Why I’m Not a Non-Diet Dietitian: Part 2

A year and a half ago I wrote an article called “Why I’m not a Non-Diet Dietitian.” It’s not the most read post on the blog, but it is something that I’m proud of since I consider myself to be a poor writer and I believe that it is the only long-form piece of writing I have done that has had a major impact on a number of people. I had planned on writing more about the topic, but honestly, I haven’t had much more to say and the original article still sums up the majority of my thoughts even though I have been in the field for almost twice as long now.

The title is 99% for clickbait. The whole point of discussing this is not to downplay HAES or the non-diet approach, since they have a lot of value in dietetics. The key message is that I believe that significant weight-loss is achievable (and maintainable) for a far greater percentage of people than statistics are currently indicating. I believe that it is the interventions used that are flawed, rather than people inherently not being able to succeed with weight-loss. And I think that it is okay for dietitians to be talking about deliberately aiming for weight-loss as one of many approaches to improving overall health.

Feedback on the Original Article

When I wrote the article, I was actually pretty concerned about getting a lot of criticism from particularly passionate HAES practitioners. I know I’m not alone with this fear. I don’t know what percentage of dietitians lean strongly towards HAES principles, but I feel like the ones who do often are more passionate about having a voice and sharing their messages than those who aren’t. So sometimes it feels like by choosing to aid clients with weight-loss, I’m going against the trend and feel guilty at times by promoting my own messages.

Even though I had this fear, I’ve got to be honest and say that I got a LOT of messages and emails from dietitians saying that the article resonated with them and made them feel more comfortable with recommending strategies to help clients lose weight, as part of an overall plan to improve their health and quality of life. With these dietitians the emphasis still isn’t necessarily on weight-loss. Often, they are looking at similar non-weight related factors and areas of the diet to improve the client’s quality of life. The only major difference I see is instead of a weight-neutral approach, they are still aiming for weight-loss as one of the pieces of the puzzle to aid in certain aspects of health.

While almost all of the messages were positive, I did see that my article was floated around some non-diet groups. I was actually in a few of those groups at the time, but for the ones that I wasn’t a part of, some colleagues sent me screenshots. Obviously, there is probably stuff I missed, but even then, in those groups the majority of the comments were relatively positive. A lot of the “negative” feedback was stuff like “we can’t fault him for not knowing the things we know” or “at least it sounds like he is trying learn more about HAES rather than just ripping on it without understanding it.” So, my initial fears were a bit misplaced. Most of it was just people recognising that I was a silly relatively new grad dietitian optimistic about the field and the impact I could have. But one leading HAES practitioner (not naming since I’m not sure they would want to be associated with this article) who I have a lot of respect for actually did end up sending me an essay of a message in an attempt to point out all the flaws in the article – so I will address those, especially since some were very valid points.

Why am I Writing a Part 2?

I can’t even remember when the last time I wrote a blog post was. I’m very lucky that the SEO on this blog is good and >80% of the traffic comes from google searches rather than social media, but I’ve got to be honest when I say that the reach probably isn’t worth the effort. But based on the conversations I have had I think people care enough for it to be worthwhile for me to do a part 2.

The other aspect is that I have recently left my previous employer and I’m now in a new phase of my career. I have talked about how one of my goals is to contribute to the evidence that dietitians can do better than the statistics currently in the research. Originally, I was even contemplating grand ideas of formalising that in some way to send a much more effective message, but there were a lot of flaws in that concept and it was never really an option. But I have been in the field for almost 3 years now and although that still isn’t a long time, I feel like what I say now is worth a bit more than what I said 1.5 years ago.

I also know a bit more than I did back then too. And more research has come out as well. For example, studies like the MATADOR study have opened the door for a whole new range of dietary approaches to be researched that could help make weight-loss more sustainable. In this study they implemented “diet breaks” where they would be in a calorie deficit for two weeks and then eat at maintenance for two weeks. There is the obvious flaw that this extends the whole process to get to the desired weight (and if you work with clients you know this is a hard message to sell). From the positive standpoint, it appears this is another tool that could be utilised to keep metabolic rates higher (although in this particular study it looks like that was mainly related to maintaining more muscle mass), make the process easier from a mental perspective and also help make the transition to maintaining the weight-loss easier since they have already had periods at maintenance.

This is just one of many different approaches that can be utilised and researched. The big thing I believe though is that we will always be slowly finding better ways. More importantly, good practitioners will be more adept at choosing which approach would be the best option for each individual client.

Anecdotal Evidence

When I wrote the last article, I had only ever had two clients regain weight to near or above their starting weight. One of those quit smoking and started binge drinking, which is a massive variable. Now I have had a few more, but it is still a surprisingly low number. It is really crushing to see it happen, since I get emotionally invested into my clients. If it is crushing for me, it is obviously harder for them. It does help me see why alternatives like a weight-neutral approach are appealing.

Personally, I have seen a lot of clients lose >20kg, decrease or come off their blood pressure, diabetes and/or cholesterol medication. I have seen people crippled by back/knee pain slowly become mobile again partly due to pressure off the joints and reduced inflammation. Perhaps they can now play with their children/grandchildren and their quality of life goes through the roof because of that. Everybody has different motivations.

That being said, I don’t have the audacity to think I’m some incredible dietitian who is doing things nobody else can. I think I’m good (lol), but there are sooooo many things I can improve upon to get better results with clients. I have come into contact with a lot of other dietitians over the years and am well aware that there are a lot out there who help clients lose weight and maintain it. And yes, there are plenty out there who are better at it than me. This goes back to my core message, it is not that weight-loss is inherently unsustainable, it is that the approaches utilised often aren’t effective enough.

I’ve got to be honest though and say that in the back of my mind there has always been a little voice saying “what if I’m wrong? What if the recommendations I’m making are not only not helping my clients, but they are also causing harm down the line for them?” Like cool, maybe their knee pain has died down for a few months, but what if they stop seeing me or another dietitian, and then end up gaining more weight than before? The longer I have practice, the more I become sure that I am doing the right thing and I am helping people, but really how am I to know? I think that concern will always be there, which is why I’m always open to learning more.

For context as to why I care about this and struggle at times, imagine having a core belief that the strategies you are using are helping people, but you are constantly reading social media posts/comments from people within your own profession suggesting that your approach might be harming people in the long-term. That’s not always easy.

As a curveball, I’m going to add in that I HAVE taken a weight-neutral approach with certain clients throughout this time as well. And once again being honest, it felt good for me and I think the clients appreciated it as well. And when I say good, I mean really good. Seeing positive outcomes from that approach gave me more satisfaction than the rest of the work I was doing at the time, oddly enough. As any good dietitian will say though, you need to treat your clients as individuals and go with the approach that is best for them. The hardest part is reading the situation well and understanding what the best approach will be, which certainly isn’t something I have mastered.

Feedback from the Respected HAES Practitioner

I’m going to start with the aspect that I think is the most valid and hit a bit close to home. This practitioner looked on my LinkedIn and saw that I am a sports dietitian. Based on this they pointed out that perhaps the fact that I work in a niche with certain athletes could be manipulating my results and isn’t reflective of the overall population. That is something that I honestly never considered. I had thought about what I was doing differently, but never really paid attention to the fact that who I was doing with could be the important variable as to why the results were so much better than what the statistics generally show.

At the time athletes actually weren’t my core clientele, but a large percentage of my clients were males of similar backgrounds to each other. While the assumption was incorrect, the intended point was very accurate. If you look through the data, you will notice that males are more likely to maintain weight loss than females. If you take a second to think about it, that makes a lot of sense. Males are less likely to have barriers such as emotional eating to the same extent. They have higher baseline metabolic rates, so have more room to create a calorie deficit, as well as more “margin for error” so to speak when eating out or going off-track. They maintain muscle mass more easily, so that when they lose weight their metabolic rate won’t decrease as much due to the loss of metabolically active tissue. There are a tonne of variables in this. The majority of my clients were also doing some minor forms of resistance training as well, which is very helpful for maintaining weight-loss.

If I spread this message and say things like “<10 of my clients have ever regained weight” than I might not be sending a message that is reflective of what is possible at a population level.

More Feedback

Another piece of feedback was “if we’re practising from a genuinely client-centred perspective, it is the client who should be in the driver’s seat about which approach is taken.” I agree with that one. It is hard though. If you are reasonably charismatic and also have a bias towards either approach, you tend to naturally guide your client towards your own views. I’m probably guilty of influencing client’s choices without realising, and you can tell from this article that I have a bias towards weight-loss, just like other practitioners could have a bias towards a weight-neutral approach when a client has come in looking for weight-loss.

A third piece of feedback was “we are obligated to give the client realistic factual information about ALL of their options, and if it happens that we are not skilled in that area, then we must refer on to someone who is – the area of weight loss should be no different.” I agree with this too. With the first part, I’ve been lucky to see clients long-term and have the opportunity to go through that first step, although like I said, my bias likely guides them towards my point of view even if that isn’t necessarily my intention. But what do you do if you are a dietitian who has been given two EPC sessions to see a client and only have time for 30-minute sessions? This is the position most dietitians are in. If you go through all aspects of their options in detail, you won’t have time to help them with whatever option they decide. But I think that model is flawed, which I will discuss later.

The second part of that, I agree with quite a bit. As much as I think we should tailor our approach to our clients, if you are in a position to refer to somebody with expertise outside of your strengths, you should refer. I have taken a weight-neutral approach before and enjoyed it, but it isn’t something I am anywhere near as skilled in as other areas of practice. If I could see somebody would clearly benefit from that approach, it’s in the client’s best interest for me to refer. Somebody who is skilled at weight-loss probably isn’t particularly passionate about the non-diet approach and therefore hasn’t taken the necessary time to learn/practice it, and vice versa. Unfortunately, not everybody has this option available/encouraged. If you are employed by somebody else, it probably isn’t in their best interest for you to turn away business. If you are in an isolated region, you likely don’t have other dietitians available to refer to and an online consult might not always be the best option for the client either.

The final piece of feedback was offered to me by somebody else on a completely unrelated topic. They said “what about the people who leave your service? How do you know what they do?” This one also hit close to home. There is no answer. Almost all the clients who stay on with the dietitian service do well, but who knows what happens to those who leave. I have been fortunate that a very large percentage of my clients who started with me stayed on ongoing and were then handed over to other practitioners who they continued seeing, but there are still people who slip through the cracks. I have seen quite a few former clients go on to achieve incredible results, but one would make the safe assumption that on average the results for the people I don’t hear from after leaving the service aren’t as good as the people who stay on.

If X percent of people regain weight and Y percent gain MORE weight, at what point is it ethical?

This is the biggest question that used to be on my mind. At what point is it ethical to try to help people lose weight. If the mythological number of 95% people regaining weight was true, it would be hard to build an argument for recommending weight-loss.

The number I tend to go with is that ~80% of people regain weight. It’s still hard to build an argument for weight-loss if this number is accurate, which is part of why it is relatively easy to align with HAES principles. In one of the HAES Facebook groups somebody commented on my article saying something like “it’s hard to fault his blinding optimism that he thinks it is worthwhile still having a crack at attempting to find and help the ~20% of people who DO maintain the weight-loss.” That’s not exactly how I would word it, but I guess it is accurate to say that I don’t think we should just write off weight-loss completely just because it is hard to maintain and a low percentage of people succeed.

But if we are talking numbers like that, maybe it is an interesting thought experiment to consider sub-groups? I don’t know the answers, but if men who start consistently resistance training are more likely to maintain weight-loss, maybe it is more ethical/helpful to work with them to lose weight if they would benefit from that. Maybe a sub-group of females with depression, body dissatisfaction and disordered eating are far less likely to maintain weight-loss, and would benefit more from a weight-neutral approach. And there is individuality within those sub-groups.

When looking at it from that perspective, it makes the issue more complex, but could also give certain practitioners a bit more peace of mind that what they are doing is more likely to be the right approach if they are working with a specific sub-group as their core clientele.

One other perspective that I won’t comment on in detail is that a lot of HAES research is undertaken on females. You could also argue that it is undertaken on a sub-group of females where the approach would be more suitable for them. Based on my assessment above, you could make the assumption that a non-diet approach is likely a more effective approach for for females on average than males. So just like the flaw in my original article where I didn’t acknowledge that part of my success has been the sub-group I was working with, it is worthwhile recognising that this newer area of research still has aspects we need to think about if we are extending the conclusions to be applicable at the population level.

That being said, even though health-focused size accepting approaches like HAES are most validated in a sub-group of people, they are unlikely to cause harm in other sub-groups. The same can’t necessarily be said about weight-centric approaches used across the board.

Flawed Approaches

Dietitians are better than other practitioners in the nutrition space on average. We all know it. Yes, there are good and bad dietitians, just like there are good and bad practitioners in other areas of the nutrition field. But on average, dietitians are pretty good.

One thing I wanted to touch on though is that there are plenty of studies out there that have dietitian involvement, but the majority of participants still end up showing the trend of regaining weight. Often these statistics are better than the interventions that don’t have dietitian involvement, but it is still worth noticing.

We don’t have much data on what you would call a dietitian’s traditional model of care. In my opinion, one “flawed model” for weight loss that I have observed is the EPC model where a dietitian will often only get 2 sessions with a client (unless they convert them to an ongoing private client). Generally, these sessions are only 30 minutes and they are often bulk billed. How much are you going to be able to do in two 30 minutes sessions? Will you be able to change their life and help them lose a significant amount of weight and maintain it? Is it going to be harder to get results if you bulk bill vs if they invest their own money into the process? Sure, it is possible to help them get all the outcomes they desire, but it is wayyyyy harder than if you see them on a regular basis throughout the process. Dietitians are good, but I’m not sure this is the best model to use if you want to have an impact.

My thought process is that there is no optimal approach that is guaranteed results, but there are better approaches out there. The more things you can do to tip the balance in your favour, the more likely it is that what you are doing is ethical, beneficial and rewarding. I see a lot of people leave dietetics (or talk about leaving) because they aren’t sure whether dietetics is for them and they aren’t really happy with what they are doing. In my opinion, if you are using a more effective and satisfying your approach, it is likely you will be happier with what you are doing. We all got into this industry to help people.

Further Thoughts on how to Maintain Weight Loss (Or Build on It)

I ended the last article with my thoughts on how to maintain weight loss. Key points I touched on last time were the importance of follow-ups, education, listening, exercise and protein. I’ll add some new points or elaborate a bit on old points below. As I said last time, I have a lot of thoughts on this, but I’m not even sure I’m right with the entire concept, let alone the keys to success.

1) Follow-up and accountability – When I studied to become a dietitian, I had delusions of grandeur that I would give our clients all the tools they need to get to their goals and then teach them to self-manage without me. Sure, that is possible, but my interpretation of the research is that people tend to start regaining weight when the “intervention” stops. Seeing a dietitian could be classified as part of the “intervention.” If we continue to see the client ongoing, we improve their chances of success.

Obviously, this has the difficulty that we need to have great client retention for this to be an option. But constantly trying to improve in that area can lead to better client outcomes. Utilising a business model that encourages long-term care could also be helpful, since often that is the barrier.

In addition to the accountability of seeing a dietitian, it could be worth considering the accountability of paying money. A former mentor of mine once said to me “I used to see some clients for free as a government funded dietitian and they weren’t getting great results. When I opened my private practice and these same clients had to start paying, they suddenly got incredible results even though I was giving the same advice as before.” Accountability matters.

2) Volume eating – I’ve discussed in the previous article and in a lot of other places how protein can be an effective tool for appetite management in comparison to the number of calories consumed. But another way to help with this is the concept of volume eating in general. Focusing on eating a larger volume of foods that are lower in calories can make the process easier. The research is clear that when people cut down on their food volume in an attempt to lose weight, they are less likely to succeed long-term in comparison to people who increase their volume for the same number of calories.

It makes sense to focus on eating a large amount of fruits and vegetables. It makes sense to eat high fibre foods in general vs low fibre foods, since that will also be more satiating. It makes sense to drink larger volumes of water or non-caloric drinks.

Focusing on these concepts can increase the likelihood of success.

3) Diet breaks – I touched on this earlier, but diet breaks can make the process easier. In the past, people had the opinion that cheat meals or refeed days could help keep their metabolic rate high. Short-term studies showed positive outcomes, but the research doesn’t support that this does actually impact metabolic rate over the course of the week/month.

Taking regular 1-2 week diet breaks where the individual eats at maintenance however DOES appear to help keep TDEE higher. This means people can eat more calories throughout their weight-loss phases and continue to make progress, and also end their diets on higher calories than they would have if they didn’t have diet breaks. That is a good position to be in.

It also helps from a mental perspective. If you have “dieted” for 10 days and have 3-4 days before a diet break, it might make it easier to stick to the plan vs if you are 10 days in and have 20+ weeks to go. Plus, it gets people used to eating at maintenance (and experiencing the benefits associated with this) rather than constantly striving to be in a calorie deficit.

I’m of the opinion diet breaks are beneficial and should be utilised at times. Nobody knows the best way to implement them. Two weeks on, two weeks off is a bit excessive in my mind. Nobody wants to take twice as long as necessary to reach their goals, even if it is the “smart way to do things.” There are other options that are/have been researched such as 3 weeks on, 1 week off, but we don’t exactly have a massive amount of research on this are yet. But food for thought, if you see somebody 150kg+, it probably isn’t the best plan to try to get them down to their (often unrealistic) goal weight in a linear fashion without any time at maintenance calories.

4) Mental Health – For people with depression that impacts their food choices, it could be best to start by addressing that in a weight-neutral fashion. I’m not sure if I’m onto the right approach with this one, but it is something I have thought about a lot and would love to discuss with other dietitians to hear their opinions. There is plenty of research coming out showing that dietary approaches can help with depression. Using the SMILEs Trial as an example, 32% of people with severe depression went into complete remission from depression within twelve weeks by attempting to follow a Modified-Mediterranean diet. These people didn’t even come close to following exactly what the dietitians recommended, but they did make major positive changes to their diets, in a weight-neutral fashion.

Depression can seriously effect somebody’s diet. Potentially, improving that variable could help open up the door for greater success with weight-loss down the line. That being said, there are a lot of non-dietary factors in depression and only so much we can as a dietitian.

What if I’m Wrong?

I previously said that if I reach the 5-year mark and I haven’t had more than a ~20% success rate with clients maintaining their weight-loss, that will be a sad realisation. I won’t have access to that data, but based on the trends, I’m confident that won’t be the case.

I’m not sure if I will ever write another blog on this topic though. Partly because blogging sucks and is time consuming, but partly because I’m now mostly seeing athletes and have different interests in what I want to achieve as a dietitian.

If this post has prompted you to think about this topic, feel free to get in touch and share your perspective. I would love to hear it, even especially if you disagree with me.

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