefully these “clarifications” will be taken in the respectful and constructive spirit in which they are offered – I am fully aware that nothing in medicine is black and white; we all happily operate in shades of grey (as I always emphasize to my patients). I’m also very aware that today’s certainties may well turn out to be yesterday’s follies – as our understanding of disease processes and treatments evolve, so do our clinical approaches (as they should).
All I ask of you, is to bear with me…
Today’s post comes from Maryam Kebbe, a fourth year Doctoral student studying under the supervision of Dr. Geoff Ball in the Department of Pediatrics at the University of Alberta. Maryam has a passion for patient-oriented obesity research in children and plans to continue doing health research in this area after completion of her PhD.
As readers are probably well aware, often times, the first line of treatment for adolescents seeking health services for obesity management consists of behavioural changes targeting nutrition, physical and sedentary activities, and sleep habits, including an addressing possible issues of mental health.
However, health professionals often encounter a lack of adherence to a healthy behaviours by adolescents with overweight or obesity, resulting in challenges in maintaining or losing weight. This may be due to a number of factors, including difficulties in changing established habits and a lack of consideration for adolescents’ priorities in managing weight. To help with clinical consultations, both adolescents and health professionals can benefit from tools and resources that can be tailored to adolescents with obesity attempting to change their lifestyle habits.
Our team conducted a multi-phase project that included adolescents, health professionals, and researchers to develop Conversation Cards for Adolescents (CCAs), an adolescent-tailored, bilingual (English and French) clinical tool aimed at streamlining conversations and facilitating lifestyle behavior change in adolescents via collaborative goal- setting. Specifically, we completed a review of the literature (1) and a qualitative study including in-person interviews, focus groups, and patient engagement panels (2-5) from which we identified 153 factors that help, may help, or deter adolescents with obesity from adopting healthy lifestyle behaviors. Next, we asked adolescents to prioritize (online survey) and validate (telephone consultations) these factors to help refine our tool (6). The design of this tool included another three rounds of refinements with The Burke Group in collaboration with Obesity Canada.
CCAs comprise a deck of 45 cards. Each card contains an individual statement pertaining to a barrier, enabler, or potential enabler (15 statements per category) that adolescents often encounter in making and maintaining healthy lifestyle changes. These cards are organized across seven categorical suits: nutrition, physical activity, sedentary activity, sleep, mental health, relationships, and clinical factors.
CCAs are intended to be used by adolescents and health professionals and are complementary to an already existing deck of cards (Conversation Cards©) created for parents and health professionals by our research team in 2012 (7-10). Our future steps include completion of a pilot randomized controlled trial to determine the feasibility and user experience of using CCAs by adolescents with obesity and health professionals working in primary care.
- Kebbe M, Damanhoury S, Browne N, Dyson M, McHugh TL, Ball GDC. Barriers to and enablers of healthy lifestyle behaviors of adolescents with obesity: a scoping review and stakeholder consultation. Obesity Reviews, 2017; 12: 1439-1453.
- Kebbe M, Perez A, Buchholz A, Scott S, McHugh TLF, Dyson M, Ball GDC. Health care providers’ delivery of health services for obesity management in adolescents: a multi- centre, qualitative study. BMC Health Services Research, 2019; Under Review.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Dyson MP, Ball GDC. Recommendations of adolescents with obesity to facilitate healthy lifestyle changes: a multi-centre, qualitative study. BMC Pediatrics, 2018; Under Review.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Mohipp C, Dyson MP, Ball GDC. Barriers and enablers for adopting lifestyle behavior changes among adolescents with obesity: a multi-centre, qualitative study. PLoS ONE, 2018; 13: e0209219.
- Kebbe M, Perez A, Buchholz A, Scott SD, McHugh TLF, Richard C, Dyson MP, Ball GDC. Adolescents’ involvement in decision-making for pediatric weight management: a multi-centre qualitative study on perspectives of adolescents and health care providers. Patient Education and Counseling, 2019; In Press.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Dyson MP, Ball GDC. Conversation Cards for Adolescents: a communication and behavior change tool for health care providers and adolescents with obesity. Health Services Research, 2019; Under Review.
- Kebbe M, Byrne J, Damanhoury S, Ball GDC. Following suit: using Conversation Cards for priority-setting in pediatric weight management. Journal of Nutrition Education and Behavior, 2017; 49: 588-592.
- Ball GD, Farnesi BC, Newton AS, Holt NL, Geller J, Sharma AM, Johnson ST, Matteson CL, Finegood DT. Join the conversation! The development and preliminary application of conversation cards in pediatric weight management. Journal of Nutrition Education and Behavior, 2013; 45: 476-478.
- Farnesi BC, Ball GD, Newton AS. Family-health professional relations in pediatric weight management: an integrative review. Pediatric Obesity, 2012; 7: 175-186.
- Farnesi BC, Newton AS, Holt NL, Sharma AM, Ball GD. Exploring collaboration between clinicians and parents to optimize pediatric weight management. Patient Education and Counseling, 2012; 87: 10-17.
Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, that guides us through a systematic assessment of factors influencing energy metabolism, ingestive behaviour, and physical activity, we ca now apply this framework in clinical practice:
This paper provides a comprehensive framework, which should enable clinicians to systematically assess and identify the socio‐cultural, biophysical, psychological and iatrogenic determinants of increased energy intake and reduced energy expenditure in patients presenting with excess weight or weight gain. Beginning with an assessment of energy requirements and metabolism, clinicians should systematically assess the role and determinants of ingestive and activity behaviour to identify the factors promoting positive energy balance. This will enable clinicians to develop management plans that address the root causes of weight gain and move beyond the simplistic and generally ineffective recommendation to ‘eat less and move more’.
Thus for example, in a listless patient ‘self‐medicating’ with food, identification and treatment of depression may be the first step to reducing food intake and preventing further weight gain. In a patient with socioeconomic barriers to healthy eating or physical activity, referral to a social worker who can assist in identifying and accessing community resources may be important. Identification and effective treatment of obstructive sleep apnoea may be the key to increasing activity in someone with this disorder. Psychological counselling to manage alcohol or substance abuse or to help patients deal with binge eating resulting from past trauma, emotional neglect or grief, can put patients on a path to successful weight management. Clearly, the common notion that all forms of obesity can be addressed simply by counselling patients on diet and exercise should be considered ineffective and obsolete.
To conclude this series, we will tomorrow look at some of the potential limitations of this system.
Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, we now turn to the some of the factors that can affect ingestive behaviour, this post focusses on medications:
Medications and Drugs That Affect Hunger and Appetite
A wide range of medications and illicit drugs can promote hunger and appetite. These include some oral anti‐diabetic agents, antidepressants, atypical antipsychotics, anticonvulsants, certain hormonal preparations including corticosteroids and oral contraceptives, as well as the medicinal and recreational use of marihuana. Alcohol and other mind‐altering drugs can also promote over‐eating by increasing appetite, reducing dietary restraint and promoting disinhibition. Patients presenting with weight gain and obesity need a careful review of their medication and substance abuse history.
Commentary: Obviously this a complex topic as the number of medications and recreational substances that can affect appetite and eating behaviour is long. Nevertheless, assessing the possibility that a change in appetite and weight gain are due to this factor is an essential part of clinical assessment.
Psychological or Hedonic Factors
In contrast to hyperphagia resulting from physical hunger, over‐eating for emotional reward or as a coping strategy is regulated by the hedonic system and has little to do with the body’s real or perceived need for calories. The range of psychological or emotional factors that can initiate and influence eating encompass virtually the entire range of emotional responses including stress, frustration, loneliness, anxiety, anger, disgust, fear, grief, joy, relief, all of which can significantly alter dietary restraint or promote disinhibition. Typically, hedonic hyperphagia is associated with the selection and consumption of highly palatable energy‐dense ‘comfort’ foods, although homeostatic hyperphagia also tends to be associated with the preferential consumption of palatable foods.
In addition to simple ‘emotional’ over‐eating, specific psychiatric conditions that affect food intake or can pose important barriers to maintaining a healthy diet must be considered. Increased appetite is a feature of atypical depression and can be interpreted as ‘self‐medicating’ with food – particularly in cases where these foods affect the serotonergic and reward systems to improve mood. Binge eating, night eating and other abnormal eating behaviours must also be seen in the context of underlying emotional or psychological processes that are distinct from homeostatic ingestive behaviour. Other mental health conditions that can significantly affect eating include attention deficit disorders, post‐traumatic stress syndrome, sleep disorders, chronic pain, anxiety disorders, addictions, seasonal affective disorder and cognitive disorders. Particularly sleep deprivation has been associated with increased appetite and ingestion of highly palatable snacks as well as increased risk for diabetes. Patients with obesity resulting from emotional eating or hedonic hyperphagia are most likely to benefit more from psychological and/or psychiatric interventions rather than simply from dietary counselling.
Commentary: Although for didactic and practical purposes I find it helpful to distinguish between what I have referred to as “homeostatic” vs. “hedonic” hyperphagia, it is important to note that at a physiological level, the distinction between the “homeostatic” and “hedonic” pathways is not as clear cut as is often assumed. In fact, there is close and complex cross talk between these pathways. For example, hunger, a feature of the “homeostatic” pathway, is also a powerful activator of the “hedonic” pathway, thus leading to seeking out and consumption of caloric-dense foods. On the other hand, “hedonic” drivers to eat can override satiety and lead to eating even when not hungry. This, physiology, however, does not take away from the fact that in clinical evaluation, trying to distinguish between homeostatic and hedonistic is often helpful in determining the appropriate treatment path.