When "do no harm" can mean NOT talking about dieting

There has been much controversy in the nutrition and weight management world about the sometimes harmful role professionals can play when trying to help a client lose weight. Since doctors carry so much weight (so to speak) with their advice, it is extremely important that they give useful, easy to understand and sympathetic advice. By sympathetic I mean advice that takes into consideration their clients as people (not just bodies) who have limitations, feelings and are probably doing more for their health than they see. Obviously, it is also important to that doctors know their limitations in knowledge and make referrals. Knowing your limits can be harder than you think especially if you come from a background of an "all knowing" profession like medical doctors. This is where a lot of my frustration stems from- the "all important god" that is better known as your doctor who gives harmful and often wrong advice on weight loss. One big argument is the fact that the hippocratic oath may suggests that bad weight loss advice is unethical by actually doing harm to their clients.
Before I go further, I must state that not all doctors frustrate dietitians or give harmful advice to their clients. Unfortunately, I only hear the sad stories from my clients.

Recently I had a few clients who were (and I quote) "traumatized by what my doctor told me about the need to lose weight". I can only guess that the doc's goal was to motivate the client to lose weight (little did he know that she is already doing many things to try to lose weight...did he even ask her?). However, I wonder the usefulness of stating that "[she] would be better off as a drug addict than addicted to food". Yes- that is a direct quote from the client quoting her doc.

Firstly, being obese is vastly different than being addicted to food (which is not a well supported theory amongst eating disorder professionals) so he first assumed she was addicted to food (again, not a diagnosis as popular as say, binge eating) and secondly that being skinny while doing drugs is better. Is that really based on science? Will that advice really help her lose weight? All that encounter did was make that day the "worst day of [her] life" (another actual quote). Was that advice ethical considering she may turn to unhealthy ways to lose weight such as diet pills, fasting, or very low calorie diets? All of which may lead to binge eating, skewed relationship with food and body hate.

Not only do my clients already feel ashamed and hateful of their bodies, but they have to return to see their doctor for a follow up. It's no wonder that they are scared, anxious, preoccupied about the upcoming visit. I wonder if these feelings will help or get in the way of communication at their next appointment?? It was certainly something that got in the way in talking about nutrition at our session. I was more than happy to discuss the encounter since issues that influence eating is something we discuss (not just diet advice) at appointments. However, I can only imagine how frustrated my paying client felt after leaving our session with little spoken about the topics for which she sought advice.

Weight shaming and weight bias as well as misunderstanding the complexity of weight loss is something that is expected from the masses. NOT from educated health professionals.

My advice to my clients who bring these stories to our session is easier to give than to take- find another doctor. Not an easy task in this city or in Canada. If that's not possible, perhap a firm but polite acknowledgement that things are being taken care of in the weight loss area with the help of another professional, then asking the doctor to get back to what they specialize in practicing.

Think taking the addiction approach to food is best? Think again.

I am so sad to hear of yet another book toting overeating or binge eating as food addiction. In the brief adaptation I read recently in Macleans magazine, I find it interesting that everything the author is describing as addiction can also be considered binge eating. More specifically, the trap of the binge eating and restrictive eating cycle. I am flabbergasted that people continue to chose the "addiction" route versus the mindful eating approach to dealing with a skewed relationship with food. It astounds me because the way in which they are treated are quite different- one being very harsh and relying on "discipline" and the other a more flexible, kinder, realistic way to live. 

Many feelings and thoughts written in the adaptation sound familiar- many of my clients have told me the same things. However, not one of them was able to fully adapt the addiction method without cycling between food restriction and binging. Also, every one of them have found that although addiction is an easier way to think about food, understanding how their emotions and body shame lead them to overeat or binge has helped more in the reduction of binges and cravings for binges. Here is a short summary of the difference between both treatments:

Sure, there may be aspects of the addiction model for treatment that can work for people, but in my experience, clients need way more than this approach to heal relationships with food and their bodies. Cravings are a normal part of life, how we deal with them depends on how we see ourselves (i.e. our weight and shape) and our relationship with food. People who eat intuitively may eat the food they crave, listen to their hunger to determine how much of it that they want and continue to eat according to their hunger for the rest of the day. This may mean they will eat a lighter dinner because they are less hungry. In fact, people who are intuitive eaters get more pleasure and comfort from food than people who eat mindlessly. 
People who do not eat intuitively and eat due to emotions, tend to get less comfort from food and end up cycling between eating for comfort, not being comforted and then eating more because they are ashamed of caving into a craving (which is a negative emotions that can start the cycle all over again). 

If you are looking for more information on binge eating or how to decrease over eating, these books take a more gentle and effective approach :

Eat what you love, love what you eat for binge eating by Dr. Michelle May
Overcoming binge eating by Dr. Christopher Fairburn
Eating Mindfully by Dr. Susan Albers (there is also a companion workbook called Eat, drink and be mindful)

If you are a dietitian looking for more information on the CBT and mindful eating approach to treating binge eating disorder, try these books (of course those mentioned above are a good read too):
A clinician's guide to binge eating disorder by June Alexander, Andrea GOldschmidt and Daniel Le Grange
Nutrition Counseling in the treatment of eating disorders by Marcia Herrin and Maria Larkin
Cognitive behavioral therapy and eating disorders by Dr. CHristopher Fairburn

Can losing weight lead to gaining weight??!!

If there is one major negative thing that has emerged from recent research on weight loss is that it often leads to weight regain. If done in an unhealthy, unbalanced way, regaining the weight along with a few extra pounds is also a big possibility. This weight regain is not only frustrating but makes any subsequent attempts at weight loss even harder.

So, if losing weight often leads to weight regain, wouldn't weight maintenance be perhaps the better option for some people? Yes. Also, it is important to note, that if you are gaining weight over time, stabilizing your weight (or stopping the gain) is, in itself, weight loss. To read more on maintaining weight, read my last post.

Another consideration is the idea of preventing weight gain rather than actively trying to lose weight (especially in an unhealthy way). Preventing weight gain has been the focus of much research recently. One reason is because it is easier for people to prevent gaining weight then to try to lose it.

Keeping the weight off after losing it requires most people to be vigilant with their eating and exercise- more so then they did before they lost the weight. Consider that for a moment- to keep off the weight, you cannot merely return to your "usual" way of living. You have to have learnt about healthy eating, made sustainable changes to food and exercise AND found a way to continue this new lifestyle for life. No wonder most people put weight back on especially if short term solutions are used. If done in a healthy way, "watching" what you eat can be an easy thing (if you have practiced mindful eating). It could also be a constant struggle if you have just followed a diet plan and never reconnected with hunger and fullness cues.

One study in particular that focused on weight gain prevention is the "Strategies to prevent weight gain in adults". I think the name of the review says it all! Their main conclusions were that (although the strength of evidence is low for all the strategies) effective approaches may be: low fat diets (where 20% of calories is coming from fat. So if you eat 2000cal per day, 400cal are from fat or 44g per day), eating fewer meals prepared away from home, eating more fruits and vegetables, monitoring heart rate during exercise and participating in group sessions that deal with lifestyle change  (that includes text message reminders). Some of these approaches sound more fun and interesting than others. It's also important to note that other strategies may work but have not been studied (such as mindful or intuitive eating).

One interesting quote from this systematic review paper is :

"The lack of rigorously conducted long term trials to inform those who aim to prevent weight gain may be indirectly contributing to the obesity epidemic"

Interesting. If we are relying on old-school techniques to prevent weight gain we may in fact be pushing people in the wrong direction?! I feel this is another reason why "losing weight at any cost" or "losing weight any way possible" are both bad ideas.

So, be prudent when deciding what strategies to use for losing weight. Consider the possibility of maintaining your weight, at least for a little while before taking on weight loss.

Saying what no one wants to hear.....weight maintenance

As a dietitian most, if not all of my clients want to lose weight. I would even guess that most people I know want to lose weight. It does not matter the reason, nor does it really matter how much they actually weigh- many people want to change it, regardless of the healthiness of their weight. So, how do I go about suggesting that they should abandon their goals/dreams/hopes? Very carefully.
For some people, maintaining their weight rather than losing weight may be the healthiest option- both for the mind and for the body. This applies both to healthy weight people and - yes- people who are labelled as overweight or obese. Many studies over the last 10 years have shown a weak link between being a fit heavy person and development of diseases. So the age old statement of "I want to lose weight to be healthier" is no longer relevant. The act of losing weight may not have an impact on health if blood pressure, blood sugar, cholesterol levels, etc do not actually improve. This may happen if these risk factors are already in the normal range or if an unhealthy approach to weight loss is taken. Not to mention any psychological issues that can arise from dieting! (guilt, deprivation and shame do not help anyone eat healthier!)
So, how does a dietitian broach the subject that weight maintenance may be the best bet for a client? I have had this discussion a few times recently and despite their differences, each client's situation was eerily similar. My first client was a gentleman who has been struggling to lose weight through exercising more and calorie counting to try to eat less. He has found a nice balance between feeling hungry and eating just enough so that his cravings for certain foods has decreased. With less hunger, he can focus less on eating and more on work/life/family. He has been maintaining his weight for the last 2 months. He feels he cannot dedicate more time to exercising nor can he imagine eating any less (or changing much about his food choices)- but he wants to lose weight. Unfortunately, there is no magic trick I can pull out of my hat for him. Instead of following the same old dietetic approach of offering advice on eating more fibre, less dense foods, etc, I decided to listen to what he was really saying. Reflecting back to him this conundrum and pointing out the facts that he just mentioned (not possible to change exercise or eating),  I helped him come to the conclusion that maybe maintaining his weight right now is the best option. It is a good option because anything else may lead him to further frustration.
The other client was in a similar position except her family and work obligations meant she could not spend any more time exercising. She already was very conscious of what she ate and could not dream of eating less or being more careful.
Neither person was putting their lives in danger by maintaining their weight. In fact, by realistically maintaining rather than unrealistically losing weight and likely putting it back on, they are actually healthier.
Sometimes the role of a "Diet"itian is to give clients permission to maintain weight rather than take jabs at their weight like so many others do.

The KEY to eating less is...

PORTION SIZE.
It may be one of the more difficult things to change about the way you eat (and is certainly one of the less glamorous), but it is one of the most efficient ways to eat fewer calories.
Step one: understand just how big your current portion sizes are which must come before determining what to cutting down on. To do this, you have a few options: start measuring out what you each with measuring cups OR use something that is always handy.... like your own hand!

Portion sizes are the most basic concept on which the “healthy versus less healthy” universe is based. No one food is evil since it’s really the portion of the food that counts. However, this is one of the least understood technical info in the nutrition world. It’s not complicated and certainly anyone can learn basic portion sizes! 

Since your hand is in proportion to you overall body size, it's a great reference tool on which to base your food needs.

Check out these simple ways to use your hand to estimate portion sizes, no matter where you are or what you are eating.
(please note that a fist is generally = to one cup)

Weight loss and the Macguffin

What does the Atkins diet and Skyfall have in common? or to be more broad, what does any action or spy movie have in common with diets? A Macguffin.

These movies have very similar structures: you have a good guy, a bad guy and the reason why they have come face to face. This reason, the thing that differentiates one movie from the next, is called the Macguffin. How can we sit through countless bond films and still be entertained, is the slight difference between each movie. 

The same can be said for diets. They usually promote certain foods (the "good foods") while vilifying others (you guessed it, the "bad foods"). The Macguffin is the "catch" on how this diet is different from the others. All of these fad diets are low calorie- it's the way that they get you to restrict your calories that is different (or the "macguffin"). They may not state outright that the diet is low calorie, they are more likely promote some "miracle" food or supplement that is the "trick" to weight loss.

The reason why diets are not a healthy or smart way to lose weight, is the fact that they are not sustainable. They are designed to work only in the short run and can only really be followed for a few weeks or months. 

Also, they can recommend eliminating healthy foods, such as milk and alternatives, fruit and whole grains. I suppose you could say they all have the same unhappy ending: weighing more than what you weighed when you started dieting. 

Here are some popular diets and their Macguffins:

Atkins diet: good guys = protein and fat; bad guys = carbs (fruit, grain products, other starchy foods).  

Paleo diet: good guys = protein and fat; bad guys = carbs (grains, dairy, other starchy foods).

South beach diet: good guys =low glycemic index foods, good fats; bad guys = high glycemic index foods and bad fats like saturated and trans fats. Certainly less restrictive than other diets but low calorie never the less. 
Montignac: good guys =low glycemic index foods; bad guys = high glycemic index foods. Oh and lots of complicated food combing to limit what you can eat.
Eat right for your blood type: good guys = "depends on your blood type"; bad guys = "depends on your blood type". Basically, each blood type will be limiting certain foods to get calorie intake down.  

Many of these diets have common bad guys and good guys, only proving that creative labeling foods as good and evil is not the best strategy to manage your weight. 
It's funny how, despite having all of these diets, that there still is an "obesity epidemic" in most countries. Perhaps it is because they do not work? or because they are not "the answer"? 

Quebec has an interesting site to visit regarding diets and weight loss plans. Here is an interesting pamphlet if you are considering taking on a diet. 
Equilibre is another great site for more info. 
If you are a health professional, joining the Canadian Obesity Network is free and their website is great!

"Successful" weight management

Many studies have proven that the best source of motivation for lifestyle changes is seeing success and feeling like your efforts are making a difference. However, many of my clients "see" or perceive their successes differently and too often with a skewed view.

Defining the success of anything involves multiple factors. For example,  a "successful" business not only means it is making money, but also that they have loyal customers, the employees are happy, and the company is growing. "Successfully" raising children not only means they are kept alive until the age of 18, but that they can critically think for themselves, are respectful, healthy, etc.
So why is it that defining success for weight loss is often only based on the number of pounds you lose? Like in the examples above, there are other factors to consider such as your health, happiness, self esteem, waist circumference, relationship with food and ability to plan and prepare healthy meals.

Defining success as a change in the numbers on a scale does not show you the whole picture. It does not acknowledge all the time and efforts put into meal planning, prepping, recipe searching, extra time spent exercising or reading labels.

So, next time you feel down about your lack of change in your weight despite all the hard work you've done, make a check list of all the other accomplishments you want to carry out to lose weight. Go through the list and focus on accomplishing these tasks- seeing all the boxes checked will help to boost your motivation and keep you on track.