True Being RD
Emily Marshall 

I Won't Promote Weight Loss Anymore...Here's Why

 

I have been a dietitian for almost 3 years. During my first year I aimed to find practical ways to help clients lose weight based on what I was taught in school. In my 2nd year I struggled to help people lose weight and I began to question why that was. In my 3rd year I chose to take a different approach for most of my clients and I noticed a profound difference.  That approach was called Intuitive Eating and Health at Every Size. Now, I pledge never to help someone intentionally lose weight ever again. Here’s why. 


Weight Loss Perpetuated Disordered Eating and Poor Body Image

What first made me question my approach to helping clients with their diet was noticing how distraught my clients were while trying to lose weight. I don’t exaggerate this. Everything made them distraught from talking about their body, to discussing what foods they ate or didn’t eat, their exercise routine, and their health.  What was especially antagonizing was stepping on the scale. This was such a dreaded moment for so many people. Clients would either beg me not to weigh them during their session or ask to be weighed (to see their progress) and end up always feeling sorely disappointed or angry. There was so much guilt that my clients felt. They would feel guilty for eating foods, enjoying certain foods, going out to eat, not exercising, or not walking as much. The sessions would feel like confessions. 

I was not prepared for this in the slightest from my schooling. Talking to clients during the first session was the most challenging. We would begin by discussing why they had sought out my services. This opened up the door to uncovering all the pain they kept inside of them.  Women would sob in my office telling me how much they hated their bodies and all the things they had done trying to lose weight. While most of the men I would see wouldn’t cry, they still belittled their bodies. They would tell me how much they wanted to “get rid of” certain parts of their bodies or used humor to hide behind how they really felt about themselves.  It was unbelievably heart-breaking. 


I Was A Hypocrite

To be honest, I was a complete hypocrite. I could empathize with what my clients were going through because I had been through it too. Before starting my degree in nutrition I struggled with my body image. I never felt “good enough” so I chose to control my food and exercise to make me feel like I was better. I counted calories and restricted certain foods. I exercised excessively and I weighed myself at least weekly, sometimes more. Seeing the number on the scale was the trigger for me. For some reason, that number was always too high in my mind. If I could just get it down, then I would feel better about myself. I thought “only 5 more pounds; get it down and then you’ll be ‘good enough’”. Well, I got to a point when enough was enough. I chose to stop weighing myself and over time my relationship with myself, food and exercise improved. By the time I was a dietitian, I no longer thought about calories day to day and I only weighed myself at doctor visits. I did this because I knew it was better for my mental health. 

So as a dietitian in a counseling position, I was doing exactly the opposite of what I knew to be true.  I made meal plans with calorie limits, instructed clients to count calories or macros, and weighed clients when they would come to my office. I did this because my clients asked for it and because it was the standard method of practice for dietitians in a weight loss setting. Clients put their trust in me because I held a degree and also have a culturally acceptable thin body. 


No Scientifically Valid Method to Lose Weight…and Keep it Off

I began to investigate how I could make the experience with clients better. Doing the same thing over and over and expecting a different result is insane, right? What was I doing wrong? I questioned everything. Were calories the answer? Can a person seek weight loss and not have a distraught relationship with food and their body? What was the ideal macro ratio for weight loss? It was a rude awakening when actually looking into the research. 

Turns out there is no scientifically valid method to weight loss. Let me explain. What most studies involving weight loss and anecdotal stories show is on average people can lose about 10-20 pounds (a number typically less than the desired amount of weight loss) in any given weight loss intervention[1] [2]. Some people will lose more and others will lose less and some won’t lose anything or will gain weight [3]. However, the likelihood that this weight is regained is very high. In fact, according to a panel of experts convened by the National Institutes of Health “one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years” [4].  

A particularly frustrating fact for those attempting to lose weight is the likelihood of gaining back more weight than was originally lost, thus increasing their weight to a higher weight than before they started dieting. One review study found one-third to two-thirds of dieters regain more weight than was lost on their diets [5]. Other studies have shown this as well, even with weight loss surgery. For most dieters this will cause them to repeat the cycle over and over. A process of dieting and losing weight, then regaining more weight, and dieting again to lose the weight again. This is known as “weight-cycling”. Weight cycling has been associated with worse health outcomes including increased inflammation, type 2 diabetes, high cholesterol and high blood pressure [6] [7]. For an in depth explanation on why weight gain is almost always inevitable after weight loss, I would highly recommend reading the book Health at Every Size by Lindo Bacon. She explains all the mechanisms in place in our body which promote weight stabilization (a.k.a. set point theory) in addition to how dieting slows down our metabolism and ability to burn more calories. Clients would describe to me how they had lost weight so easily the first time they dieted.  Each time they regained weight, it would be more difficult to lose the weight again. 


Calories Are Not the Answer 

No matter what type of diet a person may try to lose weight, the theme of the diet is always eating fewer calories. Whether it’s low carb, low fat, weight watchers points, “watching my sugar intake”, keto, intermittent fasting, etc. Limiting a certain nutrient means limiting calories. Which is the basic argument for how to lose weight. Take in fewer calories and burn more, because physics. However, this conventional method has been disproven. The common wisdom of how to lose weight comes from the 3,500 calorie rule. This was discovered in 1958 and was used to describe how much energy 1 lb of fat stores. It was co-opted as a way to manipulate dietary intake to subtract 3,500 calories per week to equal 1 lb of fat loss per week. However, this theory paints the picture that weight loss will be linear and every individual who follows this will lose 52 lbs of fat per year. This is definitely not the case. People lose weight at a much slower rate than this, if at all [12]. It is so disheartening that health professionals would still use this logic to explain their rationale for prescribing a dietary restriction that would never result in the weight loss being so perfect. It perpetuates self-blame among people who are trying to lose weight, when it is really not their fault at all. 

What is more, counting or tracking calories has been linked with higher levels of eating disorder symptoms and disordered eating [13][14]. Counting or tracking calories, points or macros is a common method of keeping track of one’s caloric intake with the aim of staying under a limit so as to produce weight loss. However, evidence suggests that it is this preoccupation with food, rigid measuring of food and also fitness tracking which can exacerbate or promote disordered behaviors and thinking about food. 

Find out all the reasons why calorie tracking isn't getting you to your goals here


Is Having a Higher Weight Unhealthy? 

Most people who seek weight loss have a couple of reasons as to why they want to see that change. Most people will report health being a factor. No doubt this has been ingrained into their head that they must be a “healthy weight” in order to prevent or reduce their risk of chronic health conditions. However, the evidence that we currently have only points to an association between having a higher BMI and greater risk of disease. The evidence does not show causation. Also, contrary to popular belief there are conditions in which having a higher weight is actually beneficial to health including type 2 diabetes, hypertension, atherosclerosis, and cancer [8]. Furthermore, there’s no evidence that demonstrates being thin as a ticket to perfect health. People of “normal weight” BMIs are just as susceptible. While most people want to feel and be healthy, there are other reasons why someone would want to lose weight. A main reason being wanting to escape the stigma. 


Weight Stigma Contributes to Poor Health

There is emerging research surrounding the effects of “weight stigma” on a person’s health and wellbeing. Weight stigma is the discrimination experienced by people in larger bodies in overt and subtle ways. It can range from negative comments made by friends, family members, health care providers or strangers to the inability to find a comfortable seat in public places (i.e. planes, buses, restaurants, waiting rooms) or clothing in their size and negative stereotypes portrayed in the media. Those who experience and internalize weight stigma are more likely to have higher rates of depression, anxiety, eating disorders, inflammation, cortisol levels (stress hormone) and diabetes risk [9] [10][11]. 

It’s no wonder why people who experience this stigma are less likely to engage in health promoting behaviors due to the avoidance of shame and embarrassment. For example, they may be less likely to exercise in public settings and will delay or avoid routine medical appointments for screenings or general check ups [10]. They may also isolate themselves and avoid social settings or meeting new people. This is not something you would typically hear on the news, but it is so common among people in bigger bodies. 

I learned about this from my clients who told me stories of when they experienced outright disrespectful treatment and judgement from their doctors, significant others, personal trainers, and complete strangers. One client said her doctor told her she was lying to her when she explained to her that she was exercising and consuming a healthy diet. Her doctor didn’t believe her, but little did that doctor know that this client of mine was actually under-eating and overexercising! The doctor’s comments increased her disordered behaviors and made her not want to go to the doctor’s office for a long time. Another client of mind told me they received hurtful comments and judgmental looks from a complete stranger in a grocery store when shopping for food. 


Intuitive Eating and Health at Every Size

Knowing all of this and seeing how it affected my clients, it was really something that made me question everything about what I was doing and why I was in my profession. To me, helping someone with weight loss and being educated on how it can harm their health, wellbeing and relationship with food, it goes against ethical standards. After all, as a healthcare provider we must follow the principle “do no harm”. This is why I am ultimately grateful and proud of the Intuitive Eating (IE) and Health at Every Size (HAES) frameworks. These frameworks promote health over weight. That means that instead of focusing on weight loss, the focus is on instilling health-promoting behaviors, enhanced quality of life, and non-restrictive eating habits. 

When I began to use these frameworks with my clients, it was like the difference was night and day. I stopped weighing a majority of my clients. When this happened, clients seemed to be more at ease around me, like they could be themselves because they didn’t have the constant pressure to change. The conversation shifted from learning how to control and limit foods, to learning how to challenge food fears and misconceptions. It granted them more freedom. We discussed ways to improve their body image and be more accepting of their current body. It made a real difference in how they carried themselves. Being more confident and comfortable was important to my clients. We took steps to get them there. We also focused on health habits such as managing stress, having adequate sleep, exercising in ways that were enjoyable (not punishing) and living a life full of values that were meaningful to them. 

I feel even more confident using this approach because of the research that has been done which shows an improvement in health outcomes. In the research thus far, improvements such as reduced total cholesterol, low-density lipoprotein (LDL cholesterol), triglycerides, and systolic blood pressure were seen in HAES groups as compared to conventional diet groups. These changes were sustained in the 2 year follow-up [15]. Also, “the HAES group decreased eating restraint, physical hunger rating, disinhibited eating, drive for thinness, bulimic symptomatology, body dissatisfaction, poor interoceptive awareness, depression, and body image avoidance and increased self-esteem at both 1-year and 2-year follow-up” [15]. 


Moving Forward

I hope that this post adequately explains my reasoning for changing my approach to working with clients. If it does not, I invite you to look into the resources I have provided below or ask me any questions.  I wish I could take back what I did to help clients with weight loss. I know I caused a lot of harm and I am truly sorry for that. I hope that moving forward with an Intuitive Eating and HAES approach, I can make it right. 

Read more about Intuitive Eating here. 



Sources: 

  1. Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. International Journal of Obesity & Related Metabolic Disorders. 1997;21(10):941. doi:10.1038/sj.ijo.0800499.
  2. Franz MJ, VanWormer JJ, Crain AL, et al. ▪Weight-Loss Outcomes: A Systematic Review and Meta-Analysis of Weight-Loss Clinical Trials with a Minimum 1-Year Follow-Up. Journal of the American Dietetic Association. 2007;107(10):1755-1767. doi:10.1016/j.jada.2007.07.017.
  3. Howard BV, Manson JE, Stefanick ML, Beresford SA, Frank G, Jones B, Rodabough RJ, Snetselaar L, Thomson C, Tinker L, et al: Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. JAMA. 2006, 295: 39-49. 10.1001/jama.295.1.39.
  4. Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel. Annals of Internal Medicine. 1992;116(11):942-949. http://search.ebscohost.com.dom.idm.oclc.org/login.aspx?direct=true&db=a9h&AN=137743904&site=ehost-live&scope=site. Accessed April 2, 2020.
  5. Mann T, Tomiyama AJ, Westling E, Lew A-M, Samuels B, Chatman J. Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer. American Psychologist. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220.
  6. Strohacker K, McFarlin B: Influence of obesity, physical inactivity, and weight cycling on chronic inflammation. Front Biosci. 2010, E2: 98-104. 10.2741/e70.
  7. Montani JP, Viecelli AK, Prevot A, Dulloo AG: Weight cycling during growth and beyond as a risk factor for later cardiovascular diseases: the ‘repeated overshoot’ theory. Int J Obes (Lond). 2006, 30 (Suppl 4): S58-66. 10.1038/sj.ijo.0803520.
  8. Bacon, Linda. Health at Every Size: the Surprising Truth about Your Weight. Benbella Books, 2010.
  9. Puhl RM, Heuer CA: The stigma of obesity: a review and update. Obesity (Silver Spring). 2009, 17: 941-964. 10.1038/oby.2008.636.
  10. Hunger JM, Major B, Blodorn A, Miller CT. Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health. Social & Personality Psychology Compass. 2015;9(6):255-268. doi:10.1111/spc3.12172.
  11. Wu Y, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. Journal of Advanced Nursing (John Wiley & Sons, Inc). 2018;74(5):1030-1042. doi:10.1111/jan.13511.
  12.  Hall KD, Chow CC. Why is the 3500 kcal per pound weight loss rule wrong? Int J Obes (Lond). 2013;37(12):1614
  13. Levinson CA, Fewell L, Brosof LC. My Fitness Pal calorie tracker usage in the eating disorders. Eating Behaviors. 2017;27:14-16. doi:10.1016/j.eatbeh.2017.08.003.
  14. Simpson CC, Mazzeo SE. Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eating Behaviors. 2017;26:89-92. doi:10.1016/j.eatbeh.2017.02.002.
  15. Tylka TL, Annunziato RA, Burgard D, et al. The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity. 2014;2014:1-18. doi:10.1155/2014/983495.
Photo above is by mojzagrebinfo on Pixabay

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