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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.

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