bad practices that must alarm us

Anyone you want being followed by a nutritionist for a problem of overweight, obesity or for diseases such as diabetes, thinness, sports, dyslipidemia, dyspepsia and constipation, has the probability of running into an ‘expert’ who has not studied the subject. It has always been like this, but in the last 15 years the number of ‘nutritionists’ has multiplied dramatically and now they are present in gyms, pharmacies, private practices, etc. Not to mention the ‘slimming centers’, franchise chains that offer supplements to lose weight, or closed Facebook groups, followed by tens of thousands of users, whose administrators block any dissent to the rigid dogmas proposed. Other nutritionists have worked for years for free (the customer did not pay them) at pharmacies, dispensing diets and suggesting supplements produced and sold by the pharmacies themselves (see photo below).

The variety of tips, proposed supplements or dietary regimes simply leave you disoriented. It almost seems that dietary choice is a philosophical question, as if evidence-based medicine did not exist. In this jungle it is also difficult for doctors to refer their patients to truly trained nutritionists. Very often the general population independently chooses who to turn to, thanks to word of mouth or internet reviews that can be completely false. In short, it is a chaos in which it is difficult to extricate oneself.

In this note let’s try to provide some suggestions to understand when it is better to stop and think and change direction. These are indications drawn from real cases.

1) First case – 53-year-old mother and 25-year-old daughter (60 kg per 1.68 m, BMI 21) simultaneously refer to the same nutritionist who prescribes a very similar computerized diet, with a daily calorie consumption ranging from 1,000 to 1,300 kcal / day (some days are 1,200, others 1,100, others 1,300). The girl rightly wonders why both her and her mother, who have different nutritional needs, were given the same diet. A 25-year-old girl generally has a basal metabolic rate, i.e. a caloric expenditure at rest in 24 hours, which is around 1,500 kcal (a 50-year-old woman of normal weight, on the other hand, can have a basal metabolic rate of 1,300 kcal per day), while the total calorie expenditure can be 2,200 / 2,500 kcal per day. It would therefore be advisable to prescribe a diet of at least 1,300-1,500 kcal / day and not go below the basal metabolic rate. We talked about it here. Furthermore, the girl in this case is perfectly normal weight, why should she follow a 1,200 kcal diet? Unfortunately, it sometimes happens that a low-calorie diet is prescribed to those who, even without necessity, are willing to pay to receive it.

2) Second case – A 30-year-old nurse with two previous miscarriages becomes pregnant again and has health problems. She is in her 5th month of pregnancy and has gained weight too quickly. The doctor who follows her, with a double specialty in gynecology and endocrinology, recommends that the patient be followed by a nutritionist. The nurse turns to a nutritionist who estimates her basal metabolic rate at 1,500 kcal and directly prescribes a 1,200 kcal diet without signing it with the patient’s name, and without stamping her and personally signing her as a professional. Also in this case the choice of giving such a restrictive diet in a woman in the 5th month of pregnancy with two previous abortions is very questionable. It is contraindicated to give too restrictive regimens during pregnancy, and even in this case the mistake is made to give a diet below the basal metabolic rate.

3) Third example – Overweight 18-year-old girl with a history of anorexia nervosa at the age of 13-15. She turns to a nutritionist, who prescribes a diet of 1,200 / 1,300 kcal per day that makes her lose 28 kg of weight. A nutritionist should never prescribe slimming diets (in a broad sense) and especially so restrictive to a person with a history of anorexia: the most likely result is triggering a disordered eating behavior with binges and rapid weight recovery. This was done on time! If you have current or past health problems, or are taking various medications, it is always better to consult a dietician or at least it is good that the dietary intervention of a dietician / nutrition biologist is supervised by a doctor. In the cases mentioned, however, the various nutritionists have always worked independently, alone without consulting any doctor.

But let’s come to a virtuous case that indicates what serious dietary treatment should be like. The family doctor identifies a 14-year-old patient of his with severe obesity in which there is certainly a family component (genetic?) Since there are several cases in the family of origin: grandmother and paternal grandfather, an uncle and a cousin with severe obesity. He prescribes tests for her and then refers her to a nutritionist who works in the same office as the family doctor.

The treatment it lasts two years and the girl manages to lose 18 kg very gradually going from 100 to 82 kg! This is an exceptional result that was achieved thanks to the support of the girl’s family, the skill of the nutritionist (empathy, use of cognitive behavioral techniques, extremely personalized and continuously adapted dietary prescription). They are hours and hours of psychological and educational support during the two years of treatment. Nothing stratospheric or esoteric, no miracle treatment ‘7 kg in 7 days’ but an average weight loss of only 750 grams per month. Unfortunately, many get lost along the way because they dream of treatments in which they lose at least 4/5 kg per month ‘otherwise it is a failure’, but it would not be a regime suitable for a teenager of only 14 years! Sometimes it is the parents themselves who have exaggerated expectations and who cause their child to stop treatment because ‘he does not lose enough weight’.

In this case the ‘nutritional rehabilitation process’ went very well because there was coordination and synergy between the family doctor and the dietician, no miraculous, unique, original, drastic, low carb or ketogenic diet. This example represents in the dietary context the ‘banality of good or the banality of what is right to do’. In reality, it can be done even better by involving when necessary also other professional figures such as psychologists and physiotherapists.

Unfortunately it is difficult even for serious nutritionists to work properly because they have to spend a long time explaining to patients and family members that what other ‘nutritionists’, diet gurus and weight loss centers are doing is not correct; explain that in dietetics there are no shortcuts and that when you think you have found the magic formula for losing weight quickly, it means that ‘you have been screwed’. And it is for this reason that many medical specialists in food science (real dieticians) decide to do something else, because being a nutritionist becomes an ‘alienating’ job, having to continually confront all these parallel realities of diet industry. This explains why there are so few medical specialists in food science who are dedicated to the profession. On the other hand, today a degree in medicine is in great demand and there are many opportunities to dedicate oneself to other fields, much more profitable and less ‘crowded’.

Antonio Pratesi and Abril Gonzalez Campos

© Copyright reserved Photos: Fotolia, AdobeStock

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