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DISORDER IN DISGUISE

RECOGNIZING THE NEED FOR CHANGE WHEN COMMON DIET TRENDS CAUSE HARM

Schilling, Leslie P. M.A., RDN, CSSD, CSCS

Author Information
doi: 10.1249/FIT.0000000000000422
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Abstract

INTRODUCTION

When clients seek professional help with a desire to diet for weight loss or for improving their nutritional intake, we should stop to think about the consequences of supporting this goal. Consumers put their trust in health and fitness professionals to guide them toward wellness using evidenced-based practices. In our world of seemingly unlimited information and the rise of passionately uninformed “gurus,” delivering those evidence-based recommendations to our clients can become a high hurdle. Much like the people we are trying to help, our own behaviors and professional advice can be swayed by popular trends.

Although the word diet can simply mean a collection of the foods we eat, many refer to the words diet or diets as a means to restrict foods or energy intake for the purpose of weight loss. Dieting for weight control is typically viewed as a benign process in our society, yet research indicates that the chronic pursuit of weight loss and weight cycling are linked to poor physical and mental health (1). Our clients often desire to diet without realizing that it can cause harm to their physical and mental health. As health and fitness professionals, we are the front lines of defense for intercepting and safely redirecting potentially dangerous behaviors.

Our clients often desire to diet without realizing that it can cause harm to their physical and mental health. As health and fitness professionals, we are the front lines of defense for intercepting and safely redirecting potentially dangerous behaviors.

When our clients get to know us, they often share their personal stories as well as their struggles and fears involving their health and weight concerns. Our interactions with clients can allow us to spot red flags and help them move to a healthier path. We can support clients by acknowledging how common diet trends can become dangerous, focusing on health-promoting behaviors, and avoiding the promotion of harmful strategies in our own practices.

The goals of this article are:

  1. To discuss common nutrition trends that may increase the risk of disordered eating behaviors and body dissatisfaction.
  2. To shed light on the dangers and consequences of dieting behaviors commonly used by our clients and in our practices.
  3. To provide evidence and tips for using behavioral strategies that are weight-neutral in lieu of those focusing on weight loss or nutritional purity.
    1. Evaluate our own beliefs and biases in our roles as health and fitness practitioners.
    2. Understand how a weight-neutral, nondiet approach can be used in practice.

Common Diet Trends that Can Lead to Harm

There are thousands of diet programs that claim to boost health in some way or to help consumers lose weight. The diet industry’s seductive and often predatory marketing schemes hit consumers where they’re most vulnerable — the pursuit of health and longevity or the desire to change their bodies. According to Marketdata Enterprises, Inc., the diet control and weight loss market was worth just more than $66 billion in 2016, with expectations for continued growth in 2017 (2). As the use of the phrase “diets don’t work” becomes more common, typical weight loss and restriction diet programs may simply change their marketing to a lifestyle change instead. This wolf-in-sheep’s-clothing approach can land our clients and practices in dangerous waters. Check out this video to hear more from author Leslie Schilling, M.S., RDN http://links.lww.com/FIT/A91.

According to the Binge Eating Disorder Association, chronic dieting, irregular eating patterns, and large weight changes (weight loss and subsequent regain) are risk factors for developing binge eating disorder (3). Considering that many of our clients could be engaging in harmful behaviors as a means of weight control, it’s important that we help guide them toward safer and more sustainable approaches. These dangerous behaviors and consequences aren’t just seen in our adult clients. Adolescents who reported using weight control behaviors were at higher risk for being overweight (3×) and using disordered eating behaviors (6×) than their peers five years later who did not use weight control strategies at all (4). Dieting in itself can be a gateway to disordered eating behaviors.

Current dieting trends and fads are far too numerous to list and discuss. For the sake of brevity, the trends discussed in this article have been grouped into three categories: calorie restriction, macronutrient restrictions, and food-type restriction. Some of these trends may overlap in method, yet it is the underlying motivation or understanding of the consumer that makes the difference how they are categorized. A simple attitude of “I just want to eat better or lose weight” in any category could lead to disordered eating behaviors, body dissatisfaction, poor health, and even clinical eating disorders. Any nutritional or weight control trend can become dangerous.

CALORIE RESTRICTION TRENDS AND HARM

It’s well documented that calorie restriction can lead to short-term weight loss. For this reason, one of the most popular methods of achieving weight loss is simple caloric restriction. Eating less (calories) has been the go-to strategy for weight loss and a means to what many perceive as the path to health. There are numerous trends that may have new or exciting terminology that are ultimately simple calorie counting.

Using a variety of prediction equations, our clients can roughly estimate the daily energy needs of their bodies. If weight loss or eating less is a goal, consumers aim to eat less calories, creating a deficit to illicit weight loss or weight control. It’s often viewed as the easiest method to control weight.

Recently, we have seen a boom of wearables and online trackers. These devices help the user estimate their daily caloric expenditure. Newer wearables have many other functions like activity tracking, GPS, heart rate, and sleep monitoring. Some of our clients don’t wear the trackers specifically to count calories, yet many are using trackers that sync to calorie-tracking programs for weight loss purposes.

Another method of calorie counting simply converts calories in some way to points or units. This may initially make the consumer feel that their using a new, or lifestyle, approach. Yet, it still is based on simple caloric restriction for the purpose of weight loss.

These quantitative approaches to eating tend to ignore quality-of-food and quality-of-life approach. In addition, prolonged caloric restriction can lower the metabolic rate, increase binging behaviors, heighten preoccupation with food, cause weight gain, and increase the risk of eating disorders (4,5). This approach also ignores many other factors that impact body weight such as genetics, medications, disease states, and food insecurity (1).

MACRONUTRIENT RESTRICTION TRENDS AND HARM

Manipulation of macronutrients also is a popular trend. There are recommended ranges for protein, fat, and carbohydrate and very appropriate reasons to use them as a guide when trying to provide adequate fueling based on activity levels and disease states. However, many of these trends can lead clients to deficiencies, fear of foods, and binging behaviors.

The most typical form of macronutrient counting simply sets specific ranges for protein, fat, and carbohydrate intake within a specific caloric amount. Macronutrient range-based dieting has been a component of dieting for decades but has recently become more popular. Although fat in the diet does not need to be as restricted as much as once thought, severely cutting fat intake in the diet continues to be popular. Fat has long been demonized in our culture, and the lingering effects and fears of the fat-free craze linger (6). Much like restricting fat, restricting carbohydrate intake can go too far.

When certain macronutrients are extremely limited, there is a potential risk of missing specific nutrients in the overall diet. It’s not uncommon to see clients that report severely restricting fat that also have clinical symptoms like hormonal dysregulation (i.e., amenorrhea) and vitamin deficiencies (7). In addition, attempting to maintain extremely low levels of carbohydrate intake may not be sustainable. Like other methods of restrictions, these trends may lead to binging behaviors and subsequent chronic dieting behaviors (4).

FOOD-TYPE RESTRICTION TRENDS AND HARM

Diet advice related to becoming gluten free, vegetarian, organic-only, or eating foods of ancient cultures isn’t hard to find. Some of these trends have underlying concepts of eating more whole foods, whereas others may focus only on food attributes like being plant-based or free of certain ingredients. These food-type restrictions don’t always lead to disordered eating patterns and aren’t always related to the pursuit of weight loss. Instead, many consumers begin these eating patterns based on their perception of a healthy lifestyle or reasons that may be related to human longevity or animal welfare (8).

Those with the autoimmune disorder celiac disease absolutely need to avoid the intake of gluten (the protein found in wheat) to reduce symptoms and further damage to their gastrointestinal tract. Some consumers have true intolerances to gluten that have less adverse symptoms when abstaining from gluten. Yet, for those dieters who adopt a more gluten-convenient approach, avoiding foods containing gluten as a fad or a means of socially acceptable restriction may be at risk for adverse effects like micronutrient deficiency (9).

For some clients, adopting a paleo-style eating pattern simply means trying to eat more whole foods, and for others, it can be far more restrictive. This style of eating omits foods that were presumably not available during the Paleolithic era. Some users of this type of diet incorporate “cheat meals” or “cheat days” that, for some, mimic binge-like behaviors and increase guilt and shame around eating certain foods.

Vegetarianism and veganism are common in food-type restrictive lifestyles. Many consumers engage in a mostly or strictly plant-based eating style without nutritional deficiency or further health concerns. Yet, some consumers make the leap into a strict lifestyle or eating pattern without the knowledge of how to replace nutrients found in a typical mixed diet. This, coupled with the use of this lifestyle approach as a means to restrict intake, can become a path to deficiency and disordered eating behaviors (10).

Regardless of the trend or intention, some food-type restriction eating patterns can land our clients in dangerous situations. Many consumers who choose to limit or avoid some foods can live healthy and fulfilling lives. Others can take food-type restrictions too far. Knowing the intention of the food limitation or omission is crucial to discovering if our client will end up with nutrition deficiencies, disordered eating behaviors, or a decreased quality of life (8).

If the intention of the restriction is to achieve nutritional purity or perfection within one’s perceived definition of health, it can become detrimental to both physical and mental health (8). This unhealthy fixation on being healthy is called Orthorexia nervosa, coined by Steven Bratman, M.D., in 1997 to describe his patients who were extremely health obsessed. Although it’s not currently a recognized diagnosis, it can lead to severe disordered eating behaviors as well as a diagnosis of a clinical eating disorder.

BOX 1 – NUTRITION CHARACTERISTICS

Health and fitness professionals have the opportunity to work with clients and help guide them away from dangerous trends. Knowing the difference between normal eating behaviors and pathological eating behaviors can help us determine if our clients’ eating behaviors are becoming worrisome. The following points demonstrating the different characteristics of normal and pathological eating are based on the work of Jessica Setnick, MS, RD, CEDRD-S, of www.UnderstandingNutrition.com. Adapted with her permission.

Characteristics of Positive Nutrition:

  • Promotes health and successful physical functioning
  • Health-seeking through including nutritious foods
  • Motivated by a desire to live a healthy life
  • Promotes a feeling of accomplishment and pride, yet allows for flexibility and unavoidable snafus
  • Allows for enjoyment of food as one of many aspects of a balanced life
  • Promotes positive social interaction and relationships

Characteristics of Pathological Nutrition:

  • Seeks health, but deteriorates it and impairs function
  • Health-seeking through excluding unacceptable foods
  • Motivated by a need to manage anxiety
  • Success depends on adherence to food rules; mistakes or uncertainty are not acceptable
  • View food as a source of fear and danger that must be controlled
  • Causes isolation and interferes with relationships

Consequences of Chronic Dieting

Losing weight does not equate to increasing health (11). To date, weight loss interventions have demonstrated that weight loss is rarely sustainable long term and may even worsen health outcomes (1). Research dating back to the 1940s suggests that dieting can be harmful (11,12). Documented adverse effects of weight loss dieting and weight cycling include (but are not limited to) food obsession, hyperphagia, increased body fat, muscle loss, weight gain, heart disease, binge eating, osteoporosis, gallstones, inflammation, and suppressed metabolism (1,4,5,11,13).

That leaves us with this question — is promoting weight loss for the sake of weight loss an evidence-based or ethical practice? The question isn’t if these methods lead to weight loss because years of short-term weight loss intervention studies demonstrate temporary success. The question is, are we perpetuating harmful behaviors by promoting weight loss strategies without evidence of long-term benefit? This doesn’t mean that we can’t help people with their eating and fitness behaviors. It means that using weight loss as a primary outcome of success isn’t healthy, sustainable, or evidence based; and, it can contribute to disordered eating behaviors and poor overall health (11,14).

Moving our Practice Forward as Nondiet Health and Fitness Professionals

Health and fitness professionals play a critical role in promoting the health of our clients. Not only must we increase our own awareness of behaviors that are health promoting, we must be willing to evaluate areas where we can continue to learn and grow in our own practice. Many practitioners in the field of physical and mental health use the mantra “you can only take a client as far as you’ve taken yourself.” If we’re struggling with nonmedical food restrictions, rigid eating patterns, or chronic dieting for weight loss, it’s possible we’re providing the same advice to our clients. When we recommend a way of eating that isn’t sustainable, causes social isolation, and makes our client fearful of certain foods — we are causing harm.

Many practitioners in the field of physical and mental health use the mantra “you can only take a client as far as you’ve taken yourself.” If we’re struggling with nonmedical foodrestrictions, rigid eating patterns, or chronic dieting for weight loss, it’s possible we’re providing the same advice to our clients. When we recommend a way of eating that isn’t sustainable, causes social isolation, and makes our client fearful of certain foods — we are causing harm.

Research suggests that nutrition, fitness, and health professionals, in particular, may be at greater risk for orthorexic tendencies and eating problems than the general population (8,15,16). One of the first steps in helping our clients is increasing awareness of our own eating behaviors and nutritional beliefs (see Box 1). If it seems that, as a practitioner, there are unhealthy issues around food and weight control, the next step is seeking professional support and/or supervision. It is not uncommon for health and fitness professionals to seek additional help in these areas for personal and professional growth. In addition, practitioners can benefit their clients by becoming more aware of weight stigma and bias while adopting an approach that promotes well-being over weight loss (1).

Recognizing Weight Stigma and Bias

According to studies conducted and published by the UConn Rudd Center for Food Policy & Obesity, health care providers are one of the most common sources of weight bias (17). Weight bias occurs when an underlying prejudice causes a belief that persons living in larger bodies are lazy, unsuccessful, unintelligent, overindulgent, and lack willpower. Despite the evidence that weight loss interventions are rarely helpful or sustainable, health care professionals with this underlying bias continue to recommend them and blame their patients’ poor discipline for noncompliance and lack of long-term success (17,18).

Weight bias occurs when an underlying prejudice causes a belief that persons who are overweight or living in larger bodies are lazy, unsuccessful, unintelligent, overindulgent, and lack willpower. Despite the evidence that weight loss interventions are rarely helpful or sustainable, health care professionals with this underlying bias continue to recommend them and blame their patients’ poor discipline for noncompliance and lack of long-term success.

Those living in larger bodies may internalize these beliefs as well, creating stigma. Persons with internalized weight stigma are less likely to go to health-related appointments (because of weight bias) and are more likely to experience depression, bullying, lower self-esteem, disordered eating behaviors, and inadequate health care (17,18). Evaluating, recognizing, and moving toward a more weight-neutral practice can help professionals and clients alike. Watch this video to learn more http://links.lww.com/FIT/A92.

Promoting Nondiet Health Behaviors in Practice

Emerging evidence suggests that weight-neutral approaches may have a greater impact on physical and mental health and be less harmful than traditional weight management regimens (1,14,19). Many practitioners that have shifted their practice philosophy from a weight-focused to weight-neutral practice once asked themselves: “if not dieting, then what?” The weight-neutral, nondiet approach removes weight as an indicator of health and instead emphasizes focus on the many factors that impact overall well-being (1,19).

In a 2015 systematic review of studies that used nondiet approaches, the authors noted many health-related benefits across the interventions (19). Benefits included improved fitness levels, increased fruit and vegetable intake, improved dietary patterns, improved emotional health, reduced eating disorder symptoms, reduced body image dissatisfaction, reduced blood pressure, and reduced blood cholesterol levels (19). Investigators in this field have called for more interventions to be designed and funded using the nondiet approach (14). In addition, researchers who studied body weight in relation to fitness levels found that an individual’s cardiorespiratory fitness level was more predictive of mortality than body mass index (20). Learn more in this video http://links.lww.com/FIT/A93.

BOX 2 Non-Diet, Weight-Neutral Practice Tips
  • Remove weight as a primary indicator of success by removing weight scale from prominent location in your practice setting. Use sparingly (if at all).
  • Guide clients toward behavior change instead of a weight loss focus.
  • Evaluate your own personal and professional beliefs about weight and health practices. Determine how they may influence your practice.
  • Promote healthful and pleasurable eating by encouraging clients to eat regularly and avoid getting too hungry.
  • Avoid talk that dichotomizes food into good and bad categories. No foods are off-limits unless a client has a food allergy. Balance is the key (vs. fear).
  • Provide information about the dangers of common diet and weight loss trends.
  • Help clients become more intuitive and attuned eaters — understanding that their bodies can be trusted to signal hunger, fullness, and what foods fuel them best.
  • Avoid making comments about weight loss or weight gain.
  • Redirect clients if they make disparaging remarks about their body or shape. Comments like “health doesn’t have a look” and “all bodies are good bodies” can be helpful.
  • Focus on improving fitness levels regardless of body size.
  • Don’t make assumptions about someone’s health based on their weight or shape.
  • Help clients understand the many variables that influence well-being in addition to nutrition and movement, like sleep, self-care, and healthy relationships.
  • Find nondiet practitioners in your area who can provide professional support and be used as referral sources.
  • Review resources that promote nondiet, weight-neutral approaches like the Satter Eating Competence Model, Intuitive Eating, Mindful Eating, and Health at Every Size® (see recommended readings and additional resources).

As health and fitness professionals, we can play an important role in promoting positive change in the lives of our clients. There are several ways to start implementing health and well-being behaviors into our practices. Well-being is multifaceted, and we continue to learn about the many things that impact our overall health besides weight. The first step is focusing on health-promoting behaviors and helping our clients understand that a number on the scale isn’t one of those behaviors.

BRIDGING THE GAP

Common dieting trends can land our clients and practices in dangerous waters. Recognizing these trends and helping our clients embrace sustainable health behaviors can reduce the harmful effects of weight loss dieting and rigid eating trends. By evaluating our own beliefs around weight and dieting strategies, we can evolve our practices to be more accepting of those seeking health and fitness guidance, regardless of their weight or body size. A nondiet, weight-neutral approach removes the focus on weight and allows clients to focus on health-promoting activities instead.

References

1. Tylka T, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity. 2014; Article ID 983495.
2. Web Wire Web site [Internet] Atlanta (GA): Web Wire; [cited 2018 January 9]. Available from: https://www.webwire.com/ViewPressRel.asp?aId=209054.
3. Binge Eating Disorder Web site [Internet] Severna Park (MA): BEDA Online; [cited 2018 January 23]. Available from: https://bedaonline.com/understanding-binge-eating-disorder/binge-eating-disorder-causes/.
4. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc. 2006;106:559–68.
5. Dulloo AG, Jacquet J, Montani JP, Schutz Y. How dieting makes the lean fatter: from a perspective of body composition autoregulation through adipostats and proteinstats awaiting discovery. Obes Rev. 2015;16(Suppl 1):25–35.
6. Mozaffarian D. Food and weight gain: time to end our fear of fat. Lancet Diabetes Endocrinol. 2016;4(8):633–5.
7. Tenforde AS, Barrack MT, Nattiv A, Fredericson M. Parallels with the female athlete triad in male athletes. Sports Med. 2016;46:171–82. https://doi.org/10.1007/s40279-015-0411-y.
8. Koven NS, Abry AW. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385–94. doi:10.2147/NDT.S61665.
9. Niland B, Cash BD. Health benefits and adverse effects of a gluten-free diet in non–celiac disease patients. Gastroenterol Hepatol (N Y). 2018;14(2):82–91.
10. Bardone-Cone AM, Fitzsimmons-Craft EE, Harney MB, et al. The inter-relationships between vegetarianism and eating disorders among females. J Acad Nutr Diet. 2012;112(8):1247–52. doi:10.1016/j.jand.2012.05.007.
11. Tribole E, Resch E. The Intuitive Eating Workbook: 10 Principles for Nourishing a Healthy Relationship with Food. Oakland (CA): New Harbinger Publications, Inc.; 2017. 251 p.
12. Stunkard A, McLaren-Hume M. The results of treatment for obesity: a review of the literature and report of a series. AMA Arch Intern Med. 1959;103(1):79–85.
13. Lissner L, Odell PM, D’Agostino RB, et al. Variability of body weight and health outcomes in the Framingham population. N Engl J Med. 1991;324(26):1839–44.
14. Mann T, Tomiyama AJ, Ward A. Promoting public health in the context of the “obesity epidemic”: false starts and promising new directions. Perspect Psychol Sci. 2015;10(6):706–10.
15. Bo S, Zoccali R, Ponzo V, et al. University courses, eating problems and muscle dysmorphia: are there any associations? J Transl Med. 2014; [cited 2018 February 12];12:221. Available from: https://translational-medicine.biomedcentral.com/articles/10.1186/s12967-014-0221-2 doi:10.1186/s12967-014-0221-2.
16. Dittfeld A, Gwizdek K, Koszowska A, et al. Assessing the risk of orthorexia in dietetic and physiotherapy students using the BOT (Bratman Test for Orthorexia). Pediatr Endocrinol Diabetes Metab. 2016;22(1):6–14.
17. Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100(6):1019–28. doi:10.2105/AJPH.2009.159491.
18. O’Brien KS, Latner JD, Puhl RM, et al. The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress. Appetite. 2016;102:70–6.
19. Clifford D, Ozier A, Bundros J, Moore J, Kreiser A, Morris MN. Impact of non-diet approaches on attitudes, behaviors, and health outcomes: a systematic review. J Nutr Educ Behav. 2015;47(2):143–55.e1. Available from: http://www.jneb.org/article/S1499-4046(14)00796-9/fulltext.
20. Vaughn WB, Baruth M, Beets MW, Durstine LJ, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a meta-analysis. Prog Cardiovasc Dis. 2014;56(4):382–90.

Recommended Readings:

  • Bacon L. Health at Every Size. Revised ed. Dallas (TX): Benbella Books: 2010. 400 p.
  • Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness. New York (NY): The Guilford Press: 2016. 276 p.23
  • Tribole E, Resch E. Intuitive Eating: A Revolutionary Program That Works. 3rd ed New York (NY): St. Martin’s Press: 2012. 344 p.
  • Tribole E, Resch E. The Intuitive Eating Workbook: 10 Principles for Nourishing a Healthy Relationship with Food. Oakland (CA): New Harbinger Publications, Inc.; 2017. 251 p.
  • Scritchfield R. Body Kindness: Transform Your Health from the Inside Out–and Never Say Diet Again. New York (NY): Workman Publishing Company: 2016. 288 p.
  • Willer F. The Non-Diet Approach Guidebook for Dietitians: A How-To Guide for Applying the Non-Diet Approach to Individual Dietetic Counselling. Raleigh (NC): Lulu Publishing: 2013. 127 p.

Additional Resources:

Keywords:

Dieting; Disordered Eating; Nutrition Counseling; Weight Stigma and Bias; Weight-Neutral Practice

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