Why I Love And Respect DietitiansMonday, November 25, 2019
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…
Monday, November 25, 2019
Thank-you Dr. Sharma for this!!
Tuesday, November 26, 2019
Thank you for all you share and all you do! Respectfully
Monday, November 25, 2019
Thank you for this follow up to your original blog post.
There are a few points I wish to raise that I think you have missed in this follow up post.
First, your original post singled out younger dieticians, and you have doubled down on the ageist tone in this post. While it may be a “handful of (younger?) dietitians,” there are many well seasoned RDs that do and long have taken issue with the work of the former Canadian Obesity Network and Obesity Canada with its new stance on obesity as a chronic disease, as well as those who promote these views. When you name “(younger?)” dietititans as the source of criticism of CON’s, OC’s, and your position on “obesity,” you not only dismiss the work of seasoned non-diet RDs, you appear to be dismissing younger RDs due to a perceived lack of knowledge or skills, or simply naiveté.
Second, you refer to ” Reluctance (of at least some practitioners) to consider weight loss as a realistic (and often necessary) therapeutic option,” without considering the legitimacy of having an opinion that is different than yours, or the evidence base on which weight-inclusive RDs views are built upon. I assure you that there are more than a “handful” of weight-inclusive RDs, and the number is ever growing.
Third, while balance might be boring, as you suggest, providing your colleagues, young and seasoned, the respect they deserve is not negotiable, even if in service of social media views.
Finally, while I would agree with you that we have time and again discovered that today’s certainties are tomorrow’s follies (as we have learned with the gross medical violence inflicted on women, LGBT communities, racialized communities, Indigenous communities, and trans folks), this is not just about increasing/enhanced knowledge of “disease process and treatments.” Rather, weight-inclsuve RDs are concerned with social and structural inequities, in addition to disease processes and treatments. What we are talking about when we use the term “evidence-based” is not simply the medical/scientific literature. If we have learned anything from “yesterday’s follies,” one takeaway should be that social and structural inequities are at the heart of unequal health outcomes, and to ignore this risks repeating history (which I would suggest the medicalization of “obesity” is doing as we look on).
I appreciate that you have expressed your respect for RDs, their expertise, and their commitment to their work in this follow up post. However, dismissing the views of weight-inclusive RDs, whether young or seasoned, who are no less committed, knowledgable, and skilled, belies your stated respect. As you ask us to “bear with you,” I would ask that as we do, you don’t completely dismiss the views and practice approaches of a growing number of knowledge, skilled, passionate, and committed RDs.
Monday, November 25, 2019
The term “younger” was the exact term that your colleagues used when they discussed their concerns with me – I am sure that it by no means applies to all “younger” colleagues (whatever that may mean). As for the exact issues, as noted, I will be discussing them in greater details in subsequent posts – so please do bear with me 🙂
Tuesday, November 26, 2019
As a dietitian with 10 years of experience, I quite appreciated your initial post. Not once while reading it, did I think you were attacking the RD profession. I don’t think that creating conversation can be a negative thing. I’m sure in every profession there are people who have a certain stance on topics, more or less experience in certain areas and personal bias. As a professional, it is our jobs to read the evidence, practice person centered care and not elicit personal bias, which I do think is often the case in obesity management. There needs to be the right person in the right field in every profession, including dietetics. Thank you for your post and starting a very colorful conversation.
Tuesday, November 26, 2019
Hi Dr Sharma,
I am one of the “younger dietitians”. I enjoyed reading both of your posts precisely because of the controversial nature of the very discourse surrounding “obesity”.
I am of the opinion that the so-called “obesity management” must be discussed and explored side by side with eating disorders, as the former may well precipitate into the latter. As always, treatments have the potential to harm.
Interestingly, I notice health care system’s tendency to myopically focus on the individual’s responsibility in the context of eating behaviors, whether we talk about overeating or restriction. However, an understanding of the evolution of agriculture and subsequently the food industry (and capitalism) will certainly instill a different perspective amongst many health professionals regarding diet-related diseases.
I encourage you (if I may) and other health professionals to investigate into the system in which we all eat and function. It has been revelatory for myself to have a political and historic understanding of food, because it reveals the inevitability of the very obesity discourse we are having right now.
In the mean time, it is with great hope that I envisage more interventions supporting community integration and social acceptance (not just diet and exercise prescriptions) for people struggling with body morphology-related distress.
Wednesday, November 27, 2019
Thanks for taking the time to comment and I fully agree that one needs to very much consider and address eating disorders (as well as disordered eating) in the context of obesity management. This is exactly why psychologists are such a vital part of any obesity clinic, as they have extensive training and qualifications for using the wide range of psychological interventions that are essential and effective in dealing with these issues. After all, this is not really a food problem, but rather a sign of often deep-rooted psychological issues that have complex causes, often entirely unrelated to actual food intake. Thus, for example, in our clinic, patients diagnosed with BED, undergo a treatment approach that has little to do with weight or addressing food choices but attempts to address the complex underlying psychological issues, often related to emotional, physical, or sexual trauma, grief, PTSD, etc. Similarly, our emotional eating interventions are led by clinical psychologists with experience in eating disorders, body image issues, all-or-none thinking, etc. This is why we need a whole team of health professionals to sometimes address these issues.
Thursday, November 28, 2019
There is a growing movement of health care providers who don’t use the “O” word at all and refer to fat bodies as “fat”. This aligns with the fat liberation movement and recognizes that fatness is a (largely unchecked) form of oppression in our society. By singling out fat bodies, we are not only doing more harm (aren’t we all supposed to “do no harm” in our practices??), we are not addressing the root causes of poor health and justice for ALL. I agree with others’ posts that shifting the discussion to addressing capitalism, racism, commodification of food, developmental and other forms of trauma, income distribution and climate change might actually get us much further. I recommend you read some of Lucy Aphramor’s recent work and theory on the radical concept of social justice as primary to our role as health care professionals. I find it amazing that social justice for ALL and respect for ALL bodies is radical in this day and age.
Thanks for opening this discussion, it is an important one.
Krystal (RD for 12 years, if that matters, human for longer). I would also like to note that I am living with thin privilege, with I think is relevant to disclose.