Clients on diets
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7326.1435a (Published 15 December 2001) Cite this as: BMJ 2001;323:1435
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Although it is a pity that Dr Dunea waited 15 years before putting
pen to paper to vent his frustrations of his experience in obesity
management, I think he would be surprised to note the advances that have
happened in our understanding of the topic during this time.
Obesity is a disease of major epidemic proportions in developed
countries. Its prevention and treatment are of major concern and needs to
be tackled at many levels, involving individuals and populations with a
variety of approaches.
Diet is a vital element of treatment and Dr Dunea will be pleased to
note that dietitians have long recognised the complexity of obesity
management and it is now generally recognised as a specialist area needing
specialist skills and expertise. There is good evidence that an
individualised approach based on actual energy requirements, with a
deficit of 600 kcal/day is more effective than the indiscriminate use of
the ‘old’ 1000 kcals/day diets (Frost 1989, Lean & James 1986). This
aspect of good practice has been incorporated into national clinical
guidelines for the management of overweight and obesity (NOF 2001, SIGN
1996).
Long-term changes in lifestyle, including eating and physical
activity behaviour are needed for sustained changes in weight. Dietary
consultations need to address how these changes can be achieved. The diet
should be nutritionally sound. Dietitians are all too familiar with the
consequences of over-strict ‘dieting’.
Modern dietetic consultations focus on a more holistic approach,
which includes a thorough assessment, along with a collaborative
discussion about the various treatment options available that are best
suited to the individual. Maintenance of weight lost is essential for
successful treatment outcomes and ongoing support is vital for the its
achievement
Like medicine dietetics is moving towards evidence-based practice and
it would appear that the dietitian Dr Dunea spoke to was if anything ahead
of her time!
Refences:
Frost, G., Masters, K., King, C., Kelly, M., Hasan, U., Heavens, P.,
White, R. & Standford, J. (1991) A new method of energy prescription
to improve weight loss. Journal of Human Nutrition and Dietetics 4, 369-
373.
Lean, M.E. and James, W.P. (1986) Prescription of diabetic diets in the
1980s. Lancet, 1, 723-725.
NOF, National Obesity Forum available at: www.nationalobesityforum.org.uk
SIGN, Scottish Intercollegiate Guidelines Network Obesity in Scotland
(1996) 'Integrating prevention with weight management', Guideline No 8,
Published by Scottish Intercollegiate Guidelines Network, Edinburgh.1996.
Also available (updated version) at website: http://www.sign.ac.uk/
Competing interests: No competing interests
It is a pitty to hear comments such as the ones Dr. Durnea reported
in the BMJ com. Dietitians assess their patients from different angles and
this assessment depends very much on the applied professional criteria. We
should remember that the individuality of the patient is paramount if we
want a better outcome. Obesity is a very complex health condition, and
cannot be addressed just by advising the patient to reduce to 50% the
dietitians prescribed diet. Doctors should refer their patients to the
dietitians, they don't have the time and the knowledge to advise the
patients appropriatelly on dietetics matters. Team work is essential when
treating obesity; compliance is more likely to improve when professional
support from different disciplines is considered, what about the
participation of the psychologist for example?, or the social worker if
economic problems are an issue? Perhaps what I would have to criticise in
the dietitian was her tactless approach to Dr. Durnea, her lack of good
manners or politeness to a colleague. Regards,
Gladys Hitchen, APD, MPH, Diabetes Educator.
Competing interests: No competing interests
Although he is very confident about it, Dr. Dunea's patients might be
better advised to disregard his advice than the dietician's. It is
questionable whether his more stringent regimen will result in greater
long-term success (obviously, it will result in greater short-term weight
loss, but is that the goal?). It is certain that the lower-calorie diet
will be more unpleasant and will increase the patient's risk of dieting-
related cholelithiasis.
You have your opinion, Dr. Dunea, but where, I would ask, is your
evidence?
Competing interests: No competing interests
Dear Sir
Dr Dunea's experience with a recalcitrant dietitian 15 years ago
would not reflect the experience that most physicians have today.
Dietitians certainly realise that obesity is a major epidemic in western
countries and take it seriously. What we do know, however, is that single
episodes of counselling with general advice - such as eating half the
usual amount - are unlikely to be effective. The determinants of food
behaviour are complex and changing them is a process that needs careful
individual assessment and takes time. The heartening news is that studies
are now showing that significant success can be achieved with intensive
dietary counselling. In the recent Finnish study, the risk of developing
type 2 diabetes was reduced by 58% in a group of at risk overweight
subjects, but that took seven sessions with a dietitian in the first year
and one session every three months thereafter (1).
Dietary compliance is more difficult to achieve than drug compliance,
and all health professionals need to work together to support each other
in achieving better health for our clients.
Peter Williams PhD APD
President, Dietitians Association of Australia
1) Tuomilehto J et al. Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose tolerance. New
Eng J Med 2001;344:1343-50.
Competing interests: No competing interests
Thank you for an eye-opening letter from a physician's frank
position. If you wouldn't mind, I'd like to share mine. It's simply
this: continuous undereating leads to overeating. It's well known that if
calories are deprived eventually cravings and hunger return, with a
vengence. Many studies have indicated "dieting" habits lead to obesity.
And then there's the whole discussion on the lack of success of the "low
fat" diet trend of the 80s and 90s that has led to the highest percent of
obesity America has ever seen! Cutting calories to ridiculously low
levels is hardly the answer. As Nancy Clark, MS, RD says: "Dieting does
not lead to weight loss. Eating does." Try consistent eating, no
skipping meals, no skimping. Try cutting out the "liquid" calories from
juices and sodas. I'm sure you and I could agree on the places to cut
down on or cut-out. But we couldn't agree on an impractical, low calorie
diet. Those are out. As a recent health market survey by the NPD group
states, there is a growing trend among women to forgo dieting and instead
are commited to a healthy lifestyle. They estimate 20% of American women
are in this category. They say that in 1990 35% of American women were on
a diet while in 2000 that dropped to 29%.
See this link for further info:
http://www.caloriecontrol.org/newsnet61.html
I hope you, as a physician, and other physicians, understand that we
desire to improve health in our clients as much as you do. I happen to
work with a healthy population and choose not to work in an outpatient
setting. But I couldn't imagine myself saying to a client who was paying
for a consult by a Personal Trainer (who has a master's degree and is
certified) to "heck, listen to what he has to say but go home and do your
own exercises your way. What does he know."
Hmmm ... now who sounds silly?
Respectfully,
Debbie Schmidt
Competing interests: No competing interests
I would ask Dr. Dunea to try living on 800 or 1000 calories a day --
even 1500 -- and see how successful he is long-term in eating without
overeating. Extremely low-calorie diets -- such as 800 or 1000 calories -
- induce starvation, particularly in very large people. The body's normal
response is to overeat, thereby setting up people who are trying to lose
weight to gain weight, or at the very least, be unable to keep off lost
weight. Ancel Key's studies on food restriction during World War II
showed this bodily response long before America's love affair with dieting
confirmed it. Dietitians aren't encouraging overeating; we just don't
encourage undereating that creates more problems than it solves.
Competing interests: No competing interests
Clients on Diets
In response to the letter from George Dunea (BMJ 2001;323:1435), it’s
certainly true that food is important in maintaining optimal health and as
the obesity epidemic continues to rise the world over beyond our control,
we need to work together as health professionals to tackle the problem.
One bad experience with one un-polite individual should not tarnish
the good name of all the dietitians around the world. Dietitians are the
experts in food and nutrition, having studied and specialised in this
topic for several years at university level. It is certainly a relief that
doctors who do not value the unique and specialist skills of the dietitian
are very few and far between. Most of our medical colleagues, in our
experience, recognise the expertise of dietitians and do refer on patients
who need specialist advice.
Obesity has been linked to a multitude of diseases, as we all know.
As such the treatment of obesity must be given a high priority. Obesity is
an incredibly complex problem, it is certainly not solved by simply
prescribing an 800kcal diet or indeed by asking patients to “listen
politely then eat half of what the dietitian prescribed”.
Firstly 800kcal per day is likely to be too low an intake for most
people; very low calorie intakes encourage weight loss at an excessive
rate. When weight is lost too quickly not only does this increase risk of
gallstones and possibly electrolyte abnormalities, but also the weight is
likely to go back on again (1). Eating habits that require such low
calorie intakes are also not sustainable in the long term. If we are truly
to stem the epidemic of obesity we need long term and sustainable
solutions, not the old ‘quick fix’ crash diet followed by the weight
piling back on again.
Dietitians have a unique blend of skills which enables them to give
holistic advice to patients; not only on their nutrient intake and meal
patterns, but also on behaviour modification and the long term maintenance
of new eating habits and lifestyle changes.
There are many self-appointed nutrition experts giving inappropriate
advice to the unsuspecting public, and doctors and dietitians must work
together to ensure patients receive optimal care.
Mary McNab DipHSc, NZRD
President
New Zealand Dietetic Association
1. National Institute of Health, National Heart, Lung and Blood
Institute, North American Association for the Study of Obesity (2000)
Obesity. The practical guide to identification, evaluation and treatment
of overweight and obesity in adults. NIH Publication Number 00-4084.
Competing interests: No competing interests