Possibilities of nutritional therapy

The prevalence of people with overweight and obesity in Europe is almost 60%, and the World Health Organization (WHO) estimates that obesity is (partly) responsible for around 1.2 million deaths in Europe alone. The current recommendations, challenges and possibilities of nutrition therapy for obesity will be highlighted.

The prevalence of people with overweight and obesity in Europe is almost 60%, and the World Health Organization (WHO) estimates that obesity is (partly) responsible for around 1.2 million deaths in Europe alone. The current recommendations, challenges and possibilities of nutrition therapy for obesity are highlighted below [1,2].

According to the WHO, people with a body mass index (BMI) over 30 kg/m² are classified as obese (Table 1). It is widely known that the BMI is limited in its informative value, but is nevertheless used as a readily available “tool” for risk assessment [3,4].

The German S3 guidelines on the prevention and treatment of obesity from 2014 by Hauner et al. [6] are being revised at the time of writing this article. As a result, some of the recommendations in this article are based on the more recent Canadian guidelines “Obesity in adults: a clinical practice guideline”, from 2020 [1]. Similar to the German guidelines, these point out that BMI alone is not meaningful for assessing the risk of obesity-associated diseases. For an adequate assessment, a detailed medical history and the fat distribution pattern, which is determined using waist circumference or the ratio between waist and hip circumference, are also recommended. The “Edmonton Obesity System” could be used to determine the degree of severity. As is well known, obesity is associated with an increased risk of cardiovascular and oncological diseases, type 2 diabetes mellitus, etc. However, the risk increases not only in terms of BMI, but also in terms of fat distribution. In addition, influences such as socio-economic status and genetic factors play an important role [1,6].

Therapy by nutritionists

For the management of obesity, the guidelines recommend individually tailored nutritional therapy with a trained nutritionist as part of an interdisciplinary treatment strategy. Similarly, the European Association for the Study of Obesity (EASO) demands that every person suffering from obesity should have access to nutritional intervention by a specialist [1,6,7]. Nutritionists either have several years of professional training, such as dieticians in Germany, or a Bachelor’s or Master’s degree, such as dieticians in Austria and nutritionists in Switzerland [8–10].

Dietitians and nutritionists are faced with the challenge that dubious recommendations are quickly available via the Internet, books, family, friends, acquaintances or healthcare professionals. One study showed, for example, that only just under 3% of books on nutrition and dieting were written by trained nutritionists. What is striking about the remaining 97% is that most of the information is contradictory, much of it is not based on scientific research and health promises are made with a certain type of diet [11]. In practice, it has been shown that patients often make use of this information due to the high level of suffering. However, these proposed solutions often promote rigid eating behavior and sometimes exclude entire food groups. In addition, they are not personalized and are often difficult to integrate into everyday life. People who work in the healthcare sector also give patients nutritional tips with the best of intentions, but these are often not tailored to the patient’s individual needs and resources. In order to take a first step towards better quality of care, nutritional therapy for people with illnesses is legally regulated in Austria: only dieticians are allowed to make nutritional recommendations to people with illnesses [12]. In Germany, anyone is generally allowed to provide advice, but outpatient nutrition therapy is only (partially) funded by health insurance if the appropriate training is available and a doctor has issued a medical certificate of necessity [13].

Risk of the “yo-yo effect”

In nutritional therapy practice, it is often the case that patients only make contact with a qualified nutritionist for the first time, if at all, after years or even decades. Until then, diets were practiced that were sometimes very restrictive. This often reduced the weight in the short term, but the entire weight or even more was gained back in the course of time. This so-called “yo-yo effect” is a highly complex interplay of hormonal, biological and metabolic processes that cannot be broken through motivation, compliance, adherence or willpower [14]. The yo-yo effect is not only frustrating for those affected, but repeated weight fluctuations can also increase the risk of cardiovascular disease and type 2 diabetes mellitus [14–16]. In this case, a nutritionist can work with the patient to stabilize their weight. As a review by the European Association for the Study of Obesity (EASO) showed, a diet tailored to the individual needs of patients by nutritionists enables higher success rates. In order to achieve long-term success, it is necessary to take a detailed medical history to determine which form of nutrition can be integrated into the person’s everyday life.

The diets studied for obesity include the Mediterranean diet, the “DASH diet”, the Nordic diet or even a meal replacement product in the short term [7]. It is therefore essential to include barriers and support factors, such as the living and working situation, financial resources, mental state, etc., in the recommendations (Fig. 1). Nutritional therapy aims less at pure calorie restriction and more at promoting well-being and health through dietary and behavioral changes. This could, for example, involve encouraging the selection of high-fiber foods in order to achieve a long-lasting feeling of satiety and thus consume less total energy. Eating can also be learned as a form of self-care by trying to make time for regular meals in order to provide the body with sufficient nourishment and thus avoid cravings.

It has been shown that pure calorie reduction only has a short-term effect and leads to weight gain in the long term [17]. Even if the route of pharmacotherapy is chosen with the patient, the guidelines recommend an accompanying change in diet and behavior. Studies have shown that weight gain usually occurs after discontinuation of medication if there has been no change in diet or behavior [1,18]. There could also be a risk of malnutrition if sufficient protein and nutrient intake is not ensured during treatment with weight loss medication. Process models, such as the “German Nutrition Care Process” in Germany or the dietetic process in Austria, have been created to ensure the quality standard of nutrition therapy. Using these process models, the nutritionist works with the person concerned to find an individual way to improve their nutritional situation [19,20].

Those affected suffer from stigmatization

The increasing prevalence of mental illness and eating disorders in people with obesity is a further challenge, not only for nutritionists but also for the healthcare system. Mental health influences food intake: eating or not eating can be a mechanism for regulating or controlling emotions. In addition, some of those affected are also subject to weight stigmatization and discrimination. Eating disorders that are not recognized in time can pose a danger. In practice, it is important to take conspicuous behavior such as severely restricted eating behavior, compulsive exercise, laxative abuse and other counter-regulatory mechanisms, disturbed body perception and amenorrhea seriously, especially in the case of successful weight loss. This requires recognition of the problem and an interdisciplinary solution with the help of psychotherapy, behavioral therapy and nutritional therapy [1,21].

Weight stigmatization is an issue that affects not only nutrition therapy, but also the healthcare of people with excess weight in general. Called “weight bias”, it describes the prejudices that people who are overweight and obese are exposed to. An example of this would be the assumption that people with obesity do not practice sufficient personal hygiene, are lazy or eat too many high-calorie foods. Those affected are often not only subject to these beliefs, but also experience verbal abuse, discrimination and microaggressions due to their body shape and weight. As a result, people with health problems may not visit a healthcare facility out of fear and shame. Weight discrimination and stigmatization can therefore lead to a reduced quality of life and poorer health care and also promote disordered eating and eating disorders [1,22,23].

Talking about your weight can be a stressful experience for some people. It is therefore necessary in the treatment of obesity to be aware of “weight bias” and discrimination against people with excess weight, to register the level of suffering and to take complaints seriously. It can be helpful for everyday practice to actively engage with the topic. For example, chairs specially designed for people with obesity could be a first step towards creating a safe environment in the practice where those affected can feel comfortable. To help, the Canadian guidelines have developed a patient communication guide that provides a step-by-step guide to a patient-centered approach (Fig. 2) . For example, one way to start the conversation in a more sensitive way is to ask patients if they feel comfortable talking about their weight. Once a consensus has been reached, a guideline-based treatment strategy for improving health can be developed together with the patient [1].

Weight-neutral interventions are gaining in importance

The EAOS and Canadian guidelines agree that the management of obesity should not only be carried out for the purpose of weight loss, but above all to improve health [1,7]. For this reason, nutritional therapy should not be aimed exclusively at weight reduction, but rather at improving health parameters. In recent years, there has been an increase in weight-neutral interventions based on the principles of “intuitive nutrition” and/or “health at every size”. These principles are implemented in groups or in individual settings by interdisciplinary teams. In addition to nutritional knowledge, a holistic approach is also used to teach skills such as emotion regulation, relearning how to feel hunger or working on body image in order to reduce disordered eating behavior or improve body image [24,25]. As noted in the Canadian guidelines, too little research has been done on weight-neutral interventions for people with obesity to include them specifically in the recommendations [3].

In summary, nutrition therapy carried out by a qualified nutritionist offers a great opportunity in the treatment of patients with obesity. No single form of nutrition or pharmacotherapy can be cited as a recipe for success here. Instead, a diet that is individually tailored to the patient’s needs and requirements is recommended. The more individualized the therapy is, the greater the chances of long-term success. Individual therapy can therefore also mean that weight stabilization is aimed for instead of weight loss. This can help to avoid the negative consequences of the yo-yo effect, promote health and improve quality of life at the same time. In addition, close interdisciplinary cooperation between all healthcare professions is required to ensure the care of people with obesity and mental illness. Each individual can make a difference here by reflecting self-critically on prejudices and the way people with obesity and excess weight are treated. In the future, weight-neutral interventions could also play a greater role, as the success of the therapy is not only measured by weight loss. Rather, health parameters can be improved regardless of weight through dietary and behavioral changes. However, further studies are needed to integrate specific recommendations into evidence-based guidelines.

Take-Home-Messages

• BMI alone is not meaningful for assessing the risk of obesity-associated diseases. For an adequate assessment, a detailed medical history and the fat distribution pattern, which is determined using waist circumference or the ratio between waist and hip circumference, are also recommended.
• To ensure quality and safety in nutritional therapy, nutritional therapy for people with illnesses is legally regulated in Austria: only dieticians are allowed to make nutritional recommendations to people with illnesses.
• The “yo-yo effect” is a highly complex interplay of hormonal, biological and metabolic processes that cannot be broken through motivation, compliance, adherence or willpower.
• An accompanying change in diet and behavior is also recommended for pharmacotherapy to reduce weight. Studies have shown that weight gain usually occurs after discontinuation of medication if there has been no change in diet or behavior.
• Nutritional therapy for obesity should not only be carried out for the purpose of weight reduction, but above all to improve health and quality of life.

Literature:

1. Wharton S, Lau DCW, Vallis M, et al: Obesity in adults: a clinical practice guideline. Can Med Assoc J 2020; 192(31): E875-891.
2. New WHO report: Europe can reverse its obesity “epidemic”. www.who.int/europe/de/news/item/03-05-2022-new-who-report–europe-can-reverse-its-obesity–epidemic (last accessed: 25.01.2024).
3. Obesity and overweight. www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (last accessed: 10.01.2024).
4. Ahima RS, Lazar MA: The Health Risk of Obesity – Better Metrics Imperative. Science 2013; 341(6148): 856-858.
5. A healthy lifestyle – WHO recommendations. www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle—who-recommendations (last accessed: 19.01.2024).
6. Hauner H, Moss A, Berg A, et al: Interdisciplinary guideline of quality S3 on “Prevention and therapy of obesity”: of the German Obesity Society; the German Diabetes Society; the German Nutrition Society; the German Society for Nutritional Medicine Version 2.0 (April 2014); AWMF Registry No. 050-001. Obesity – Causes Consequences Therapy 2014; 08(04): 179-221.
7. Hassapidou M, Vlassopoulos A, Kalliostra M, et al: European Association for the Study of Obesity Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Adults Developed in Collaboration with the European Federation of the Associations of Dietitians. Obes Facts 2023; 16(1): 11-28.
8. SVDE ASDD – Swiss Association of Dietitians. Basic training/studies. https://svde-asdd.ch/bildung/grundausbildung-studium/ (last accessed: 10.01.2024).
9. Dieticians: Education. www.diaetologen.at/diaetologie/ausbildung (last accessed: 10.01.2024).
10. Dietitians – the experts for nutrition | VDD. www.vdd.de/diaetassistenten (last accessed: 10.01.2024).
11. Marton RM, Wang X, Barabási AL, Ioannidis JPA: Science, advocacy, and quackery in nutritional books: an analysis of conflicting advice and purported claims of nutritional best-sellers. Palgrave Commun 2020; 6(1): 43.
12. Federal Act on the Regulation of Higher Medical-Technical Services (MTD Act) StF: BGBl. No. 460/1992 (NR: GP XVIII RV 202 AB 615 p. 78. BR: AB 4332 p. 557.).
13. DGE: Nutritional therapy: Simplified recommendation thanks to updated “Medical certificate of necessity www.dge.de/presse/meldungen/2023/ernaehrungstherapie-vereinfachte-empfehlung-dank-aktualisierter-aerztlicher-notwendigkeitsbescheinigung (last accessed: 22.01.2024).
14. Busetto L, Bettini S, Makaronidis J, et al: Mechanisms of weight regain. Eur J Intern Med 2021; 93: 3-7.
15. Ceriello A, Lucisano G, Prattichizzo F, et al: Variability in body weight and the risk of cardiovascular complications in type 2 diabetes: results from the Swedish National Diabetes Register. Cardiovasc Diabetol 2021; 20(1): 173.
16. Park KY, Hwang HS, Cho KH, et al: Body Weight Fluctuation as a Risk Factor for Type 2 Diabetes: Results from a Nationwide Cohort Study. J Clin Med 2019; 8(7): 950.
17. Brown J, Clarke C, Johnson Stoklossa C, Sievenpiper J.: Canadian Adult Obesity Clinical Practice Guidelines: Medical Nutrition Therapy in Obesity Management. Available from: https://obesitycanada.ca/guidelines/nutrition.
18. Pedersen SD, Manjoo P, Wharton S: Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy for Obesity Management. Available from: https://obesitycanada.ca/guidelines/pharmacotherapy.
19. German-Nutrition Care Process | VDD. www.vdd.de/fuer-experten/german-nutrition-care-process (last accessed: 22.01.2024).
20. Dietitians: Diaetological process. www.diaetologen.at/
    diaetologie/diaetologischer-prozess (last accessed: 22.01.2024).
21. Burnatowska E, Surma S, Olszanecka-Glinianowicz M: Relationship between Mental Health and Emotional Eating during the COVID-19 Pandemic: A Systematic Review. Nutrients 2022; 14(19): 3989.
22. World Obesity Federation: Weight Stigma. www.worldobesity.org/what-we-do/our-policy-priorities/weight-stigma (last accessed: 20.01.2024).
23. Alberga AS, Russell-Mayhew S, von Ranson KM, McLaren L: Weight bias: a call to action. J Eat Disord 2016; 4: 34.
24. Tribole E, Resch E: Intuitive eating: a revolutionary anti-diet approach.4^th edition. New York: St. Martin’s Essentials 2020.
25. Grundl M, Brandacher J: Influence of Intuitive Eating on Body Perception and Disordered Eating Behavior – Observational Study of an Online Group Intervention (#81). Obesity – Causes, secondary diseases, therapy 2022; 16(03): 177; doi: 10.1055/s-0042-1755696.

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