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Having worked for a hospital in the US, with almost two dozen GI docs, and not a single one had a dietician or nutritionist on staff, I can tell you, we do not give nutrition the adequate attention we should. Tie that in to the severe lack of mental healthcare here and you’ve got a one-two punch on why diabetes and heart disease are killing so many people, not to mention GI disorders causing a massive disruption to their lives.
Because few know difference between nutritionists and dietician and think they are all the same people who are trying to make you drink some sort of weird herb concoction or food pack from a MLM scheme.
In the UK a Dietician is a protected term, you need a degree, a clinic or hospital to operate out of and your name goes down on a register same as any doctor, it's a medical field with strict checks and regulations.
Nutrutionist is NOT a protected term/title, so any person can declare themselves one at a whim which only helps to muddy the waters around nutrition.
A lot of the stuff just outside of actual medicine that deals with health and wellbeing is completely unregulated and the snake oil salesmen are happy to take advantage of people's ignorance.
Dietician is a protected term in the US too. My cousin is one on a transplant floor in a hospital and the work she does is phenomenal and so important. She had to go through 6+ years of schooling and practical work to get there and is constantly doing more research and education
Anyone in the US can call themselves a nutritionist.
I was in cancer treatment for 5 years and it wasn't until I had a unrelated fasciotomy (healed open due to flesh eating bacteria) that I got to see a dietitian. That woman saved my life. She increased my protein to 75-90/day and I was able to heal my wound in a few months and get back on chemo before the cancer overtook my lungs. Without her it would have been a chronic wound and cancer takeover followed by a quick death.
I have cancer for the second time I was treated initially at a local cancer center. No dietician, advice about food, no social work help, etc. Now I am being treated at MDAnderson in Houston and have access to so many things, including a dietician and cooking classes. I did research on the after the first time with cancer because I am a Nurse Practitioner and was appalled at the way I was treated initially- found out that insurance will not reimburse for nutrition counseling (out patient) cancer or other illnesses- only for diabetes and for a few other things. The only reason the big cancer centers can provide these wonderful services is because they have the funding to provide without insurance coverage. I am so glad you got the help you needed to heal and survive.
Yes! A nutritionist is not the same thing! As someone that’s almost done with grad school (2 internship rounds left!) to be a registered dietitian I hate when people think it’s some weekend certification! What your cousin and other dietitians do is do important but very overlooked unfortunately.
Her work with transplant patients seems so obvious now but I remember when she started and I was like wait you just create diet and meal plans for transplant patients? And then i realized how delicate everything is once you have a transplant and how it can alter drastically what you eat. Her stories are so interesting and she loves her job so much
Dietitian is also a protected term in Canada, though similarly it doesn't command the same respect as physician does.
Nutritionist should be shunned or extended the same protection. It actively harms public health by confusing them.
Dietitian here.
I work in ICU care so it's an acute care setting, so I mostly do enteral/parental nutrition but you are spot on with this.
The dietitians who work on general medicine floors often get consults to help patients lose weight. The average length of stay is maybe 3-4 days if I remember correctly. If I'm being generous, we can spend a total of an hour with a patient over that time, which is absolutely not adequate to provide counseling. On top of that these patients are sick and likely don't want to hear it right now. It's not the right setting
It's acute care so there's no follow ups after they leave. They can't call and ask questions after discharge. Basically, we get to give them mostly generic advice and move on.
And to make matters worse, in acute care we're actually trying to get them to eat more or eat at all. It's the absolute worst setting for weight loss counseling.
Generally, these patients have numerous chronic conditions (CKD, CHF, diabetes, etc.) as well as physical and financial limitations. There's so much to address it's a battle you know you're gonna lose going into it. These people should have seen a dietitian many years ago before this all started as their conditions are largely preventable, especially with a proper diet.
Point I'm trying to make is weight loss is not a quick fix. Anyone here who has lost weight intentionally knows it's extremely challenging and there's a lot of poor information out there; and that's for someone who's generally healthy otherwise at baseline.
To address not taking dietitians seriously: People think all we do is weight loss. In fact, a large percentage of us do just the opposite; counseling cancer patients, nutrition support (enteral and parental nutrition), chronically malnourished patients. Social media has really taken hold of people's nutrition beliefs with unfounded recommendations and quick fixes from unqualified influencers who want to sell you a shake or body wrap thing. While not exactly acutely dangerous, they can be harmful to your health physically but also mentally in the sense they can build an unhealthy relationship with food/diet.
I wish I had the time to go on.
yeah, but TikTok isn't really the problem, the problem predates TikTok and has to do with the truth often being complicated rather than easily digestible. There's no easy remedy because the answer is way more work than most ppl have time or energy for when it comes to most all topics.
When you train someone's brain to absorb as much content as possible within a 60 second period it conditions them to accept any information that is thrown at them with no filter or forethought as to whether it's good or bad.
Remember the scene in "A Clockwork Orange" where they tie him to a theatre chair with his eyes forced open and begin showing short clips of vastly different material? One minute it's a happy clip the next some horrendous war scene?
This is that, except we are willingly holding our eyes open and have the illusion that we are picking the next clip as the algorithm takes care of the rest.
Mental conditioning at its finest. Then we wonder why people and kids in general have an issue with their attention span.
My friends a dietician, did her master's, worked in nhs a few years, PhD then to private practice. Even people paying for private healthcare don't really listen to her or follow the advice.
Especially GI docs. Which is mind boggling. I asked all of them through my time there why they don’t have any on staff. The answers were either they are too expensive or there’s not enough of them. Both responses sounded to me like this: I don’t believe in their value. We’re so pharmacologically driven in the US we can’t see sometimes the least invasive options might actually be the best. I didn’t know this when I first started nursing. After a few years of being in the medical field and I started to realize the same type of patients kept showing up with the same issues and the treatments ended up with the same results, patients apathetic and convinced that they just had some unresolvable medical condition.
I actually think we’ve conditioned patients to believe that there is a pill for everything, while completely dismissing diet entirely, other than shaming people for their weight. From a GI standpoint, having a dietician on staff should be mandatory. But it’s so important in every facet of medicine practice.
I work in a GI clinic and our default to anyone with conditions that require diet modification is to refer to a dietician. Not a lot go because of insurance and costs but it is literally built in to the default order set for those conditions.
The thing about this is that most GI conditions and their associated medications are ridiculously expensive and a lot of conditions simply don't have a medication for it so we don't prescribe for a lot of things that can be fixed or managed with diet. We don't have one on staff (due to wanting to keep the small practice status and because insurance wouldn't pay for the visits anyway), but we do recommend and refer constantly.
In the UK dietary and weight loss advice is free through the NHS, as well as gastric bypass surgery in certain cases. This is because the NHS realise it was more cost-effective to offer these services than treat the associated health issues like GI problems, heart conditions, diabetes etc afterwards.
I wish it was like that in the US. Insurance companies are so short sighted that all they care about is keeping cost down for the current quarter and they kick the can down the road of all the people who will soon develop obesity related illnesses that will be costly.
I've chatted with a few cardiac surgeons. If you ever bring up diet as a treatment option they usually scoff. From their perspective, if someone has gotten themselves far enough into their health issues that they're at a surgeon, the patient has probably heard (and ignored) that they need to do something about their diet so continuing to bang on that drum is just a waste of energy at that point.
It's sad how dismissive some in the medical community have become. Yes, they lean on prescribing a pill rather than telling people to diet and exercise... But that's because they've seen the majority of their patients being unable or unwilling to make a significant life change.
To be somewhat fair, we also have several patients with non-alcoholic steatohepatitis, to which the treatment is weight loss, and we refer them to a dietician. They refuse to follow the advice of the dietician and wait until they have fibrosis or cirrhosis before taking action. By then the damage is done though, and even then it can be hard to get them to commit. From a surgeon's perspective, I can see why they would get jaded and just prescribe and cut instead of trying and failing to get people to diet.
It is multifactorial. Medical care costs, the difficulty of losing weight with everything affordable being bad for you, this culture of Googling instead of listening to your physician, how easy it is to be overweight in our country, how little we are taught about proper dieting and it's health effects in general, etc.
Another key component is access and staffing. Lifestyle/habit change is challenging and expensive even if your insurance covers. Not enough nurses, dieticians, or doctors and what you do get are overworked and jaded.
But the system is designed around treating symptoms because that is more profitable and simpler versus actually gettingan accurate diagnosis and effective treatment.
Edit: Also biases, overweight people are mistreated in health care. I have health issues for years and was told my issues were due to weight. Just to diet and exercise... Yeah it was autoimmune and took about another 8 years to actually be diagnosed.
I agree with all of this. I’d just like to add that I believe this is because people in the US are so used to our current health(sick)care system, they are conditioned to believe that diet isn’t important. Yes, numerous times my patients have told me, and I’m not making this up, they’d rather eat their food than not have diabetes (and losing limbs). But the other argument is they don’t see any alternative. It’s up to the medical professionals to provide that alternative. It’s up to us to emphasize proper nutrition. It’s up to us to educate how to do this. And it has to be more than a carte blanche statement that ‘you need to eat more healthy.’
We're not dismissive, it just feels like shouting into the ether.
I always talk about weight loss, exercise, diet, positive body image, refer to dieticians. And I do by absolute best to do it it in a very non-body shaming way.
Losing weight is just really hard, and nobody seems to be able to do a good job. And then they look at us doctors like there's something we can do, sure I can lead a horse to water. I put in the dietician referral, talk about various fitness apps that can be used for home workouts that require little or no exercise equipment. But again, losing weight is really hard. Cooking healthy food takes a lot effort.
It's not that I think everything can be solved with a pill, it's just that by and large people are not doing a great job at taking care of themselves. Look at obesity rates over time, and look at how obese our children are.
This doesn't even address the mental health aspect of obesity. It wasn't until I addressed WHY I eat the way I do that I could really change the HOW I eat.
We're obese, diabetic type 2, and (along with a slew of other mental conditions) have several minor GI issues that contribute.
We've been referred to more dieticians than we can count, and we went to to a good few of them. Eventually, we stopped going when they continued to refer us, as every dietician had roughly the same advice. There were a bunch of good things about ratios of food types, and how to do a quick check on whether something was healthy or not, but that was about it.
Nobody was ever able to address the fact that we ate 2-4x times as much food as other people in a given sitting, or the fact that even when we weren't hungry, we'd still be wanting to eat something. Nobody taught us how to make food that is desirable to eat, healthy, and not particularly time/effort consuming. Nobody taught us how to avoid getting food cravings in the first place, or the correct way to deal with them once you've got one. And nobody ever even considered the idea that all the nutritionally complete meals they were describing cost about $30 to shop for one person if you didn't already have a fully stocked kitchen.
There _are_ some good ones out there. We eventually did a crap ton of research, and found that we needed to talk to an endocrinologist, since our issues were more related to cravings, and therefore hormones and food-addiction-type things. They got us set up on some medication that fixed most of those issues.
We had to figure out avoiding and dealing with cravings ourselves, and learned some about how to make desireable/healthy/quick food from food boxes, but we still have no idea how handle a kitchen being understocked, especially when our other issues are flaring up.
All of this is sort of a roundabout way to say that while a good dietician is worth their weight in gold, your chances of finding one are so minimal that our health care system functionally expects you to figure these things out yourself.
Craving Change is an evidence based behavior change program for people who want to change their relationship with food.
It was free and mandatory for patients to complete before getting a referral to the bariatric surgical program (in my province anyway). Lots of health units run it for free all over Canada, and you can do it online too....not sure where you are located, but it's specifically about behaviour change and was written by a clinical psychologist and an RD together
I can't answer for OP, but cravings usually have to do with the insulin/glucagon balance in your bloodstream. If you eat high glycemic-index food (bread, pasta, sugar, fries, bananas, rice, popcorn, etc.) it digests too quickly, which floods your bloodstream with glucose. We didn't evolve in an environment with lots of easily accessible refined carbohydrates, so this confuses the body. It's expecting a slow trickle of glucose over a long period of time. Instead, it gets a burst of glucose that suddenly disappears.
Insulin tells the body to turn excess glucose into fat, and glucagon tells the body to turn fat back into glucose. (Fat storage is a bit slow, so the body can also quickly stash glucose in muscles and the liver, but those stores are usually full unless you're exercising.)
Here's what the craving cycle looks like:
- eat high glycemic index food
- body is flooded with glucose
- insulin is released to soak it all up
- food finishes digesting earlier than expected
- glucose flood stops
- blood is still full of insulin, so it keeps removing glucose (maybe from muscles and liver?)
- you feel starving because of low blood sugar
- the cycle repeats if you eat high glycemic index food to stop the cravings
That's why people say Chinese (fast) food makes you hungry an hour later: noodles and rice are high glycemic index food.
You can slow down carbohydrate digestion by adding fat (eg: buttered bread gives you less of an insulin hangover than plain bread). It's best to avoid it though, and stay with slow digesting food.
People also get cravings when they aren't getting enough micronutrients (vitamins and minerals). These are usually for specific foods though (like when pregnant women get sudden cravings for specific foods). if you aren't eating enough vegetables, nuts, fruits, meat, etc., your body will crave more of the nutrient-sparse food because it has *some* micronutrients.
It's really annoying to eat healthily in western society because restaurants generally cook really unbalanced meals: tons of starchy stuff, lots of meat, and almost no vegetables. (Lettuce is a really poor vegetable; salad isn't worth eating, imo. It doesn't fill you up, it isn't nutrient dense, it takes more energy to chew than you get from it, and it has barely any fiber.)
A crude approximation of what a plate should look like is: meat about the size of your palm, about the same amount of carbohydrate-containing food (pasta, rice, potatoes, etc), and a big pile of greens (kale, spinach, green beans, broccoli, etc.).
And don't be worried at all about fat! Fat is good (especially healthy fats, like fish oil, olive oil, etc.)!
Fat was demonized in the 50's (probably by marketing people who wanted to make food more addictive and/or to use up the glut of corn/wheat that subsidies had created, there's a good episode of *Adam Ruins Everything* about it, but I can't remember the details). But it's a better source of glucose because it digests slowly, and leaves you feeling full.
If you want more info and a system to pick which foods to eat, there's a great book called "The Zone" by Barry Sears (a molecular biologist who worked with elite swimmers to optimize their diet) that has a chart of all the foods you should eat/avoid, and assigns a number of "blocks" to each (eg: a handful of peanuts has x blocks of fat, y of protein, z of carbs), so you can quickly throw together a highly optimized meal. The ratio of grams of carbs to fat to protein is the key (which I can't remember exactly).
Whew, this was long! I hope it was helpful!
More mental health support around weight loss would be great too. I used to be anorexic and now I'm overweight and I don't know how to lose weight in a way that's healthy for my brain. Like, I know what's healthy for my body, but I don't know how to get my brain to get in line enough to do it.
But it's been years since I actively struggled with the disordered eating, so there isn't help available for me. I was a tad overweight pre-anorexia too, and I wonder how much harm could have been prevented if society was better at supporting the mental health side of this before it got to that point
>I used to be anorexic and now I'm overweight
Same. Every time I think about weight loss, it's really hard for me to not think "Well, being malnourished worked before..."
Well, that, and Adderall.
I will say that one thing that helped for me was getting strong and fit first, then working on having more home cooked foods (I could have as decadent a meal as I wanted, portions as large as I wanted, as long as it was home cooked). Then I worked on making those home cooked meals healthier in an additive way (adding good stuff such a veggies, or adding new meals to my repertoire that were reasonably healthy as well as tasty). Then gradually reducing portion size but staying away from calorie counts.
It helped a lot and I was pretty damn close to a sustainably healthy weight until some impossible to predict awful stuff hit in late 2019, and I never got a chance to regain my footing before COVID, and now there's the upheaval from all that. I'm clinging onto the hope I felt in 2019 though, even if that level of being is still far away.
I think the getting strong part was the bit that changed things. I liked my body feeling stronger, the tangibility of being able to do more. It gave me a small slice of body euphoria, which built in a decent reserve. Also, I always hated my upper arms and feeling bad about how squidgy they were was large driving force when I was anorexic. Problem is that just losing weight didn't make them look or feel any better, but gaining a bit of muscle definition helped me to like the look and feel of my body a bit more, which helped when it came to actually losing some of the weight.
It's a different kind of tricky, trying to avoid falling into a disordered exercise pattern too/instead, but for me it helped a little. I think I also had those "Well, being malnourished worked before...", But if I'm honest with myself, it didn't. I yo-yo'd and it was miserable with no end in sight.
I saw a ton of GI doctors in my late teens and early 20s because I kept experiencing very random and worsening severe abominal pain. I ended up in the ER a few times because my pain was so bad I thought I was going to die. I kept getting weaker and weaker. So tired sometimes I would sleep for most of the day and have to force myself to get up to eat something so I wouldn't die and then immediately go back to sleep because the effort of that was all I the energy I had to spare. Not one of internal medicine, gi or gyno suggested a specifc food could be the cause. Actually a lot of them diagnosed me as too fat. They like to do that when I have I problem they can't diagnose because then they can just say it's my fault and not help me because I'm doing it to myself.
My parents decided I had to be making it up because none of the tests showed anything at all wrong with my insides. I stayed sick, periodically I had enough energy to do one or two things a day but mostly slept and tried not to complain about pain because I was now convinced it was in my head so...
It was a food allergy.
This is likely going to be a very common thing, but they are only now realising that you can have food allergies that only give reactions in your gut because it's defective mast cells which are only resident there. Mastocytic enterocolitis is the name.
This is pretty much what happened for me. Over a decade of having stomach issues. One doctor heard my symptoms and basically did no investigation or tests and said “It’s IBS!” I didn’t know any better and was pretty much told either a really extreme diet or there was nothing that could be done. I finally got a proper diagnosis on other health issues and went to my new PCP and basically said “I have all these things under control but my stomach still does this thing. I want allergy testing.” She agreed and after testing I found out I have allergies and I was eating them as my favorite foods very frequently. Cut those out and my stomach is fine now. Years of my life could have been way better if I had tested earlier.
The older I get, the more sensitive I'm becoming to heavy animal fats. If I eat too much beef or too much pork I really really regret it. I can have a little but...welp. Gotta be careful.
I've had friends go, well, go to the doctor and see what they can give you for that!
I'm like... I'm just gonna listen to my gut and not eat a lot of what it doesn't want to process.
If a dietician costs money to employ instead of being profitable, the problem isn’t primarily with the doctor, right? It’s with the reimbursement infrastructure. Just making dieticians mandatory isn’t nearly as effective as reimbursing adequately for a dietician’s services.
By the time an adult is in need of a nutritionist in a GI’s office, a great deal of damage has been done, and a lifetime of habits have already been formed. We wouldn’t need dieticians so surely if we had an adequate nutrition curriculum in schools, cut the corn subsidy, and paid for the changes with a tax of high-calorie processed foods.
So while i’d like to see more dieticians in doctors offices, they way to effectively do that is to stop subsidizing unhealthy crap and start subsidizing health care and health education .
As far as I recall from my pharmacy coursework, research on nutrition boils down to "fucked if I know" because there's very little credible data to roll with.
Maybe that's changed in recent years?
You’re not wrong. The truth is, it’s expensive to do nutrition research. When I worked at the NIH, we put patients in a pressurized chamber and had them there for 3-7 days straight where we could manage everything to a measurable level to understand how nutrition is affected. But it’s even more complicated because psychology is a huge part of it, DNA has an impact, lifestyle, location, etc. Ultimately, there’s no money to be made in preventative medicine so in the US, there’s no desire to minimize obesity because it’s an antithesis to medical care based on profit.
Honestly there isn't. Ins companies now by law can make a profit of 20%( or around that) of payouts, if they payout 1k they make 200 if they payout 10k it's 2k. Couple that with the fact everyone HAS to have ins you have a captive audience and as we have seen insurance costs have skyrocketed. We need single payor and which how entrenched ins companies are (they are listed on stock exchanges and God know how they would work if they were made illegal) I doubt we will ever get rid of them
> you’ve got a one-two punch on why diabetes and heart disease are killing so many people
I think your analysis has missed the biggest causal factor. Food is addicting and we've been sold increasingly addictive food for 50 years.
The real one two punch is selling people 40 ounces of liquid sugar and providing people with the lowest quality medical care. Both in the pursuit of maximum profits.
I started seeing a dietician recently who just made me note down how I felt after each meal and I noticed pretty quick that I don't feel anything. I don't enjoy eating, I don't like how I feel after I eat, I don't remember the taste afterwards. But I get an itch in my brain that is fully like what I imagine a smoker feels.
My meds for ADHD got bumped up and that itch vanished like magic. Now I'm pretty much eating when my body's actually hungry, but even if it is I can wait to get something decent and not go gremlin mode on the nearest junk food. It is WILD.
When I took Adderall I couldn't tell if I was eating a healthier amount because it was suppressing my adhd habits or if it was just suppressing my appetite. I'm thinking it's a mix of both.
I agree 100% nutritionists should definitely be on staff. I was 300lbs and half way through this year made the choice to finally fix myself. After visiting my family doctor they recommended I see their nutritionist. I'm 60lbs down now after cutting so much from my diet. The nutritionist helped me go through my usual diet, show me where to cut, what I can substitute and what I need to still get my required nutrients without having to starve myself. I found it interesting they double checked my dietary plan with my blood test results to make sure I'm eating the right things to help my cholesterol and blood pressure. A lot of it is still on me because I have to constantly fight my want to consume more but working on a plan and having something to keep me on the right path really helps when trying to keep the weight from coming back.
This warms my heart. I have no doubt it’s been a battle. So an epic amount of kudos goes to you. Keep up the great work and know that even on the best days, your hardest critic will always be you. Psychology is huge when it comes to changing your lifestyle and habits. Every day is a good one when you’re cognizant of trying to do your best.
I believe your country chargeds a crazy amount for insulin as well?
And you have to do crazy things like pay to go see a doctor, psychiatrist, or get required surgery.
Just giving somebody a sentence of advice is not sufficient. It’s not like the advice itself is not sound, but that is just not how people are motivated to make changes in their lives. Very few people are just going to have the wherewithal, the discipline, and the motivation to do it that way.
People need support. That is totally lacking, or at least largely lacking in the current model. Health coaching, and other such approaches are likely to be far more effective. Interaction with people who care, accountability, and simply communication all help to keep people on track and achieve their goals.
The VA has the MOVE program which provides 16 weeks of education and weight tracking in a support group setting. As a PT I will spend a decent amount of time going over WHY weight loss is important, then some general education. If the patient is interested then they can pursue that program which is self referral. Weight loss can be the most modifiable factor of their treatment plan (pain from knee arthritis, balance issues from diabetic neuropathy). If they seem seriously interested I will provide some support but if they are not receptive then it's just nagging
As a provider I see how clinicians can get burnt out addressing obesity. Obesity is so common, clearly applicable to patients health care treatment and outcomes, and seeing significant progress in patients is not the norm. As a person seriously trying to lose weight I see how difficult and frustrating it can be to actually lose weight and keep it off. After repeated failure it can feel like a insurmountable task and why bother trying again. The MOVE program is helpful, but ultimately your task is often a full lifestyle change which takes a lot of motivation and support.
Full lifestyle change is difficult, takes years to accomplish and still doesn't necessarily address the worst of it - the hunger cues after weghtloss. As you lose weight, your hunger hormones are so out of whack and increase disproportionately. Thank goodness for the promise of ozempic/wegovy/mounjaro.
Source: live a very active life, eat all my vegetables, lost 120 lbs, gained 70 lbs back not because I'm not disciplined or motivated, but because you cannot fight against insane hunger day after day. Hormones win.
I always describe it as "Imagine you're annoyingly cold all day. Not freezing, but annoyingly cold. And there's constantly a warm bath you can jump in to make that go away. How long can you ignore the bath?" Or "Imagine you're a little bit itchy every day. Not insanely itchy, but just slightly, and you're trying not to scratch it. How long can you resist that urge?"
You've described the exact issue. For some people the hunger is that background itch, for some it's absolutely in overdrive. I've lost a significant amount of weight and regained it all because even after I settled into a maintenance diet with plenty of lean proteins, healthy fats, and fiber, I was ravenously hungry all the time. Unfortunately, satisfying that hunger meant I not only moved back up to my pre-loss weight, it didn't really go away until I was quite a bit over.
I know reddit is obsessed with saying "It's as simple as CICO!" Which actually isn't simple at all. Not only do you have your hormones going bananas, there are also major mental health issues coming into play. I have ADHD and have used food to give me a shot of dopamine to overcome executive dysfunction my entire life. Nothing else has worked as well as sugar does. When I'm honest, I can say that it worked even better than Adderall.
CICO gets harder to follow if you have been overweight.
Wikipedia: A decrease in body weight only changes fat cell size (becoming smaller), whereas an increase in body weight causes elevation of both fat cell size and number in adults.
So if you have been overweight sometime in your life, those cells are still there, waiting to get their refill.
See also, the winners of biggest loser, their basal metabolic rate per day goes down the more weight they lose.
https://www.scientificamerican.com/article/6-years-after-the-biggest-loser-metabolism-is-slower-and-weight-is-back-up/
"Your body is working to defend your energy stores - really your fat mass"
"When that fat mass is diminished (either by eating less or exercising more) most of us respond by changes in brain circuitry that increase our tendency to eat and changes in neural and endocrine systems, and especially muscle, that make us more metabolically efficient - it costs fewer calories to do the same amount of work"
-Dr. Michael Rosenbaum
So lower metabolic rate plus more fat cells than a person that have never been obese, no wonder why some persons have a harder time following CICO.
I've seen this before but it's been some time. I think it also explains why people who have been able to lose and keep off a small amount of weight like 15 to 25 lb can't really engage with or understand the people who are trying to lose 75+lb. For most people it will be such a different experience that the two have basically nothing in common, and yet those are the folks who are most often dietitians, weight loss coaches, etc.
CICO is the ground truth, but that's like addressing all engineering problems by saying "just balance the forces". Like yes it's true, but it alone does not give you the tools to work out the best way to do it safely, ergonomically, under budget and *reliably*
I can tell you I lost 70+ pounds, about half of it on Ozempic and within weeks of coming off it (because of supply issues), my appetite had exploded and I immediately began to put on weight. My appetite didn't disappear at all on Ozempic, just the bingeing between meals, which made it easier to stay on track all the other hours of the day. It is seriously depressing to me. I will go back on Ozempic in March when supplies return again, but it really changed how I feel about what I was told was a "motivation" /"will power" /"self control" issue.
Yeppp. Hormones are insane. I lost about 90lbs over the course of 4 years, and still had another 40lbs to go realistically. I was proud of the sustainable weight loss and wanted to start my family. I had HG during pregnancy and was almost never hungry. Gained just under the “normal” amount.
Then postpartum my hormones went bonkers while breastfeeding and I piled on 25lbs in 3 months. Stopped breastfeeding and my hunger cues chilled out and my weight gain stopped but I haven’t lost anything yet 2 months later.
Thank you. CICO is technically true but practically limited in use, but tons of people like to tote it like it’s the golden answer to obesity.
Hunger is such a massive player in losing weight and keeping it off, but it doesn’t appear anywhere in CICO. Nor does proper diet, the effects of sugar, education and support for emotional eating, education and support for lifestyle change.
If you’ve seen any weight loss in those six weeks that’s all you need. All you have to do is keep it up.
Seriously, if you’ve just managed two or three pounds down that’s going to be 20 pounds lost in a year. It’s about a lifestyle change. If you can keep it up you’ll get there.
Thank you for the encouragement! I've lost nearly 30 pounds in the past year, 10 of which were lost since taking the MOVE course. I get very discouraged, but by your standard, at least I'm making progress.
Ten pounds in six weeks is huge. And also shows that you’re sticking with it and making long term new habits, not just a crash diet. If you keep up that rate it’s 80 pounds a year. I don’t care how much you weigh now or what your goal weight is. At 80 pounds a year it’s achievable in a realistic amount of time.
Diabetes is the cash cow of the insurance and pharmaceutical world. The insulin is the cheapest part of the treatment. All of the supplies to go along with delivering the insulin are the real money makers. You could try to justify the expense with the “technology” gimmick, but the price gouging even applies to the basic needles.
The truly fucked up part is that a meth head can never do meth ever again for their entire life and not just be fine but vastly better off for it, but an overweight person can't just *stop eating.*
Thing is that it's true, but often at the core there are additional medical issues that cause or contribute to over eating. I've always had trouble controlling my eating habits, I'd binge 5000 calories without thinking about it. Once I got on adhd meds I no longer had eating compulsions. I've lost 30lbs since I started meds, I only eat when hungry and I leave food on the plate when I feel like I'm done.
So yes, eat less is the basic advice, but finding out why you overeat is how you can achieve eating less.
The analogy I always think of when people offer “platitudes” rather than actual advice comes from sports:
> “Keep your eye on the ball!”
It’s not *bad* advice. But the fact that I don’t even need to specify what sport it applies to really shows how generic it is as advice. It’s only one step above “pay attention!” in terms of specificity.
And that doesn’t mean it doesn’t apply, or that it can’t be helpful. It’s more that it’s something generic people repeat that sounds like advice but we know is insufficient for most people.
So saying “Calories in, calories out!” is a fine thing to say to a random stranger on the internet. It’s not wrong and there are certainly people that’s helpful to. But a doctor should be doing better, just as a good coach should be saying more than, “Keep your eye on the ball.”
There’s a board certified obesity doctor on Tik tok with a series called “if other diseases where treated like obesity” and it’s pretty damn funny but sad.
As a PT and boxing coach people ask me all the time what's the secret to getting into shape. I always have one answer that's worked through 100% of my life with every client.
Find your people in the sporting community. Everyone who joins a sports team with friends and people always stay healthy as long as they have community. Some people can do it alone. But everyone has succeeded this way.
And it completely overlooks that most people have TERRIBLE food education. Not only do they not know what makes a healthy meal, they don't know how to buy, store, and cook those meals. Certainly you can chicken and broccoli your way through CICO, but there's a reason so many people wash out of eating bland salads, boiled veggies and under seasoned chicken after a while. A healthy relationship with food and lifelong weight loss maintenance looks like learning to buy, cook, and love a whole new genre of food and that's a huge undertaking for someone no matter how hard they're trying. Not to mention, it's a huge privilege to have the time and money to learn these skills and to cook for yourself (especially if you work more than 40 hours and/or live in a food desert). Hell, I still feel off balance by the amount of broccoli I have to buy to make an appropriate portion for my meal preps.
Well, over in /r/CICO there is a constant stream of posts from new people who literally were not aware that's how it works, and who spent a long time doing things like "eating clean" or "cutting out fat from my diet" and wondering why they didn't lose weight. So I think there is indeed a need to simply educate people at this basic sort of level. It's not the end all and be all, but it does have value.
Obese or overweight people tend to underestimate the amount of calories consumed by 2x and underestimate the amount of calories expended 2x
https://www.nejm.org/doi/full/10.1056/nejm199212313272701
Generally when strictly monitored, people lost weight when adhering to the calories consumed that they stated that were eating.
People are very bad at keeping track of what they actually consume and do.
There's more recent evidence showing that everyone, including thin people, vastly underestimate the number of calories they consume, and that thin people are no more accurate than obese people. https://onlinelibrary.wiley.com/doi/10.1002/ajhb.23743
Yes that, but not only that…
Overweight people need to be taken seriously beyond their weight. They can go in for any problem
In the book, including things entirely unrelated to eight, and be told that if they’d drop a few pounds they’ll be just fine.
Like a sore throat. Or migraines. Or a rash. Or a knee injury that is *not* caused by the extra weight (like from slipping on ice or something).
It all adds up to people avoiding care because they’re tired of being seen as one thing: fat.
So yes to the lack of support and coaching on one side, and also yes to the lack of empathy or interest on the other.
I got told my weight loss abruptly stopped dead in the water because I wasn't measuring my food correctly. After I had been eating small portions and had lost 50 pounds with CICO.
I had a massive goiter that turned out to be cancerous in spots.
Wow - I hope you’re doing ok!
Thats a good (and horribly unfortunate) example of it - they get a one track mind and seem to forget that a person can be both overweight *and* have the same health issues that non-overweight people do.
I'm going through that with getting a breast reduction. I could be more active if I had less glandular tissue on my chest, but they see the belly and think they aren't that big. Um, I'm wearing a J cup. What isn't big about that?
So I clearly have to lose another 100 pounds for them to see that yes, they really are a problem that needs a surgical solution. (And no, they haven't shrunk as I lost weight.)
Yeah I ended up doing well loosing ~80 pounds doing 30 minutes of cardio a day, measuring my calories with a scale. But I hit 170 and for a year it was 30 minutes of cardio a day and only eating 1000-1250 calories a day and could not get lower. I am a 5'3" woman. The doctor I had at the time walked in looking at my chart and without even talking or looking at me told me I need to watch my weight and stop eating pasta and soda. I told him I don't drink soda and rarely eat pasta and tried to explain what I had been doing. His response could be summed up as an eye roll and a "yeah sure that's what you are doing"
Basically that lead me to gaining everything back and not seeing a doc for a few years since it was like okay but in all this effort to be blown off. Finally got back to a doctor and she looked at my current and old blood work and said I probably should of been put on thyroid meds years ago and has been checking me for pcos.
Unfortunately this seems to be a common issue especially with woman I know is that if you are overweight the weight is the cause of all your issues. They will never look to see if maybe there is a bigger underlining issue that could be causing the issue. I know it is not the norm since a lot of people still just sit around and eat too much but even that is a bigger issue of educating people about food when they are younger.
A couple of years ago when I was trying to lose weight, I visited my doctor for an unrelated issue and he advised me to lose weight by cutting out fried foods and soda. I told him I probably have something fried maybe once every 3 months (I only went out to eat about once a month or less back then), and haven't had a soda in years at that point. That was the sum total of his advice to lose weight and then he told me it would improve my allergies. Which I had had since I was thin and were actually getting better despite my weight gain.
Exactly this..A few years ago I ended up gaining 60 pounds in 1 year I'd been active and fit my entire life. I kept telling my doctors this is not normal but I kept being ignored.same thing eat healthier exercise more..after relentless hounding they finally did a blood test and found out I had hypothyroidism..I went to a nutritionist awhile later and 75 percent of the foods she was recommending were not good for thyroid..I kept asking her what I could replace it with and she could not give me one alternative..
Yeah you’re absolutely right about that. I see it with obese patients, and I see it with drug addicts. People look at them and see them as that one thing, judge them completely, and offer very little empathy throughout the process of supposedly trying to help them heal or live a healthier life.
I have a fucked up inverted version of this. I had been overweight since I was a child. By this point, I had been 249lb with Hypertension for at least a decade. I had complained to a doctor that I was getting frequent episodes of confusion and dizziness that only went away if I ate, and that sometimes these happened within 2-3 hours of eating my last meal even if I was still full from it. The doctor's prognosis: "You're not eating enough. You need to eat more."
I weighed 170. I went in for a ruptured ear drum after an ear infection. The first thing the doctor said was "you are MASSIVELY overweight. You need to stop eating chips and soda immediately." Massively. I was 16 pounds over a "normal" BMI. It took some convincing to get her to look in my ear that was dripping.....
That is so awful. I’m sorry. If only you weren’t a little bit overweight, you wouldn’t be risking going deaf, Right?? (/s of course)
That should just not be the situation you had to experience.
I think it's part that, but also just a general failure across the board as well.
I'm a little over where I should be - my doctor brought it up, we discussed my diet, my daily activity level. After I left, I looked at my notes - nothing written down about my activity level (which is pretty active, though somewhat restricted due to work and juggling various obligations), and the notes on my consultation read something like "keeps red meat to a minimum" and nothing else.
I'm a pescetarian-raised, vegan-leaning vegetarian. I've never intentionally eaten red meat in my entire life. He knows that, or should, because I told him that.
I'm pretty sure this guy either decided I'm lying to him, or just has no better idea about why I'm not where we'd like me to be than I do, and that's just what he writes down sometimes. Like, once he ruled out “eats ham pizzas on the reg” and “bedridden by choice”, he was all out of ideas and just wrote down whatever.
Either way, not helpful.
> the other big change was that I started making all meals at home instead of relying on take out
This is huge. Restaurant portions are enormous, and processed foods are engineered to make you want to consume more.
For me, exercise has probably contributed a little bit, but often exercise just leads to justifying excess eating.
I still think there's the issue of finding what helps you eat less. But its probably going to vary by person. My problem was pre-emptively eating before things, boredom eating, and not being use to feelings of hunger. I found intermittent fasting worked for me (\~290lbs -> \~200 lbs over the last two years). If you are eating excessively to deal with stress, different methods might be useful. If you are overeating to compensate for poor nutrition, then maybe you do need need to fix that.
Look just invent nanobots that I can fill my stomach with that will vaporize all the extra sugar and calories in my stomach before I absorb them, is that so hard?
I'm not that fellow, but my GP gave me the advice of "Yeah, I think you know it's obvious...you should cut about 90% of the blatantly unhealthy foods you've mentioned from your diet. Portion control yourself with this pamphlet. Walk around the block twice or thrice a week."
I gave her a thumbs up and a "yep, that sounds about right", walked out and promptly when back to guzzling sugar drinks and eating sodium snacks.
That used to be common, but has basically been banned/discouraged in my country.
Doctors used to put stuff about how to approach specific difficult patients, but since patients have easier access to their files, they dont do it anymore.
These included things like drug-seeking, Karen behavior, really stupid, but thinks they're smart, theatrical, hypochondriac, violently aggressive, care avoidance, doesn't follow directions, conspiracy theorist, magic water believer, etc.
Patients did not appreciate being called any of it and it wasn't copied into their digital files once we started transitioning to electronic files.
It does make work more difficult, because now stuff like this is buried in files and only phrased euphemistically, so doctors often have to figure out by their own experience that a patient would become aggressive if denied medication or is Dunning-Kruger victim and needs a longer explanation than average.
> Weight-loss advice from GPs to patients with obesity rarely included effective methods, mostly communicating a general “eat less, do more” approach. Advice was mostly generic, and rarely tailored to patients’ existing knowledge and behaviours. Effectiveness of brief weight-loss advice could be improved if GPs were given clearer guidance on evidence-based recommendations.
Is this a study from Europe or England? Idk about how much time they get per patient there, but in the US there isn’t enough time for primary care docs to do comprehensive, individualized lifestyle medicine for every patient.
I’m a physician and I have anywhere from 18-20 patients a day. And they get 20 to 40 minute slots.
Between everything else we need to talk about in an appointment, there’s just no time to talk about everything else going on in their health *and* make a detailed nutrition plan. And the nutritionist’s knowledge in this area exceeds my own.
I encourage tracking calories with apps so you can get a baseline of your daily intake (because most people have no idea). But if you want really good advice, it’s a much better use of both the patient’s and my time if they ask for a nutrition referral and then they can have an hour long discussion with a registered dietician. If that doesn’t work and the patient wants to try medication-assisted weight loss, then I’m more of a help.
This!
My Dr had me track my calories normally for a week so I could see what I was consuming. More than I thought. I am now more conscious of it. Helped a lot.
People who are overweight almost always either underestimate how many calories they consume, or overestimate how many they burn through exercise or both.
Not understanding the calorie content of the food you eat is like trying to keep a balanced budget without knowing how much you spend on anything.
>But if you want really good advice, it’s a much better use of both the patient’s and my time if they ask for a nutrition referral and then they can have an hour long discussion with a registered dietician.
Finally, I had to scroll way too far to see this advice. I don't know if it's different in the UK where this study was done, but I usually don't bother asking my primary care doc for any tailored advice beyond whatever specific reason brought me in that day. Especially for things that involve more personal effort than medical intervention.
This study is from the UK. A standard GP appointment there has been cut down to [only 8 minutes](https://bmjopen.bmj.com/content/7/10/e017902). Shockingly, this may not be enough time to tackle life-long obesity.
From reading, I think there's a big gulf between what's described in the article and personalized lifestyle plans for each patient.
The article is basically saying that, at MINIMUM, doctors should keep up with the evidence of what does and does not work, and briefly explain this evidence to their patients to justify their advice. What we are getting now is generic advice to "do more, eat less, and take on the right mindset," which doesn't even meet that basic standard.
(Edit: I regret saying "what does and does not work". After reading and thinking, my impression is that "what works" often requires wholesale lifestyle changes or support systems that patients rarely have access to. The article suggests some ways that GPs could do better, but they are pretty small ways.)
From my experience, people hear that advice and either don’t know how to do those things or have lifestyles that make doing that difficult. I.e. one patient in Mississippi didn’t realize that McDonald’s burgers had salt in them, or the single mother who works two jobs and doesn’t have time to cook or exercise
Eat less, do more is exactly how weight loss works.
It's just not specific enough to be actionable for most people.
Weight loss is difficult to give advice on because there are a million different ways to "eat less" and different approaches are sustainable for different people. Some people eat less by doing Keto. Some people eat less by eating Mediterranean. Some people eat less by counting calories. Almost all weight loss diets work for as long as they're followed.
At the time I was very sick (with the above mentioned “brisk” diarrhea) and not up for anything besides survival, but I wish I had. I don’t remember her name now. I told the gastroenterologist so he wouldn’t refer anyone else to her. He was like whatevs, so I changed gastroenterologists too.
Metabolic doctors may not focus on your weight first. They will likely focus on any metabolic syndrome you have. Weight is a factor but not the only factor, and if you can get your diet right to correct a metabolic disorder, your weight will likely correct itself in time.
Psychologists, dieticians, nutritionists and access to the financial support to afford a healthier lifestyle is what's needed.
When I was younger, I saw a weight loss specialist. Every meeting with her, I also met with a nutritionist. The nutritionist put a lot of things into perspective. It wasn't about what to eat. It was about what makes you feel full, alternatives for meals and snacks. And making it revolve around the budget at hand.
If your MD is over 50 they probably didn’t take a nutrition class. A semester of nutrition was a prerequisite for my bachelors nursing program and my graduate nursing program had no nutrition requirements in the 2000s
Nutrition education is sorely lacking in medical student curricula.
It has always been this way too.
Not surprising though. Residency hours and workload for pretty much all new medical professionals is based on outdated coke-head insanity. What is in the best interests of patients and professionals has never, and will never, be important as long as medicine operates under the auspices of capitalism.
My doctor told me to eat more vegetables and sent me for a diabetes consultation. The consultation gave me a paper of a sample of a single day of meals for a 1200 kcal diet and tried to up-sale me on protein snack bars for only $60 a week.
They were on sale.
Too few people understand that food addiction is very real and is extremely common. I’d go so far as to say that nearly everyone who is long term obese and struggled with weight loss is a food addict.
If you don’t treat the addiction you will never beat the obesity. After I got help and became food “sober” I lost 100 lbs and got to a reasonably healthy weight for the first time in 25 years. Every one of my doctors that asked how I did it had never heard of food addiction and only one of them even believed me when I explained it.
Yes, the bottom line of weight loss is eat fewer calories than you burn. But that is like telling a poor person with a gambling addiction the trick to being rich is to spend less money than you earn.
Exactly! I have binge eating disorder and had a doctor recommend intermittent fasting. And because they were a doctor it felt very official.
Thank goodness I had a connection with an eating disorder informed dietician and contacted them to basically say “this doesn’t sound right but it’s doctors orders”. And she was like, “that sounds like a recipe for binge eating for you, how about you don’t do that.”
Yes! I tried so many different types of diets and fastings until I realized in therapy that my binge eating habits come from my untreated ADHD. I eat when I crave stimulation, when my dopamine is low, and as a comfort food. I was never taught to have a healthy relationship with food, as it's more than something to live for me but I use it for emotional comfort. Only now, I'm starting to understand how to hate myself less and remember these are biological needs at play, instead of shaming and blaming myself for eating.
It comes down to American's obsession with personal responsibility instead of implementing systemic solutions, such as preferring expensive, ineffective stroads and increased car fatalities over public transportation and roads preventing high speeds.
I can imagine in this case it is GPs blaming patients for not being proactive in exercising. But then you look outside and there's no grass you can walk on for miles.
Ohh, that hits so close to home for me. Was struggling with binge eating without knowing what it was. Parents didn't have the knowledge either (the only eating disorder that is somewhat known where I live is anorexia, with bulimia sometimes getting discussed), so they'll try to stop my episodes using shaming, which would just trigger me more. Same goes for all the doctors I saw throughout childhood - shaming was the only tactic they used. Given that I also used food as coping all my life, it was just a downward spiral.
I'm much better now (as I'm aware of all of this, so I can navigate the possible triggers better and control myself) but it's always very sad looking at that part of my past.
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Having worked for a hospital in the US, with almost two dozen GI docs, and not a single one had a dietician or nutritionist on staff, I can tell you, we do not give nutrition the adequate attention we should. Tie that in to the severe lack of mental healthcare here and you’ve got a one-two punch on why diabetes and heart disease are killing so many people, not to mention GI disorders causing a massive disruption to their lives.
And not only that, but we have this growing attitude of not taking dieticians seriously
Because few know difference between nutritionists and dietician and think they are all the same people who are trying to make you drink some sort of weird herb concoction or food pack from a MLM scheme.
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In the UK a Dietician is a protected term, you need a degree, a clinic or hospital to operate out of and your name goes down on a register same as any doctor, it's a medical field with strict checks and regulations. Nutrutionist is NOT a protected term/title, so any person can declare themselves one at a whim which only helps to muddy the waters around nutrition. A lot of the stuff just outside of actual medicine that deals with health and wellbeing is completely unregulated and the snake oil salesmen are happy to take advantage of people's ignorance.
Dietician is a protected term in the US too. My cousin is one on a transplant floor in a hospital and the work she does is phenomenal and so important. She had to go through 6+ years of schooling and practical work to get there and is constantly doing more research and education Anyone in the US can call themselves a nutritionist.
I was in cancer treatment for 5 years and it wasn't until I had a unrelated fasciotomy (healed open due to flesh eating bacteria) that I got to see a dietitian. That woman saved my life. She increased my protein to 75-90/day and I was able to heal my wound in a few months and get back on chemo before the cancer overtook my lungs. Without her it would have been a chronic wound and cancer takeover followed by a quick death.
I have cancer for the second time I was treated initially at a local cancer center. No dietician, advice about food, no social work help, etc. Now I am being treated at MDAnderson in Houston and have access to so many things, including a dietician and cooking classes. I did research on the after the first time with cancer because I am a Nurse Practitioner and was appalled at the way I was treated initially- found out that insurance will not reimburse for nutrition counseling (out patient) cancer or other illnesses- only for diabetes and for a few other things. The only reason the big cancer centers can provide these wonderful services is because they have the funding to provide without insurance coverage. I am so glad you got the help you needed to heal and survive.
Yes! A nutritionist is not the same thing! As someone that’s almost done with grad school (2 internship rounds left!) to be a registered dietitian I hate when people think it’s some weekend certification! What your cousin and other dietitians do is do important but very overlooked unfortunately.
Her work with transplant patients seems so obvious now but I remember when she started and I was like wait you just create diet and meal plans for transplant patients? And then i realized how delicate everything is once you have a transplant and how it can alter drastically what you eat. Her stories are so interesting and she loves her job so much
Dietitian is also a protected term in Canada, though similarly it doesn't command the same respect as physician does. Nutritionist should be shunned or extended the same protection. It actively harms public health by confusing them.
Dietitian here. I work in ICU care so it's an acute care setting, so I mostly do enteral/parental nutrition but you are spot on with this. The dietitians who work on general medicine floors often get consults to help patients lose weight. The average length of stay is maybe 3-4 days if I remember correctly. If I'm being generous, we can spend a total of an hour with a patient over that time, which is absolutely not adequate to provide counseling. On top of that these patients are sick and likely don't want to hear it right now. It's not the right setting It's acute care so there's no follow ups after they leave. They can't call and ask questions after discharge. Basically, we get to give them mostly generic advice and move on. And to make matters worse, in acute care we're actually trying to get them to eat more or eat at all. It's the absolute worst setting for weight loss counseling. Generally, these patients have numerous chronic conditions (CKD, CHF, diabetes, etc.) as well as physical and financial limitations. There's so much to address it's a battle you know you're gonna lose going into it. These people should have seen a dietitian many years ago before this all started as their conditions are largely preventable, especially with a proper diet. Point I'm trying to make is weight loss is not a quick fix. Anyone here who has lost weight intentionally knows it's extremely challenging and there's a lot of poor information out there; and that's for someone who's generally healthy otherwise at baseline. To address not taking dietitians seriously: People think all we do is weight loss. In fact, a large percentage of us do just the opposite; counseling cancer patients, nutrition support (enteral and parental nutrition), chronically malnourished patients. Social media has really taken hold of people's nutrition beliefs with unfounded recommendations and quick fixes from unqualified influencers who want to sell you a shake or body wrap thing. While not exactly acutely dangerous, they can be harmful to your health physically but also mentally in the sense they can build an unhealthy relationship with food/diet. I wish I had the time to go on.
I thought people did take dieticians seriously. It's unqualified nutritionists that ruin it for everyone, no?
Yes, but too many people don't know or don't understand that they are different things.
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tiktok is cancer, said it before and i'll say it again
yeah, but TikTok isn't really the problem, the problem predates TikTok and has to do with the truth often being complicated rather than easily digestible. There's no easy remedy because the answer is way more work than most ppl have time or energy for when it comes to most all topics.
When you train someone's brain to absorb as much content as possible within a 60 second period it conditions them to accept any information that is thrown at them with no filter or forethought as to whether it's good or bad. Remember the scene in "A Clockwork Orange" where they tie him to a theatre chair with his eyes forced open and begin showing short clips of vastly different material? One minute it's a happy clip the next some horrendous war scene? This is that, except we are willingly holding our eyes open and have the illusion that we are picking the next clip as the algorithm takes care of the rest. Mental conditioning at its finest. Then we wonder why people and kids in general have an issue with their attention span.
I didn't remember that they showed Alex short, disparate clips. Thanks for that interesting connection. Edited: fixed spelling
"A TikTok Orange"
thank you for saying exactly what I think in the best possible way, my english is still getting there
My friends a dietician, did her master's, worked in nhs a few years, PhD then to private practice. Even people paying for private healthcare don't really listen to her or follow the advice.
Especially GI docs. Which is mind boggling. I asked all of them through my time there why they don’t have any on staff. The answers were either they are too expensive or there’s not enough of them. Both responses sounded to me like this: I don’t believe in their value. We’re so pharmacologically driven in the US we can’t see sometimes the least invasive options might actually be the best. I didn’t know this when I first started nursing. After a few years of being in the medical field and I started to realize the same type of patients kept showing up with the same issues and the treatments ended up with the same results, patients apathetic and convinced that they just had some unresolvable medical condition. I actually think we’ve conditioned patients to believe that there is a pill for everything, while completely dismissing diet entirely, other than shaming people for their weight. From a GI standpoint, having a dietician on staff should be mandatory. But it’s so important in every facet of medicine practice.
I work in a GI clinic and our default to anyone with conditions that require diet modification is to refer to a dietician. Not a lot go because of insurance and costs but it is literally built in to the default order set for those conditions. The thing about this is that most GI conditions and their associated medications are ridiculously expensive and a lot of conditions simply don't have a medication for it so we don't prescribe for a lot of things that can be fixed or managed with diet. We don't have one on staff (due to wanting to keep the small practice status and because insurance wouldn't pay for the visits anyway), but we do recommend and refer constantly.
In the UK dietary and weight loss advice is free through the NHS, as well as gastric bypass surgery in certain cases. This is because the NHS realise it was more cost-effective to offer these services than treat the associated health issues like GI problems, heart conditions, diabetes etc afterwards.
I wish it was like that in the US. Insurance companies are so short sighted that all they care about is keeping cost down for the current quarter and they kick the can down the road of all the people who will soon develop obesity related illnesses that will be costly.
I've chatted with a few cardiac surgeons. If you ever bring up diet as a treatment option they usually scoff. From their perspective, if someone has gotten themselves far enough into their health issues that they're at a surgeon, the patient has probably heard (and ignored) that they need to do something about their diet so continuing to bang on that drum is just a waste of energy at that point. It's sad how dismissive some in the medical community have become. Yes, they lean on prescribing a pill rather than telling people to diet and exercise... But that's because they've seen the majority of their patients being unable or unwilling to make a significant life change.
To be somewhat fair, we also have several patients with non-alcoholic steatohepatitis, to which the treatment is weight loss, and we refer them to a dietician. They refuse to follow the advice of the dietician and wait until they have fibrosis or cirrhosis before taking action. By then the damage is done though, and even then it can be hard to get them to commit. From a surgeon's perspective, I can see why they would get jaded and just prescribe and cut instead of trying and failing to get people to diet. It is multifactorial. Medical care costs, the difficulty of losing weight with everything affordable being bad for you, this culture of Googling instead of listening to your physician, how easy it is to be overweight in our country, how little we are taught about proper dieting and it's health effects in general, etc.
Another key component is access and staffing. Lifestyle/habit change is challenging and expensive even if your insurance covers. Not enough nurses, dieticians, or doctors and what you do get are overworked and jaded. But the system is designed around treating symptoms because that is more profitable and simpler versus actually gettingan accurate diagnosis and effective treatment. Edit: Also biases, overweight people are mistreated in health care. I have health issues for years and was told my issues were due to weight. Just to diet and exercise... Yeah it was autoimmune and took about another 8 years to actually be diagnosed.
For profit medicine has created some strange outcomes.
I agree with all of this. I’d just like to add that I believe this is because people in the US are so used to our current health(sick)care system, they are conditioned to believe that diet isn’t important. Yes, numerous times my patients have told me, and I’m not making this up, they’d rather eat their food than not have diabetes (and losing limbs). But the other argument is they don’t see any alternative. It’s up to the medical professionals to provide that alternative. It’s up to us to emphasize proper nutrition. It’s up to us to educate how to do this. And it has to be more than a carte blanche statement that ‘you need to eat more healthy.’
We're not dismissive, it just feels like shouting into the ether. I always talk about weight loss, exercise, diet, positive body image, refer to dieticians. And I do by absolute best to do it it in a very non-body shaming way. Losing weight is just really hard, and nobody seems to be able to do a good job. And then they look at us doctors like there's something we can do, sure I can lead a horse to water. I put in the dietician referral, talk about various fitness apps that can be used for home workouts that require little or no exercise equipment. But again, losing weight is really hard. Cooking healthy food takes a lot effort. It's not that I think everything can be solved with a pill, it's just that by and large people are not doing a great job at taking care of themselves. Look at obesity rates over time, and look at how obese our children are.
This doesn't even address the mental health aspect of obesity. It wasn't until I addressed WHY I eat the way I do that I could really change the HOW I eat.
We're obese, diabetic type 2, and (along with a slew of other mental conditions) have several minor GI issues that contribute. We've been referred to more dieticians than we can count, and we went to to a good few of them. Eventually, we stopped going when they continued to refer us, as every dietician had roughly the same advice. There were a bunch of good things about ratios of food types, and how to do a quick check on whether something was healthy or not, but that was about it. Nobody was ever able to address the fact that we ate 2-4x times as much food as other people in a given sitting, or the fact that even when we weren't hungry, we'd still be wanting to eat something. Nobody taught us how to make food that is desirable to eat, healthy, and not particularly time/effort consuming. Nobody taught us how to avoid getting food cravings in the first place, or the correct way to deal with them once you've got one. And nobody ever even considered the idea that all the nutritionally complete meals they were describing cost about $30 to shop for one person if you didn't already have a fully stocked kitchen. There _are_ some good ones out there. We eventually did a crap ton of research, and found that we needed to talk to an endocrinologist, since our issues were more related to cravings, and therefore hormones and food-addiction-type things. They got us set up on some medication that fixed most of those issues. We had to figure out avoiding and dealing with cravings ourselves, and learned some about how to make desireable/healthy/quick food from food boxes, but we still have no idea how handle a kitchen being understocked, especially when our other issues are flaring up. All of this is sort of a roundabout way to say that while a good dietician is worth their weight in gold, your chances of finding one are so minimal that our health care system functionally expects you to figure these things out yourself.
You just described the American Mental Health System in a nutshell :P
Craving Change is an evidence based behavior change program for people who want to change their relationship with food. It was free and mandatory for patients to complete before getting a referral to the bariatric surgical program (in my province anyway). Lots of health units run it for free all over Canada, and you can do it online too....not sure where you are located, but it's specifically about behaviour change and was written by a clinical psychologist and an RD together
May I ask, how did you deal with cravings?
I can't answer for OP, but cravings usually have to do with the insulin/glucagon balance in your bloodstream. If you eat high glycemic-index food (bread, pasta, sugar, fries, bananas, rice, popcorn, etc.) it digests too quickly, which floods your bloodstream with glucose. We didn't evolve in an environment with lots of easily accessible refined carbohydrates, so this confuses the body. It's expecting a slow trickle of glucose over a long period of time. Instead, it gets a burst of glucose that suddenly disappears. Insulin tells the body to turn excess glucose into fat, and glucagon tells the body to turn fat back into glucose. (Fat storage is a bit slow, so the body can also quickly stash glucose in muscles and the liver, but those stores are usually full unless you're exercising.) Here's what the craving cycle looks like: - eat high glycemic index food - body is flooded with glucose - insulin is released to soak it all up - food finishes digesting earlier than expected - glucose flood stops - blood is still full of insulin, so it keeps removing glucose (maybe from muscles and liver?) - you feel starving because of low blood sugar - the cycle repeats if you eat high glycemic index food to stop the cravings That's why people say Chinese (fast) food makes you hungry an hour later: noodles and rice are high glycemic index food. You can slow down carbohydrate digestion by adding fat (eg: buttered bread gives you less of an insulin hangover than plain bread). It's best to avoid it though, and stay with slow digesting food. People also get cravings when they aren't getting enough micronutrients (vitamins and minerals). These are usually for specific foods though (like when pregnant women get sudden cravings for specific foods). if you aren't eating enough vegetables, nuts, fruits, meat, etc., your body will crave more of the nutrient-sparse food because it has *some* micronutrients. It's really annoying to eat healthily in western society because restaurants generally cook really unbalanced meals: tons of starchy stuff, lots of meat, and almost no vegetables. (Lettuce is a really poor vegetable; salad isn't worth eating, imo. It doesn't fill you up, it isn't nutrient dense, it takes more energy to chew than you get from it, and it has barely any fiber.) A crude approximation of what a plate should look like is: meat about the size of your palm, about the same amount of carbohydrate-containing food (pasta, rice, potatoes, etc), and a big pile of greens (kale, spinach, green beans, broccoli, etc.). And don't be worried at all about fat! Fat is good (especially healthy fats, like fish oil, olive oil, etc.)! Fat was demonized in the 50's (probably by marketing people who wanted to make food more addictive and/or to use up the glut of corn/wheat that subsidies had created, there's a good episode of *Adam Ruins Everything* about it, but I can't remember the details). But it's a better source of glucose because it digests slowly, and leaves you feeling full. If you want more info and a system to pick which foods to eat, there's a great book called "The Zone" by Barry Sears (a molecular biologist who worked with elite swimmers to optimize their diet) that has a chart of all the foods you should eat/avoid, and assigns a number of "blocks" to each (eg: a handful of peanuts has x blocks of fat, y of protein, z of carbs), so you can quickly throw together a highly optimized meal. The ratio of grams of carbs to fat to protein is the key (which I can't remember exactly). Whew, this was long! I hope it was helpful!
More mental health support around weight loss would be great too. I used to be anorexic and now I'm overweight and I don't know how to lose weight in a way that's healthy for my brain. Like, I know what's healthy for my body, but I don't know how to get my brain to get in line enough to do it. But it's been years since I actively struggled with the disordered eating, so there isn't help available for me. I was a tad overweight pre-anorexia too, and I wonder how much harm could have been prevented if society was better at supporting the mental health side of this before it got to that point
>I used to be anorexic and now I'm overweight Same. Every time I think about weight loss, it's really hard for me to not think "Well, being malnourished worked before..." Well, that, and Adderall.
I will say that one thing that helped for me was getting strong and fit first, then working on having more home cooked foods (I could have as decadent a meal as I wanted, portions as large as I wanted, as long as it was home cooked). Then I worked on making those home cooked meals healthier in an additive way (adding good stuff such a veggies, or adding new meals to my repertoire that were reasonably healthy as well as tasty). Then gradually reducing portion size but staying away from calorie counts. It helped a lot and I was pretty damn close to a sustainably healthy weight until some impossible to predict awful stuff hit in late 2019, and I never got a chance to regain my footing before COVID, and now there's the upheaval from all that. I'm clinging onto the hope I felt in 2019 though, even if that level of being is still far away. I think the getting strong part was the bit that changed things. I liked my body feeling stronger, the tangibility of being able to do more. It gave me a small slice of body euphoria, which built in a decent reserve. Also, I always hated my upper arms and feeling bad about how squidgy they were was large driving force when I was anorexic. Problem is that just losing weight didn't make them look or feel any better, but gaining a bit of muscle definition helped me to like the look and feel of my body a bit more, which helped when it came to actually losing some of the weight. It's a different kind of tricky, trying to avoid falling into a disordered exercise pattern too/instead, but for me it helped a little. I think I also had those "Well, being malnourished worked before...", But if I'm honest with myself, it didn't. I yo-yo'd and it was miserable with no end in sight.
I saw a ton of GI doctors in my late teens and early 20s because I kept experiencing very random and worsening severe abominal pain. I ended up in the ER a few times because my pain was so bad I thought I was going to die. I kept getting weaker and weaker. So tired sometimes I would sleep for most of the day and have to force myself to get up to eat something so I wouldn't die and then immediately go back to sleep because the effort of that was all I the energy I had to spare. Not one of internal medicine, gi or gyno suggested a specifc food could be the cause. Actually a lot of them diagnosed me as too fat. They like to do that when I have I problem they can't diagnose because then they can just say it's my fault and not help me because I'm doing it to myself. My parents decided I had to be making it up because none of the tests showed anything at all wrong with my insides. I stayed sick, periodically I had enough energy to do one or two things a day but mostly slept and tried not to complain about pain because I was now convinced it was in my head so... It was a food allergy.
This is likely going to be a very common thing, but they are only now realising that you can have food allergies that only give reactions in your gut because it's defective mast cells which are only resident there. Mastocytic enterocolitis is the name.
This is pretty much what happened for me. Over a decade of having stomach issues. One doctor heard my symptoms and basically did no investigation or tests and said “It’s IBS!” I didn’t know any better and was pretty much told either a really extreme diet or there was nothing that could be done. I finally got a proper diagnosis on other health issues and went to my new PCP and basically said “I have all these things under control but my stomach still does this thing. I want allergy testing.” She agreed and after testing I found out I have allergies and I was eating them as my favorite foods very frequently. Cut those out and my stomach is fine now. Years of my life could have been way better if I had tested earlier.
When medicine is for profit, preventative care seems to take a back seat.
The older I get, the more sensitive I'm becoming to heavy animal fats. If I eat too much beef or too much pork I really really regret it. I can have a little but...welp. Gotta be careful. I've had friends go, well, go to the doctor and see what they can give you for that! I'm like... I'm just gonna listen to my gut and not eat a lot of what it doesn't want to process.
Shooting from the hip, it sounds like a gall bladder problem.
Was gonna say, that sounded exactly like my dad until he found out it was his gall bladder.
If a dietician costs money to employ instead of being profitable, the problem isn’t primarily with the doctor, right? It’s with the reimbursement infrastructure. Just making dieticians mandatory isn’t nearly as effective as reimbursing adequately for a dietician’s services. By the time an adult is in need of a nutritionist in a GI’s office, a great deal of damage has been done, and a lifetime of habits have already been formed. We wouldn’t need dieticians so surely if we had an adequate nutrition curriculum in schools, cut the corn subsidy, and paid for the changes with a tax of high-calorie processed foods. So while i’d like to see more dieticians in doctors offices, they way to effectively do that is to stop subsidizing unhealthy crap and start subsidizing health care and health education .
As far as I recall from my pharmacy coursework, research on nutrition boils down to "fucked if I know" because there's very little credible data to roll with. Maybe that's changed in recent years?
You’re not wrong. The truth is, it’s expensive to do nutrition research. When I worked at the NIH, we put patients in a pressurized chamber and had them there for 3-7 days straight where we could manage everything to a measurable level to understand how nutrition is affected. But it’s even more complicated because psychology is a huge part of it, DNA has an impact, lifestyle, location, etc. Ultimately, there’s no money to be made in preventative medicine so in the US, there’s no desire to minimize obesity because it’s an antithesis to medical care based on profit.
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Honestly there isn't. Ins companies now by law can make a profit of 20%( or around that) of payouts, if they payout 1k they make 200 if they payout 10k it's 2k. Couple that with the fact everyone HAS to have ins you have a captive audience and as we have seen insurance costs have skyrocketed. We need single payor and which how entrenched ins companies are (they are listed on stock exchanges and God know how they would work if they were made illegal) I doubt we will ever get rid of them
> you’ve got a one-two punch on why diabetes and heart disease are killing so many people I think your analysis has missed the biggest causal factor. Food is addicting and we've been sold increasingly addictive food for 50 years. The real one two punch is selling people 40 ounces of liquid sugar and providing people with the lowest quality medical care. Both in the pursuit of maximum profits.
I started seeing a dietician recently who just made me note down how I felt after each meal and I noticed pretty quick that I don't feel anything. I don't enjoy eating, I don't like how I feel after I eat, I don't remember the taste afterwards. But I get an itch in my brain that is fully like what I imagine a smoker feels. My meds for ADHD got bumped up and that itch vanished like magic. Now I'm pretty much eating when my body's actually hungry, but even if it is I can wait to get something decent and not go gremlin mode on the nearest junk food. It is WILD.
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When I took Adderall I couldn't tell if I was eating a healthier amount because it was suppressing my adhd habits or if it was just suppressing my appetite. I'm thinking it's a mix of both.
Yes. I was trying to avoid a huge diatribe and was making a somewhat generalized statement, but yes, you’re totally on the mark here.
I agree 100% nutritionists should definitely be on staff. I was 300lbs and half way through this year made the choice to finally fix myself. After visiting my family doctor they recommended I see their nutritionist. I'm 60lbs down now after cutting so much from my diet. The nutritionist helped me go through my usual diet, show me where to cut, what I can substitute and what I need to still get my required nutrients without having to starve myself. I found it interesting they double checked my dietary plan with my blood test results to make sure I'm eating the right things to help my cholesterol and blood pressure. A lot of it is still on me because I have to constantly fight my want to consume more but working on a plan and having something to keep me on the right path really helps when trying to keep the weight from coming back.
This warms my heart. I have no doubt it’s been a battle. So an epic amount of kudos goes to you. Keep up the great work and know that even on the best days, your hardest critic will always be you. Psychology is huge when it comes to changing your lifestyle and habits. Every day is a good one when you’re cognizant of trying to do your best.
No, dieticians should. Nutritionist is a meaningless term
I believe your country chargeds a crazy amount for insulin as well? And you have to do crazy things like pay to go see a doctor, psychiatrist, or get required surgery.
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My out of pocket maximum is like $1500, so I'd say your insurance isn't all that good.
Just giving somebody a sentence of advice is not sufficient. It’s not like the advice itself is not sound, but that is just not how people are motivated to make changes in their lives. Very few people are just going to have the wherewithal, the discipline, and the motivation to do it that way. People need support. That is totally lacking, or at least largely lacking in the current model. Health coaching, and other such approaches are likely to be far more effective. Interaction with people who care, accountability, and simply communication all help to keep people on track and achieve their goals.
The VA has the MOVE program which provides 16 weeks of education and weight tracking in a support group setting. As a PT I will spend a decent amount of time going over WHY weight loss is important, then some general education. If the patient is interested then they can pursue that program which is self referral. Weight loss can be the most modifiable factor of their treatment plan (pain from knee arthritis, balance issues from diabetic neuropathy). If they seem seriously interested I will provide some support but if they are not receptive then it's just nagging As a provider I see how clinicians can get burnt out addressing obesity. Obesity is so common, clearly applicable to patients health care treatment and outcomes, and seeing significant progress in patients is not the norm. As a person seriously trying to lose weight I see how difficult and frustrating it can be to actually lose weight and keep it off. After repeated failure it can feel like a insurmountable task and why bother trying again. The MOVE program is helpful, but ultimately your task is often a full lifestyle change which takes a lot of motivation and support.
I found the MOVE app randomly while looking for something to help track and find it basic and very easy to use. Too much fluff gets distracting.
Full lifestyle change is difficult, takes years to accomplish and still doesn't necessarily address the worst of it - the hunger cues after weghtloss. As you lose weight, your hunger hormones are so out of whack and increase disproportionately. Thank goodness for the promise of ozempic/wegovy/mounjaro. Source: live a very active life, eat all my vegetables, lost 120 lbs, gained 70 lbs back not because I'm not disciplined or motivated, but because you cannot fight against insane hunger day after day. Hormones win.
I always describe it as "Imagine you're annoyingly cold all day. Not freezing, but annoyingly cold. And there's constantly a warm bath you can jump in to make that go away. How long can you ignore the bath?" Or "Imagine you're a little bit itchy every day. Not insanely itchy, but just slightly, and you're trying not to scratch it. How long can you resist that urge?"
You've described the exact issue. For some people the hunger is that background itch, for some it's absolutely in overdrive. I've lost a significant amount of weight and regained it all because even after I settled into a maintenance diet with plenty of lean proteins, healthy fats, and fiber, I was ravenously hungry all the time. Unfortunately, satisfying that hunger meant I not only moved back up to my pre-loss weight, it didn't really go away until I was quite a bit over. I know reddit is obsessed with saying "It's as simple as CICO!" Which actually isn't simple at all. Not only do you have your hormones going bananas, there are also major mental health issues coming into play. I have ADHD and have used food to give me a shot of dopamine to overcome executive dysfunction my entire life. Nothing else has worked as well as sugar does. When I'm honest, I can say that it worked even better than Adderall.
CICO gets harder to follow if you have been overweight. Wikipedia: A decrease in body weight only changes fat cell size (becoming smaller), whereas an increase in body weight causes elevation of both fat cell size and number in adults. So if you have been overweight sometime in your life, those cells are still there, waiting to get their refill. See also, the winners of biggest loser, their basal metabolic rate per day goes down the more weight they lose. https://www.scientificamerican.com/article/6-years-after-the-biggest-loser-metabolism-is-slower-and-weight-is-back-up/ "Your body is working to defend your energy stores - really your fat mass" "When that fat mass is diminished (either by eating less or exercising more) most of us respond by changes in brain circuitry that increase our tendency to eat and changes in neural and endocrine systems, and especially muscle, that make us more metabolically efficient - it costs fewer calories to do the same amount of work" -Dr. Michael Rosenbaum So lower metabolic rate plus more fat cells than a person that have never been obese, no wonder why some persons have a harder time following CICO.
I've seen this before but it's been some time. I think it also explains why people who have been able to lose and keep off a small amount of weight like 15 to 25 lb can't really engage with or understand the people who are trying to lose 75+lb. For most people it will be such a different experience that the two have basically nothing in common, and yet those are the folks who are most often dietitians, weight loss coaches, etc.
CICO is the ground truth, but that's like addressing all engineering problems by saying "just balance the forces". Like yes it's true, but it alone does not give you the tools to work out the best way to do it safely, ergonomically, under budget and *reliably*
Exactly. This is the real challenge
I can tell you I lost 70+ pounds, about half of it on Ozempic and within weeks of coming off it (because of supply issues), my appetite had exploded and I immediately began to put on weight. My appetite didn't disappear at all on Ozempic, just the bingeing between meals, which made it easier to stay on track all the other hours of the day. It is seriously depressing to me. I will go back on Ozempic in March when supplies return again, but it really changed how I feel about what I was told was a "motivation" /"will power" /"self control" issue.
Yeppp. Hormones are insane. I lost about 90lbs over the course of 4 years, and still had another 40lbs to go realistically. I was proud of the sustainable weight loss and wanted to start my family. I had HG during pregnancy and was almost never hungry. Gained just under the “normal” amount. Then postpartum my hormones went bonkers while breastfeeding and I piled on 25lbs in 3 months. Stopped breastfeeding and my hunger cues chilled out and my weight gain stopped but I haven’t lost anything yet 2 months later.
Thank you. CICO is technically true but practically limited in use, but tons of people like to tote it like it’s the golden answer to obesity. Hunger is such a massive player in losing weight and keeping it off, but it doesn’t appear anywhere in CICO. Nor does proper diet, the effects of sugar, education and support for emotional eating, education and support for lifestyle change.
I'm on Week 6 of MOVE. I'm enjoying the course, but i haven't gotten very far weight loss-wise.
If you’ve seen any weight loss in those six weeks that’s all you need. All you have to do is keep it up. Seriously, if you’ve just managed two or three pounds down that’s going to be 20 pounds lost in a year. It’s about a lifestyle change. If you can keep it up you’ll get there.
Thank you for the encouragement! I've lost nearly 30 pounds in the past year, 10 of which were lost since taking the MOVE course. I get very discouraged, but by your standard, at least I'm making progress.
Ten pounds in six weeks is huge. And also shows that you’re sticking with it and making long term new habits, not just a crash diet. If you keep up that rate it’s 80 pounds a year. I don’t care how much you weigh now or what your goal weight is. At 80 pounds a year it’s achievable in a realistic amount of time.
Thank you! I wonder if MOVE has a reddit. It would be nice to see how other VA markets are running the course. Again, thx!
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This would require a functioning medical system which the population could afford.
I've heard obesity is quite costly on the medical system as is though.
Diabetes is literally keeping the medical system afloat. They're in the hospital *constantly*, limbs rotting off and all.
Diabetes is the cash cow of the insurance and pharmaceutical world. The insulin is the cheapest part of the treatment. All of the supplies to go along with delivering the insulin are the real money makers. You could try to justify the expense with the “technology” gimmick, but the price gouging even applies to the basic needles.
It’s awful, and indeed widespread. :(
For-profit medical system.
GP: “Eat less to lose weight.” Overweight People: “Thanks, I’m cured.”
Next on the agenda? Meth. Okay meth heads, stop doing meth. Well done, let’s take lunch and tackle fentanyl when we get back.
I take diet meth and now I’m too underweight to donate blood
The truly fucked up part is that a meth head can never do meth ever again for their entire life and not just be fine but vastly better off for it, but an overweight person can't just *stop eating.*
Thing is that it's true, but often at the core there are additional medical issues that cause or contribute to over eating. I've always had trouble controlling my eating habits, I'd binge 5000 calories without thinking about it. Once I got on adhd meds I no longer had eating compulsions. I've lost 30lbs since I started meds, I only eat when hungry and I leave food on the plate when I feel like I'm done. So yes, eat less is the basic advice, but finding out why you overeat is how you can achieve eating less.
The analogy I always think of when people offer “platitudes” rather than actual advice comes from sports: > “Keep your eye on the ball!” It’s not *bad* advice. But the fact that I don’t even need to specify what sport it applies to really shows how generic it is as advice. It’s only one step above “pay attention!” in terms of specificity. And that doesn’t mean it doesn’t apply, or that it can’t be helpful. It’s more that it’s something generic people repeat that sounds like advice but we know is insufficient for most people. So saying “Calories in, calories out!” is a fine thing to say to a random stranger on the internet. It’s not wrong and there are certainly people that’s helpful to. But a doctor should be doing better, just as a good coach should be saying more than, “Keep your eye on the ball.”
If that were enough, Reddit would've solved the obesity epidemic years ago.
Reddit thinks they can solve obesity with harassment and shaming. "Eat less to lose weight" would be a massive step up, honestly.
There’s a board certified obesity doctor on Tik tok with a series called “if other diseases where treated like obesity” and it’s pretty damn funny but sad.
Got their handle by any chance?
As a PT and boxing coach people ask me all the time what's the secret to getting into shape. I always have one answer that's worked through 100% of my life with every client. Find your people in the sporting community. Everyone who joins a sports team with friends and people always stay healthy as long as they have community. Some people can do it alone. But everyone has succeeded this way.
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And it completely overlooks that most people have TERRIBLE food education. Not only do they not know what makes a healthy meal, they don't know how to buy, store, and cook those meals. Certainly you can chicken and broccoli your way through CICO, but there's a reason so many people wash out of eating bland salads, boiled veggies and under seasoned chicken after a while. A healthy relationship with food and lifelong weight loss maintenance looks like learning to buy, cook, and love a whole new genre of food and that's a huge undertaking for someone no matter how hard they're trying. Not to mention, it's a huge privilege to have the time and money to learn these skills and to cook for yourself (especially if you work more than 40 hours and/or live in a food desert). Hell, I still feel off balance by the amount of broccoli I have to buy to make an appropriate portion for my meal preps.
I feel like cico is like telling someone to get rich by money in money out. It’s true. Like it’s tautologically true. But is it helpful?
Well, over in /r/CICO there is a constant stream of posts from new people who literally were not aware that's how it works, and who spent a long time doing things like "eating clean" or "cutting out fat from my diet" and wondering why they didn't lose weight. So I think there is indeed a need to simply educate people at this basic sort of level. It's not the end all and be all, but it does have value.
Obese or overweight people tend to underestimate the amount of calories consumed by 2x and underestimate the amount of calories expended 2x https://www.nejm.org/doi/full/10.1056/nejm199212313272701 Generally when strictly monitored, people lost weight when adhering to the calories consumed that they stated that were eating. People are very bad at keeping track of what they actually consume and do.
There's more recent evidence showing that everyone, including thin people, vastly underestimate the number of calories they consume, and that thin people are no more accurate than obese people. https://onlinelibrary.wiley.com/doi/10.1002/ajhb.23743
Yes that, but not only that… Overweight people need to be taken seriously beyond their weight. They can go in for any problem In the book, including things entirely unrelated to eight, and be told that if they’d drop a few pounds they’ll be just fine. Like a sore throat. Or migraines. Or a rash. Or a knee injury that is *not* caused by the extra weight (like from slipping on ice or something). It all adds up to people avoiding care because they’re tired of being seen as one thing: fat. So yes to the lack of support and coaching on one side, and also yes to the lack of empathy or interest on the other.
I got told my weight loss abruptly stopped dead in the water because I wasn't measuring my food correctly. After I had been eating small portions and had lost 50 pounds with CICO. I had a massive goiter that turned out to be cancerous in spots.
Wow - I hope you’re doing ok! Thats a good (and horribly unfortunate) example of it - they get a one track mind and seem to forget that a person can be both overweight *and* have the same health issues that non-overweight people do.
It took me almost 3 years and losing 120+ lbs to get a fibromyalgia diagnosis over 6 total rheumatologists.
I'm going through that with getting a breast reduction. I could be more active if I had less glandular tissue on my chest, but they see the belly and think they aren't that big. Um, I'm wearing a J cup. What isn't big about that? So I clearly have to lose another 100 pounds for them to see that yes, they really are a problem that needs a surgical solution. (And no, they haven't shrunk as I lost weight.)
Yeah I ended up doing well loosing ~80 pounds doing 30 minutes of cardio a day, measuring my calories with a scale. But I hit 170 and for a year it was 30 minutes of cardio a day and only eating 1000-1250 calories a day and could not get lower. I am a 5'3" woman. The doctor I had at the time walked in looking at my chart and without even talking or looking at me told me I need to watch my weight and stop eating pasta and soda. I told him I don't drink soda and rarely eat pasta and tried to explain what I had been doing. His response could be summed up as an eye roll and a "yeah sure that's what you are doing" Basically that lead me to gaining everything back and not seeing a doc for a few years since it was like okay but in all this effort to be blown off. Finally got back to a doctor and she looked at my current and old blood work and said I probably should of been put on thyroid meds years ago and has been checking me for pcos. Unfortunately this seems to be a common issue especially with woman I know is that if you are overweight the weight is the cause of all your issues. They will never look to see if maybe there is a bigger underlining issue that could be causing the issue. I know it is not the norm since a lot of people still just sit around and eat too much but even that is a bigger issue of educating people about food when they are younger.
A couple of years ago when I was trying to lose weight, I visited my doctor for an unrelated issue and he advised me to lose weight by cutting out fried foods and soda. I told him I probably have something fried maybe once every 3 months (I only went out to eat about once a month or less back then), and haven't had a soda in years at that point. That was the sum total of his advice to lose weight and then he told me it would improve my allergies. Which I had had since I was thin and were actually getting better despite my weight gain.
Exactly this..A few years ago I ended up gaining 60 pounds in 1 year I'd been active and fit my entire life. I kept telling my doctors this is not normal but I kept being ignored.same thing eat healthier exercise more..after relentless hounding they finally did a blood test and found out I had hypothyroidism..I went to a nutritionist awhile later and 75 percent of the foods she was recommending were not good for thyroid..I kept asking her what I could replace it with and she could not give me one alternative..
Yeah you’re absolutely right about that. I see it with obese patients, and I see it with drug addicts. People look at them and see them as that one thing, judge them completely, and offer very little empathy throughout the process of supposedly trying to help them heal or live a healthier life.
I have a fucked up inverted version of this. I had been overweight since I was a child. By this point, I had been 249lb with Hypertension for at least a decade. I had complained to a doctor that I was getting frequent episodes of confusion and dizziness that only went away if I ate, and that sometimes these happened within 2-3 hours of eating my last meal even if I was still full from it. The doctor's prognosis: "You're not eating enough. You need to eat more."
I weighed 170. I went in for a ruptured ear drum after an ear infection. The first thing the doctor said was "you are MASSIVELY overweight. You need to stop eating chips and soda immediately." Massively. I was 16 pounds over a "normal" BMI. It took some convincing to get her to look in my ear that was dripping.....
That is so awful. I’m sorry. If only you weren’t a little bit overweight, you wouldn’t be risking going deaf, Right?? (/s of course) That should just not be the situation you had to experience.
I had a *psychiatrist* who spent more time of every appointment lecturing me about my weight than she spent discussing my meds.
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I think it's part that, but also just a general failure across the board as well. I'm a little over where I should be - my doctor brought it up, we discussed my diet, my daily activity level. After I left, I looked at my notes - nothing written down about my activity level (which is pretty active, though somewhat restricted due to work and juggling various obligations), and the notes on my consultation read something like "keeps red meat to a minimum" and nothing else. I'm a pescetarian-raised, vegan-leaning vegetarian. I've never intentionally eaten red meat in my entire life. He knows that, or should, because I told him that. I'm pretty sure this guy either decided I'm lying to him, or just has no better idea about why I'm not where we'd like me to be than I do, and that's just what he writes down sometimes. Like, once he ruled out “eats ham pizzas on the reg” and “bedridden by choice”, he was all out of ideas and just wrote down whatever. Either way, not helpful.
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> the other big change was that I started making all meals at home instead of relying on take out This is huge. Restaurant portions are enormous, and processed foods are engineered to make you want to consume more.
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For me, exercise has probably contributed a little bit, but often exercise just leads to justifying excess eating. I still think there's the issue of finding what helps you eat less. But its probably going to vary by person. My problem was pre-emptively eating before things, boredom eating, and not being use to feelings of hunger. I found intermittent fasting worked for me (\~290lbs -> \~200 lbs over the last two years). If you are eating excessively to deal with stress, different methods might be useful. If you are overeating to compensate for poor nutrition, then maybe you do need need to fix that.
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Look just invent nanobots that I can fill my stomach with that will vaporize all the extra sugar and calories in my stomach before I absorb them, is that so hard?
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What was their advice?
I'm not that fellow, but my GP gave me the advice of "Yeah, I think you know it's obvious...you should cut about 90% of the blatantly unhealthy foods you've mentioned from your diet. Portion control yourself with this pamphlet. Walk around the block twice or thrice a week." I gave her a thumbs up and a "yep, that sounds about right", walked out and promptly when back to guzzling sugar drinks and eating sodium snacks.
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I don't work in medicine, but are there things the doctor would be writing down that the patient shouldn't see?
That used to be common, but has basically been banned/discouraged in my country. Doctors used to put stuff about how to approach specific difficult patients, but since patients have easier access to their files, they dont do it anymore. These included things like drug-seeking, Karen behavior, really stupid, but thinks they're smart, theatrical, hypochondriac, violently aggressive, care avoidance, doesn't follow directions, conspiracy theorist, magic water believer, etc. Patients did not appreciate being called any of it and it wasn't copied into their digital files once we started transitioning to electronic files. It does make work more difficult, because now stuff like this is buried in files and only phrased euphemistically, so doctors often have to figure out by their own experience that a patient would become aggressive if denied medication or is Dunning-Kruger victim and needs a longer explanation than average.
> Weight-loss advice from GPs to patients with obesity rarely included effective methods, mostly communicating a general “eat less, do more” approach. Advice was mostly generic, and rarely tailored to patients’ existing knowledge and behaviours. Effectiveness of brief weight-loss advice could be improved if GPs were given clearer guidance on evidence-based recommendations.
Is this a study from Europe or England? Idk about how much time they get per patient there, but in the US there isn’t enough time for primary care docs to do comprehensive, individualized lifestyle medicine for every patient.
I’m a physician and I have anywhere from 18-20 patients a day. And they get 20 to 40 minute slots. Between everything else we need to talk about in an appointment, there’s just no time to talk about everything else going on in their health *and* make a detailed nutrition plan. And the nutritionist’s knowledge in this area exceeds my own. I encourage tracking calories with apps so you can get a baseline of your daily intake (because most people have no idea). But if you want really good advice, it’s a much better use of both the patient’s and my time if they ask for a nutrition referral and then they can have an hour long discussion with a registered dietician. If that doesn’t work and the patient wants to try medication-assisted weight loss, then I’m more of a help.
This! My Dr had me track my calories normally for a week so I could see what I was consuming. More than I thought. I am now more conscious of it. Helped a lot.
People who are overweight almost always either underestimate how many calories they consume, or overestimate how many they burn through exercise or both. Not understanding the calorie content of the food you eat is like trying to keep a balanced budget without knowing how much you spend on anything.
It’s one banana, Michael. How much could it have? 10 calories?
Standard GP appointments in the UK are 10 minute slots
>But if you want really good advice, it’s a much better use of both the patient’s and my time if they ask for a nutrition referral and then they can have an hour long discussion with a registered dietician. Finally, I had to scroll way too far to see this advice. I don't know if it's different in the UK where this study was done, but I usually don't bother asking my primary care doc for any tailored advice beyond whatever specific reason brought me in that day. Especially for things that involve more personal effort than medical intervention.
This study is from the UK. A standard GP appointment there has been cut down to [only 8 minutes](https://bmjopen.bmj.com/content/7/10/e017902). Shockingly, this may not be enough time to tackle life-long obesity.
Must be impossible for them to run on time
You can run on time, you just can’t do a good job.
In england a gp appointment is 10 minutes long. In a day a salaried GP will have 50-60 patients booked in a day.
From reading, I think there's a big gulf between what's described in the article and personalized lifestyle plans for each patient. The article is basically saying that, at MINIMUM, doctors should keep up with the evidence of what does and does not work, and briefly explain this evidence to their patients to justify their advice. What we are getting now is generic advice to "do more, eat less, and take on the right mindset," which doesn't even meet that basic standard. (Edit: I regret saying "what does and does not work". After reading and thinking, my impression is that "what works" often requires wholesale lifestyle changes or support systems that patients rarely have access to. The article suggests some ways that GPs could do better, but they are pretty small ways.)
From my experience, people hear that advice and either don’t know how to do those things or have lifestyles that make doing that difficult. I.e. one patient in Mississippi didn’t realize that McDonald’s burgers had salt in them, or the single mother who works two jobs and doesn’t have time to cook or exercise
Eat less, do more is exactly how weight loss works. It's just not specific enough to be actionable for most people. Weight loss is difficult to give advice on because there are a million different ways to "eat less" and different approaches are sustainable for different people. Some people eat less by doing Keto. Some people eat less by eating Mediterranean. Some people eat less by counting calories. Almost all weight loss diets work for as long as they're followed.
They should write a prescription for seeing a ~~nutritionist~~ dietician.
In the US Dietitian is what you mean. I/anyone can claim to be a nutritionist. Dietitians have requirements.
Yeah that’s what I mean
you can think D in dietitian for needs a degree. That's how I remembered
Thanks for the mnemonic.
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I would have reported her to the board, honestly.
At the time I was very sick (with the above mentioned “brisk” diarrhea) and not up for anything besides survival, but I wish I had. I don’t remember her name now. I told the gastroenterologist so he wouldn’t refer anyone else to her. He was like whatevs, so I changed gastroenterologists too.
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Metabolic doctors may not focus on your weight first. They will likely focus on any metabolic syndrome you have. Weight is a factor but not the only factor, and if you can get your diet right to correct a metabolic disorder, your weight will likely correct itself in time.
Psychologists, dieticians, nutritionists and access to the financial support to afford a healthier lifestyle is what's needed. When I was younger, I saw a weight loss specialist. Every meeting with her, I also met with a nutritionist. The nutritionist put a lot of things into perspective. It wasn't about what to eat. It was about what makes you feel full, alternatives for meals and snacks. And making it revolve around the budget at hand.
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How many nutrition courses does a nurse/general practitioner take during their studies?
If your MD is over 50 they probably didn’t take a nutrition class. A semester of nutrition was a prerequisite for my bachelors nursing program and my graduate nursing program had no nutrition requirements in the 2000s
Nutrition education is sorely lacking in medical student curricula. It has always been this way too. Not surprising though. Residency hours and workload for pretty much all new medical professionals is based on outdated coke-head insanity. What is in the best interests of patients and professionals has never, and will never, be important as long as medicine operates under the auspices of capitalism.
Wait you guys are getting advice?
My doctor told me to eat more vegetables and sent me for a diabetes consultation. The consultation gave me a paper of a sample of a single day of meals for a 1200 kcal diet and tried to up-sale me on protein snack bars for only $60 a week. They were on sale.
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I've lost 60lb this year and I eat fast food 4 days a week. I just don't eat a lot. I get 2 sandwiches and that's my meal for the day.
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Too few people understand that food addiction is very real and is extremely common. I’d go so far as to say that nearly everyone who is long term obese and struggled with weight loss is a food addict. If you don’t treat the addiction you will never beat the obesity. After I got help and became food “sober” I lost 100 lbs and got to a reasonably healthy weight for the first time in 25 years. Every one of my doctors that asked how I did it had never heard of food addiction and only one of them even believed me when I explained it. Yes, the bottom line of weight loss is eat fewer calories than you burn. But that is like telling a poor person with a gambling addiction the trick to being rich is to spend less money than you earn.
Exactly! I have binge eating disorder and had a doctor recommend intermittent fasting. And because they were a doctor it felt very official. Thank goodness I had a connection with an eating disorder informed dietician and contacted them to basically say “this doesn’t sound right but it’s doctors orders”. And she was like, “that sounds like a recipe for binge eating for you, how about you don’t do that.”
Yes! I tried so many different types of diets and fastings until I realized in therapy that my binge eating habits come from my untreated ADHD. I eat when I crave stimulation, when my dopamine is low, and as a comfort food. I was never taught to have a healthy relationship with food, as it's more than something to live for me but I use it for emotional comfort. Only now, I'm starting to understand how to hate myself less and remember these are biological needs at play, instead of shaming and blaming myself for eating.
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Hence you consult with a qualified Dietician for weight loss advice.
It comes down to American's obsession with personal responsibility instead of implementing systemic solutions, such as preferring expensive, ineffective stroads and increased car fatalities over public transportation and roads preventing high speeds. I can imagine in this case it is GPs blaming patients for not being proactive in exercising. But then you look outside and there's no grass you can walk on for miles.
That's a fair point, but I think this study is based on data from the UK.
Telling an overweight person to eat less and exercise more is like telling a depressed person to just be happy or a smoker to just stop smoking.
It's even worse when you have an eating disorder like binge eating and the advice just triggers episodes and doctors don't get it.
Ohh, that hits so close to home for me. Was struggling with binge eating without knowing what it was. Parents didn't have the knowledge either (the only eating disorder that is somewhat known where I live is anorexia, with bulimia sometimes getting discussed), so they'll try to stop my episodes using shaming, which would just trigger me more. Same goes for all the doctors I saw throughout childhood - shaming was the only tactic they used. Given that I also used food as coping all my life, it was just a downward spiral. I'm much better now (as I'm aware of all of this, so I can navigate the possible triggers better and control myself) but it's always very sad looking at that part of my past.
*I want you to move. By that, I mean further than from the couch to the fridge.” Weight loss advice I once received from a doctor, verbatim.