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Patients consuming less and still not losing weight

Oct 30, 2012

Have you ever had a patient tell you, “I never get hungry and I hardly eat anything, but I still can’t lose weight?” I have several times. Most providers just assume the patient is exaggerating and really does eat all the time and just doesn’t realize it. That could be, but I really believe there are other factors that contribute. It’s not always calories in balanced with calories out for weight control.
 
When someone says “they never eat,” here are the scenarios in my opinion:
 
Patients who do not realize how many calories they are consuming. When you ask them to keep a food diary, they show drinking soda or liquid calories a few times a day, snacking on chips, fruit, and bites of candy throughout the day, and do not realize how much they are consuming. They may also have a pattern of eating out and it is very deceiving for even a dietitian to estimate the calories in a fast food meal. A vegetable-based meal could have more than three times the size or volume as a fast food meal.
 
For some patients their schedule varies so greatly that if they brought in the last three days of food records, they could be close to 1,200 calories. Then, there are other days where they are over 4,000 calories from eating out, etc. This wide fluctuation could still average their calories out to be higher than what they need. Especially for these patients, it is important to have them continue to keep records over several weeks.
 
Then there is another group of patients who really don’t have much of an appetite and do not eat that much. Their appetite is either low from a cocktail of medications they may be taking or from a slow metabolism as a result of decades of minimal physical activity. I’ve had a few patients that told me several doctors have not believed them and they have been told to eat even less or continue to cut out certain foods to lose weight. They are very frustrated because they are doing what their providers have told them and they still do not see results. This is the group that most intrigues me. They bring in their food diary and have honestly written down every bite of food that went in their mouth and it adds up to a very small amount of calories. After building rapport and trust with them during their visit, I assure them that ‘I believe them’ because they have been very defensive and attacked by other providers over the years. I also tell them to eat more frequently and consume more calories. Specifically, I have done this with a patient recently who for years has been trying to lose weight. She was so excited that after increasing her calories she finally started to lose weight.
 
I realize if you are a dietitian, you may have seen similar scenarios. I would love to know your approach or things you have found to work. If you are another type of provider who doesn’t necessarily study food diaries everyday but has a patient who complains of ‘not eating and not losing,’ I would really encourage you to refer them to a Registered Dietitian who can dig deeper into the problem. I know in some settings providers are just given a few minutes with a patient and often can be rushed and give patients quick answers to their questions. While this works with some things, my year of experience with counseling about weight loss tells me that it is so complex that each patient should be evaluated individually to troubleshoot their challenges with weight loss.
 
I’d love to get your feedback about your experience with this issue.

10 comments

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  1. Nov 14, 2012

    Amy, Thank you for sharing your experiences. Patients can become very frustrated when they eat so little that they put their bodies into starvation mode. I appreciate your insight and the ideas about food diaries over a longer period so that you can discern the true issue. Thanks, Karen Goldie
  2. Nov 07, 2012

    My experience with this issue is about the volume of food eaten as well as the liquid calories that most patients don't take into account. The patient may reveal reasonable eating habits but not understand the portion control issue. Helping patients understand a serving size and the calories these servings reflect is usually an "eye-opener". Also, the need for consistent exercise is overlooked. Patients think of themselves as having an exercise program but is may be so occassional that it does not impact their weight control efforts.
  3. Nov 05, 2012

    I have had similar patients. I start with "how" a person eats--encourage sitting at the table, no TV etc; breakfast every day. I like to add nuts to breakfast (recent research show nuts help suppress appetite and are not absorbed efficiently, so are lower in calories than previously thought); I aim for 1-1.2 gm protein/kg (Douglas Paddon-Jones' research), and really increasing vegetables to get minimum of 5 servings/day ('give lots of recipe ideas)--(I use Barbara Rolls' "Volumetrics" ideas). I encourage anything that decreases sitting as a start to increase activity (stand while working, get up once an hour and move for 30 seconds to two minutes; decrease tv/screen entertainment). Once a person has started moving a bit, I aim for some more purposeful activity (walk for 2 minutes and gradually increase--2 minutes sounds so easy that people laugh, BUT if they then increase by even 1 minute per day , they can get up to 8 minutes/day in 1 week and 15 minutes per day in 2 weeks --that is meaningful if a person has never exercised! For a very overweight person, a small amount of exercise burns a lot of calories. Eventually I aim for the guidelines of at least 150 minutes per week and add resistance training; but for some long term obese, starting with extremely small increments really helps.
  4. Nov 02, 2012

    I was asked to write a blog for the Children's hospital web site for Diabetes month. I use the analogy of the parent as their child's health coach in my interaction with them and included information about managing the game plan. Orrin Woodward of Life has written about PDCA: plan, do, check, adjust in building leaders, and it works well in anything we do in life. The published blog is attached, along with the origional one. As we help others, think about goal setting within the PDCA context.
  5. Nov 01, 2012

    Amy, Thank you for the article. There are a number of patients I encourage to eat more frequently to improve their metabolism as opposed to 'starving' until that one large meal. Isn't it true that the liver provides the glucose they need as well as extra than if they had eaten a meal at breakfast? Is 15 grams of carbohydrate sufficient to signal the liver that food is coming? I appreciate the dietitians in my practice and refer my patients to see them for education and support. Respectfully, Lisa Laird
  6. Nov 01, 2012

    I agree that there are those clients that eat very little and still do not lose. I have tried to explain to them that when they eat the right balance of foods the nutrients allow them to burn (increase their metabolic rate) better than when they miss food groups, When they eat more often and increase their variety of food groups they lose and feel better and then can move more to lose even more.
  7. Oct 31, 2012

    One recommendation that I ask clients to follow: walk, move lower limbs for 7-10 minutes after each meal. Simple, easy and when speaking with a male client I suggest using a broom in the kitchen, or dancing with the chef!
  8. Oct 31, 2012

    As a pharmacist and Diabetes educator, I always inform my patients to follow these instructions to loose weight and achieved my goal successfuly. 1- Drink 2 cups of water before half an hour of each meal, 2- avoid drink water during the meal or after a meal directly, 3- Eat fruit on an empty stomach, 4- Don't delay your dinner and don't eat sleep directly, 5- Don't deprive yourself from eating, and then you will eat randomly and eagerly, 6- Do exercise at least 10 min per day, 7- Encourage my patients to eat raw nuts when they feel hungry instead of over eating,
  9. Oct 30, 2012

    Amy, great post. I am very lucky to work with two wonderful RD, CDE's. I know our patients greatly benefit from their expertise. I appreciate your comment about building trust. Food is so personal and it is important that all educators provide a non-judgemental environment where our patients feel safe.
  10. Oct 30, 2012

    This is actually a topic I discuss with many healthcare professionals, in fact, I get asked from HCPs, "what do you say to a patient when they tell you they hardly eat but yet still have a hard time losing weight?" I think your article identifies situations that are hard for many to identify and adress. Food and Exercise diaries reveal a lot. Thanks for sharing!

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