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Navigating nutrition conversations with patients
When it comes to myths surrounding obesity, the list of misconceptions is as long as the myriad of complications it can cause. Obesity treatment consists of four pillars: Nutrition, physical activity, behavioral counseling and pharmacotherapy.
The first step in treating patients with obesity is broaching the subject, which can be difficult for a spectrum of reasons. Common barriers, which can be real or perceived, include a lack of education about obesity and its treatment, weight bias, lack of knowledge about effective communication strategies, time limitations, reimbursement challenges, fear of making patients uncomfortable, and the assumption that patients aren’t motivated to address their obesity.
It’s important to understand common obesity myths that your patients—and other health care providers—may believe to be true. Here are three common misconceptions about nutrition and obesity:
Obesity is caused by overeating
While overeating may play a role, the development and persistence of obesity is the result of numerous genetic, environmental, and biological factors. In addition to influencing obesity, these factors also affect hunger, satiety, propensity for specific foods, and response to nutritional interventions.
Normal life can resume once obesity is resolved
Many people believe that a perfect diet exists and that once it is identified and implemented, life can resume as normal. In reality, the chronic condition requires a nutritional plan that will need to be continued indefinitely to keep weight and health stable. In fact, an intensification of the entire treatment plan, including nutrition, may be required when the body metabolically adapts to weight loss. Anti-obesity medications may also be needed to enhance adherence to the nutritional plan, induce further weight loss, and/or prevent weight regain.
Weight gain or loss is solely determined by calories
Some believe that weight gain or loss is determined by a simple equation: calories in vs. calories out. On the contrary, weight and appetite are regulated by multiple neurohormonal processes that involve adipose tissue, endocrine organs, gastrointestinal tract peptides, and the peripheral and central nervous systems. The body responds hormonally to the type, quality and quantity of food eaten, which goes beyond calories. Foods that increase insulin levels, such as sugars, starches and other ultra-processed foods, promote lipogenesis and inhibit lipolysis.
With misconceptions like these, it can be intimidating for patients to have these conversations so it’s important to remember that broaching the topic of obesity with patients begins with gaining permission. Consider the following phrases: “Do I have your permission to discuss your weight?” “Would it be alright if we discuss your weight?” and “Do you have concerns about your weight?”
Once the patient has granted permission, focus on building a respectful and collaborative partnership. When patients feel that a clinician is on their side, they are much more open to discussing weight and treatment options. The goal of the conversation is to set the stage for further conversation and assess the patient’s readiness for treatment. When patients are not ready, revisit the topic at a later date and invite them to return when they are ready.
Encourage nutritional strategies
When creating a treatment plan for patients with obesity, implement nutritional strategies in increments. It is easier to be successful when eating changes are done one step at a time. Here are some important nutritional elements to discuss with patients:
Advise patients to keep their environment free of tempting foods. Many don’t recognize the importance of keeping tempting foods out of their vicinity.
Encourage your patients to find ways to socialize that aren’t food-centric, such as meeting a friend for a walk instead of at a coffee shop full of temptations.
Provide guidance for navigating eating challenges, such as travel, social events, holidays and stressful periods. This may require referral to a dietician or nutritionist for specific strategies, but it is still important to broach these topics so patients recognize the value of being prepared for eating challenges.
Administer anti-obesity medication support, if appropriate, based on ability to adhere to the nutritional plan, hunger, cravings and satiety.
Help patients connect their food choices to their hunger, cravings, function, energy, focus, sleep and pain level.
Evidence demonstrates that tracking is associated with weight loss. Tracking can identify indulgences that aren’t remembered, reveal skipped meals, or highlight snacking habits that lead patients to be overly hungry and vulnerable to eating convenient processed carbs and/or overeating. Suggesting ways for patients to track eating habits can be helpful, such as apps, spreadsheets and notebooks.
While wearables can be effective for monitoring physical activity, such as daily step counts, tracking methods that focus on calorie deficits can be problematic. If a patient has expended energy through exercise, the app may tell the patient that they can consume a specific number of calories and still lose weight. This is rarely the case and can lead to indulging in ultra-processed foods that increase insulin and inhibit lipolysis. It is better to use tracking to monitor intake and review the information with the clinician or dietician, who can assess the effectiveness of the eating plan.
Sandra Christensen, MSN, ARNP, FOMA, is a board-certified nurse practitioner. She owns Integrative Medical Weight Management in Seattle where she provides personalized, comprehensive obesity treatment.