I recently got asked the question “what would you like your legacy to be when you finish your career as a dietitian?” It’s a big question.
I had never really thought about it. I am not ambitious enough to want to be the best practitioner in any field within dietetics or even have a reputation for being near the peak.
While I do not care much about legacy, I want to contribute to providing evidence that significant weight-loss is achievable (and maintainable) for a far greater percentage of people than statistics are currently indicating. I want to show that it is the interventions used that are flawed, rather than people inherently not being able to succeed with weight-loss.
“95% of People Who Diet End up Regaining the Weight They Lost and Then Gaining Some More.”
I have heard this line many times since graduation, particularly coming from the Health at Every Size (HAES) community. It’s a number that leads to statements such as “It is not ethical to recommend weight-loss since it usually leads to poorer outcomes.” This is painful to hear if it is true.
I’ve searched for this number that people are talking about, but honestly, I haven’t found it anywhere in a group with a large sample size. If anybody does find this number, get in contact with me because I would love to see the research and discuss it. The best estimate I have found is that ~80% of people who diet regain the weight.
If 80% of people regain the weight, is it ethical to recommend weight-loss? I don’t have the answer to that. But it does make the question less clear cut than if the number was 95%.
Either way, what I want to achieve is something far more significant than an 80% “failure” rate.
I have wanted to write some variation of this post for a while, but there has always been something holding me back.
What if I’m wrong? What if my intentions of helping people lose and maintain their weight-loss are doing more harm than good?
I have only been graduated as a dietitian for just under a year and a half, so I don’t exactly have a long track record yet.
My original intention was to stay quiet until I had been a dietitian for 5 years and then start sharing my insight if I had something to say. That amount of time appears to be the longest time-frame people talk about regarding statistics for people regaining weight.
Throughout this time, I have been learning about the non-diet approach and HAES. This was so that if I did have something to say, it would be from a balanced perspective. We didn’t learn about it at University, so it was interesting to have a fresh start.
I’ve spoken to experts in the field and asked questions. I’ve joined Facebook groups like The Moderation Movement. I’ve watched webinars, read articles and books. Nothing has swayed my opinion, but I do admit there is a lot of value in the non-diet approach.
“Document, Don’t Create”
Anybody who follows Gary Vaynerchuck will have heard this line before.
Although my intention was to stay quiet until I found an answer for myself, the legacy question changed my mind.
If I want to contribute to demonstrating that helping clients lose weight is ethical, then shouldn’t I add to the discussion? Maybe other people are as interested as I am in this question? Maybe this post helps another dietitian look into finding reliable ways to help clients maintain their weight-loss?
Looking back over the last 15 months, I have had a lot of clients lose more than 10kg and keep it off over that timeframe. I moved locations 6 months into this journey. Another dietitian from Fuel your Life took over my old clients (and is smashing it), however, if anything I think that makes it more meaningful to me.
The point isn’t whether I can achieve these results myself, it is about whether dietitians or other practitioners can can. It is about the process, not an individual’s skills.
One person working at an individual level won’t make a significant impact at a large scale, but an effective approach with good practitioners might.
Still, it means almost nothing in the big picture until it reaches that 5-year mark. The only reason it is worth mentioning is the whole documenting aspect to open the discussion.
Some Thoughts on how to Maintain Weight-Loss (or build on it)
This will be brief, but I want to open the discussion. I have a lot of thoughts on this, but I’m not even sure I’m right with the entire concept, let alone the keys to success.
1) Follow-Up:
It is a long-term commitment. I try to see all clients frequently at the start, but my long-term aim is that I (or another dietitian) will continue seeing them at less frequent intervals, after they have reached their goal. Weight-loss is hard, so why not commit to that infrequent “tune-up” if it helps prevent regaining weight?
The reason I believe this is important is that people usually regain weight when the intervention stops, regardless of whether it was a specific diet or seeing a dietitian. A lot of the time, it is around that 6-month mark as well.
Maybe people aren’t inherently bound to regain weight, maybe the problem is solved if the intervention never stops?
2) Education:
Behaviour change is important of course and everybody has some idea of how to lose/maintain weight, but I think more can be done on the education side of things.
Another dietitian once asked me the question: what do you talk about when you do so many sessions? This is an important question since most dietitians do far fewer sessions than I do.
There are a lot of important things I cover in the early sessions, but as a question that might prompt some thinking: Is there anything you know about nutrition that you think others would benefit from knowing? I bet there is. These are the things I have the time to pass on.
I also have the time to really listen to clients. This makes a world of difference.
3) Exercise:
A study following up on contestants from The Biggest Loser found that the people who maintained their weight-loss over multiple years, were doing an average of 80 minutes of moderate physical activity daily, or 35 minutes of vigorous activity.
This is important because another study showed that these contestants on average had a metabolism that was 500 calories per day slower than when they started. Grim.
Not only does exercise burn calories, but it also assists in muscle maintenance/growth. Muscle is metabolically active and the more you have, the faster your metabolism will be. The faster your metabolism, the more calories you can eat without gaining weight.
I’m of the opinion that maintaining as much muscle as possible while losing a significant amount of weight is an important variable in the likelihood of maintaining the weight-loss.
As a side note, I work closely with Exercise Physiologists, which may be an additional factor as to why my clients are having success.
4) Protein:
This is a point that I would love to discuss with other dietitians in detail. I’m happy to be wrong on this one. I believe in a protein intake far higher than what most dietitians are implementing with their clients.
For athletes trying to optimise muscle mass, around 1.6-2.2g/kg/day is a good guide to follow. For natural bodybuilders getting as lean as possible for a contest, the target increases up to 2.3-3.1g/kg/day if they want to optimise muscle maintenance.
In general, the leaner you are, the higher this number is. Since most people looking to lose weight aren’t as lean as athletes/bodybuilders, the number is a bit lower. Clinical judgement needs to be used.
A number I would like to use with the average client I see is around 1.4g/kg/day, however, experience has taught me that people struggle to reach this number while staying in a calorie deficit.
Take this lightly though, because it also depends on my ability to take diet histories accurately and also relies on clients filling out food diaries accurately, which can lead to misleading results.
Either way, I often aim for >1g/kg/day with a lot of clients. For a 90kg person would be a minimum of 90g protein. Low for my liking, but way higher than the RDI.
I believe that this will help people maintain more muscle, fill them up more and also be slightly thermically advantageous.
More muscle = slightly faster metabolism. More satiety = less likely to overconsume calories. Thermic advantage = being able to eat slightly more calories.
What if I’m Wrong?
If I get to that five-year mark and find out that I haven’t had more than a 20% “success” rate with clients maintaining their weight-loss, that would be a sad realisation. At that stage, I probably would conform more strongly with the non-diet approach and HAES. The only issue would be that a lot of my sense of purpose as a dietitian would be lost. Would I continue my journey as a dietitian? Probably not.
For now, I will keep on working with clients in an attempt to achieve this goal and I may or may not document some of it along the way. If this post has prompted you to think about this topic, feel free to get in touch and share your perspective. I would love to hear it, even if you disagree with me.
p.s. there is now a part 2 to this post.
p.p.s. As of the most recent edit (late 2021), I am now at the 5 year mark of being a dietitian.
While I look back and have changed my opinions on some of the things I have written here, I am still a dietitian.
I do not keep statistics on client results or anything like that anymore. And I have not done anything formal to contribute to the evidence on this topic, for a variety of reasons. Mainly a loss of interest in the topic.
But on average, I am stoked with the results clients have gotten from a long-term weight-loss maintenance perspective. And I still enjoy being a dietitian too.
