A New Clinical Perspective: Treating Obesity with Nutritional Coaching Versus Energy-Restricted Diets

Nutrition 60 (2019) 147À151

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Nutrition

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Review article A new clinical perspective: Treating obesity with nutritional coaching versus energy-restricted diets

PaulaD1XX Helena Dayan M.D. StudentD2XaX,*, GaryD3XX Sforzo Ph.D.D4XbX, NathalieD5XX Boisseau Ph.D.D6XcX, LucianaD7XX Oquendo Pereira-Lancha Ph.D.D8XdX, AntonioD9XX Herbert Lancha Jr,D10XX Ph.D. a,1 a Biodynamic Department of Physical Education and Sport School University of Sao~ Paulo, Sao~ Paulo, Brazil b Department of Exercise and Sport Sciences, Ithaca College, Ithaca, New York, USA c Universite Clermont Auvergne, Laboratoire des Adaptations Metaboliques al ’Exercice en conditions Physiologiques et Pathologiques, Clermont-Ferrand, France d IBES, Sao~ Paulo, Brazil

ARTICLE INFO ABSTRACT

Article History: Although current guidelines for obesity treatment endorse lifestyle modiﬁcations to achieve weight loss, Received 29 June 2018 energy-restricted diets are still the most commonly used method for the management of overweight. Diet Accepted 29 September 2018 restriction, however, not only is ineffective in promoting long-term weight loss but also may have more costs than beneﬁts, predisposing the individual to fat regain. Several physiological and psychological mechanisms Keywords: protect the body against starvation and explain how food restriction can promote paradoxically the opposite Obesity of what it is planned to achieve, triggering changes in energy metabolism, endocrine function and, thus, Health promotion body composition. New approaches that focus on behavioral treatment without diet restriction, such as Health coaching Eating habits nutritional coaching, are showing strong growth that arises as an innovative way to create sustainable and Nutritional education effective lifestyle changes. Weight loss © 2018 Elsevier Inc. All rights reserved. Behavioral nutrition

Introduction number of existing diet programs make clear that none are highly successful at inducing and maintaining weight loss, even those Obesity is an abnormal or excessive fat accumulation that poten- with supporting scientific evidence. Sustainable weight loss tially can lead to development of diabetes, cardiovascular diseases, requires the patient to adopt and incorporate new behavior pat- musculoskeletal disorders, obstructive sleep apnea, and cancers, and terns into their lives. Health and wellness coaching is a relatively now affects >1.8 billion people [1]. Lifestyle interventions are often novel strategy with demonstrated effectiveness in assisting recommended to treat obesity with energy-restricted diets (ERDs), patients with obesisty in their efforts toward weight management most commonly used for management of this disease. The U.S. weight [8]. Moreover, this strategy can be adopted successfully in a nutri- loss market is valued at >$66 billion and it seems thousands of new tional coaching (NC) model to specifically work with obese indi- diets are created every year [2]. ERDs, based on dietary prescription, viduals. NC is an intervention with tremendous potential and is have largely failed in long-term obesity treatment [3]. Despite this, the focus for this review [9]. ERDs continue to be the most popular approach to weight manage- The primary aims of this review were to provide clinicians with ment [4]. The continuously growing obesity rate demonstrates that an arsenal of reasons to help convince their patients to avoid ERDs weight loss as an indicator of success is not only fruitless but also may and to introduce clinicians to the behavior-changing process of be physiologically and psychologically damaging [5]. health coaching with emphasis on NC. The intention is to help Although the management of obesity requires lifestyle inter- practitioners acquire new tools to become more effective in pro- vention, most ERDs focus more on macronutrient composition moting weight loss, which in turn should help their patients and less on changing behavior. Recent studies using low-fat or improve their health. low-carbohydrate diets reported significant weight loss with or without exercise participation [6,7]. However, simply the vast Reasons to avoid energy-restricted diets

* Corresponding author. Tel.: +55 11 3091-3096 ﬁ E-mail address: [email protected] (P.H. Dayan). ERDs may have more costs than bene ts, paradoxically promot- 1 Supported by CNPq 301213/2015-1. ing exactly the opposite of what is intended [10]. Between 90% and https://doi.org/10.1016/j.nut.2018.09.027 0899-9007/© 2018 Elsevier Inc. All rights reserved. 148 P.H. Dayan et al. / Nutrition 60 (2019) 147À151

95% of individuals following weight loss diets will regain weight in Johansen et al. [18] investigated changes in body composition and the long term, sometimes ending up weighing more than before energy expenditure in 16 obese individuals involved in a “Biggest [10]. Field et al. [11] followed nearly 15 000 adolescents over 3 y, Loser” competition. With 30 wk of ERDs and vigorous exercises analyzing the effects of dieting on their body mass index (BMI), (90 min/d mandatory aerobic or circuit training with 180 min/d of and showed dieters gained more weight than non-dieters. Fildes et optional additional exercises), a massive weight loss was observed. al. [12] also showed that the possibility of achieving a 5% reduction By the end of the competition, nearly 40% body weight was lost with in body weight through diet varies between 12% (men) and 14% relative preservation of FFM (likely owing to the high level of physi- (women), but the majority of those individuals tend to regain lost cal activity). Even with relative preservation of muscle mass, RMR weight within 2 to 5 y, as evidenced by BMI records. Weight cycling dropped out of proportion to the decrease in total body mass, dem- is seen in 30% of individuals [12] and sometimes more, as observed onstrating the presence of a substantial metabolic adaptation. Leptin by Mann et al. [13]. Finally, Anderson et al. [14], in a meta-analysis levels decreased from 43 ng/mL at baseline to <3 ng/mL at week 30, of 29 trials on long-term weight loss maintenance, indicated that and adiponectin levels almost doubled. More evidence of how the participants maintained a reduction of only 3% of the initial weight body combats the rapid loss of weight was seen in the presence of after 5 y. In summary, it is clear that weight loss is difficult to excessive increases in physical activity (energy expenditure achieve and may be more difficult to maintain. There are several increased 6 § 4.1 kcal/kg per day from baseline to week 30). physiological events that may be causing this poor sustainability of Fothergill et al. [22] reevaluated the body composition and weight loss. energy expenditure of 14 of the 16 individuals previously evaluated One hypothesis related to weight regain is “metabolic adapta- “Biggest Loser” contestants and found that all but one regained a sig- tion” or “adaptive thermogenesis” (AT). AT refers to the decrease in nificant amount of the weight lost in the competition. Also, despite resting energy expenditure (REE) or resting metabolic rate (RMR) the weight regain, the mean RMR was not significantly different after caloric restriction and weight loss. Although the precise from the end of the competition. RMR was 500 kcal/d lower than mechanism is obscure, some say AT is an autoregulatory function expected, demonstrating an ongoing metabolic slowing years after that follows reduced activity of the sympathetic nervous system rapid and massive loss of body mass via ERDs. and low plasma concentrations of leptin and T3 (3,5,30-tri-iodo- Another evolving factor is the understanding of the gut micro- thyronine) [15,16]. AT acts to restrain the rate of weight loss and is biome and how microorganism composition might affect weight not fully explained by reduction in fat-free mass (FFM) or fat mass loss and regain. Through the fermentation process, trillions of bac- [17]. There is a slowing of REE during active weight loss, even teria inhabiting the gastrointestinal tract help digest complex car- when FFM is preserved, as demonstrated by Johansen et al. [18]. bohydrates and other substances that cannot be directly This drive for excess energy (fat) storage leads the body to anabo- metabolized by human enzymes [23]. This fermentation process is lism, allowing the organism to do the same functions with less estimated to provide 10% of the energy required by the host [24]. energy, thus creating an ideal situation for weight regain. AT seems Studies involving microbiota transplantation have opened the door like an evolution-related protection mechanism that is now less for understanding the effects of the gut on metabolic function. necessary in an environment with ready access to food and a sed- Germ-free mice increased body fat after being colonized with entary lifestyle [10,15,17]. The extent of AT relates to the degree of microbiota from obese mice. Therefore, it seems that certain bacte- energy deficit and it seems AT is a mechanism favoring weight rial populations are more efficient in extracting energy from the instability and regain. diet, meaning that obese mice can extract a greater amount of Another hypothesis emerged since brown adipose tissue (BAT) energy from the same food identifying the gut microbiota as was “rediscovered” in humans as a metabolically active tissue, and another additional contributing factor to the pathophysiology of its role in thermogenesis remains unclear. BAT, which is character- obesity [25]. ized by high mitochondrial content, is responsible for the production Finally, studying cases of abdominal liposuction provides rele- of heat in a process mediated by uncoupling protein 1 [19].Inthis vant information about rapid fat reduction. Although not using context, another way to define AT is as nonshivering heat produc- ERDs, liposuction allows a large decrease in the volume of adipose tion in response to changes in environmental and physiological set- tissue mass. However, this technique did not improve metabolic tings, such as cold, diet, fever, and stress [20]. It increases in the health nor prevent regrowth of fat. Instead, liposuction seemed to presence of cold and weight gain, resulting in heat generation, boost a compensatory increase of visceral fat [26,27]. Therefore, which promotes energy expenditure and maintains homeostasis weight loss without sustainable behavioral changes will not [15]. In hunger, however, the low circulation concentrations of bio- achieve desired long-term improvements in heath. Therefore, tra- active thyroid hormones and leptin attenuate sympathetic nervous ditional prescriptive methods for weight loss (i.e., ERDs) that do systemÀmediated heat production in BAT to preserve energy, which not promote lasting lifestyle changes will not greatly affect health might partially explain weight gain when following ERDs [15,19,20]. and well-being and may be harmful over the long term [22,28]. The first to describe AT was Keys et al. [21],intheMinnesota The following side effects of successful ERD treatment for obesity Starvation Experiment, which involved 36 healthy participants and are considered natural physiological and psychological consequences: analyzed physiological and mental effects of food deprivation and reduced energy expenditure and bone mineral density, slowing RMR, refeeding. These individuals underwent severe starvation for 24 wk, increased food demand, excessive body preoccupation, repeated losing »25% of their body weight, before being given unrestricted cycles of weight loss and regain, reduced self-esteem, and potential access to food. The participants became increasingly angry, impa- eating disorders in susceptible individuals. Curiously, these “natural tient, and tired and presented symptoms of vertigo, myalgia, and consequences” are what contributes to making obesity a self-perpetu- alopecia as they lost weight. On the other hand, with refeeding, they ating condition; however, this fact often is ignored [29]. It is clear that became hyperphagic, showing overfeeding even as body weight and nutrition is not an exact science, with many factors affecting body adipose tissue returned to basal levels. REE declined by 600 kcal/d weight and weight loss that are beyond mere concepts of thermody- (39%), which was unrelated to the FFM, but with refeeding returned namics. In addition to biochemical, hormonal, and physiological fac- or surpassed the initial rate [3,4,16]. It can be concluded that human tors, there are cultural, psychological, emotional, genetic, and bodies are programmed for survival and automatically reduce RMR epigenetic adaptations; individual responses to exercise training; and if there is a sudden decrease in food intake or availability. economic, religious, and social factors that exist in a complex P.H. Dayan et al. / Nutrition 60 (2019) 147À151 149

Body Composion As proposed by the National Consortium for Credentialing Health (muscle vs. fat mass) Changing “ Behaviors and Wellness Coaches, coaching is a client-centered process to food supply facilitate and empower the client to achieve self-determined goals

Diet related to health and wellness. Successful coaching takes place Age Composion when coaches apply clearly defined knowledge and skills so that clients mobilize internal strengths and external resources for sustainable change” [31]. Saety Economics The professional coach rarely, if ever, assumes the role of con- Factors Influencing tent expert but instead espouses a client-centered model emphasizing self-discovery. In an NC relationship this means accepting the types and levels of dietary changes a client is willing to suggest Religious and cultural Weight Loss Medicaon and set as a goal. It should be understood that change is best made pracces when it is self-directed and autonomously motivated but is gener- Interrelated and dynamic ally resisted when suggested by others. Therefore, when practicing Metabolic Rate with a coaching model, we must largely give up the role of nutri- (physical acvity, Genecs REE, thermic effects tion expert and instead allow the client to take the lead. Table 1 of foodstuffs) shows differences between the traditional expert nutritionist and the NC models. Insulin Gut Sensivity Microbiota Coaching begins with a respectful and non-judgmental atti- Hormones Insulin tude while honoring each client as an expert on his or her own (Ghrelin and Resistance Lepn) life who ultimately has, or can find, all the answers needed to enhance well-being. The coach supports clients in making plans Fig. 1. Interrelated factors influencing weight loss (adapted from ref. 30). REE, rest- for action, gives them confidence, and empowers them to drive ing energy expenditure. their own life. By combining theory from positive psychology, motivational interviewing, open-ended questions, active listen- interplay and affect weight loss. Figure 1 illustrates the complexity of ing, non-violent communication, and tools for behavioral change, these interactions [30]. Such a complex problem is not solvable on a the coaching process encourages clients to overcome resistance large scale with ERDs; this simple, yet difficult-to-implement solution, to change and transform theoretical goals into practical actions, repeatedly demonstrates long-term failure. It is evident that lasting step by step [31,33]. When delivered by a trained health care behavior change is the solution to achieving sustainable weight loss professional, coaching amalgamates foundational psychological and health promotion. Instead of ERDs, a strategy relying on creating communication theories to develop rapport, express empathy a new mindset for health, wellness, and food consumption is a logical and compassion, and encourage health-promoting behavior alternative. Health coaching, and more precisely NC, is potentially a change. Motivational interviewing, non-violent communication, process that would provide innovation and the needed results. appreciative inquiry, social-cognitive theory, self-efficacy, mind- fulness, a transtheoretical model, and positive psychology are Health, wellness, and nutritional coaching central concepts providing foundations for key strategies employed by the well-trained and effective coach [38]. Health and wellness coaching (HWC) is a partnership between the When considering economics and ease of applicability, HWC coach and the client that emphasizes behavior change to better client appears a highly viable intervention. A controlled study of 1024 health [31]. NC is a derivative of the HWC behavioral strategy that patients with cardiovascular disease found a reduction of $19 419 promotes sustainable changes in eating habits [9]. The coaching pro- per person in those who received four or more sessions. The study fessional supports the clients, helping them achieve self-directed also found substantial decrease in mortality in those who received goals aligned with their identified personal values. Therefore, coach- four or more coaching sessions. In an apparent doseÀresponse ing is a patient-centered process based on behavior change theory effect, those receiving less than four coaching sessions did not that encourages self-discovery and active learning processes. Gener- achieve significant reduction in total costs or improved survival ally, the process facilitates learning and, unlike psychotherapy, coach- [39]. Moreover, flexibility of delivery makes HWC an intervention ing looks to the future and not at the past [32,33]. worthy of serious consideration for nutritional and general health

Table 1 Differences between nutritional coaching and traditional prescriptive (expert) approaches

Traditional prescriptive Nutritional coaching

Diet prescription: Goals defined by the professional No diet prescription: Action plan develops through self-determined goals based on client values Subject as patient: Not making decisions Subject as client: Active and leading in decision processes Professional as an educator and prescriptor of diet Professional as a facilitator of dietary change Professional is leader and expert who strives to solve problems Coach as non-judgmental, partner/ally of equal stature, believing the client has or can find the answers needed for solutions Distance between professional and patient Close relationship, which in itself is part of the process Professional feels responsible for the patient’s health Professional believes that client is responsible for his or her own health Asks closed questions requiring. “Yes” or “No” answers (i.e., “Do you eat Asks open-ended questions with many possible answers (i.e., “Tell me more about fruits?”“Do you see yourself as a healthy person?”“Do you exercise?”) your vegetable consumption?”“How do you see your health right now and in the future?”) “Why” questions with present and past focus “How” questions with present and future focus Focus on fixing a problem: Sometimes motivated by fear Focus on optimal performance: Behavior change motivated by happiness and growth Adapted from refs 33À37. 150 P.H. Dayan et al. / Nutrition 60 (2019) 147À151 care situations. In a study of encouraging smoking cessation, HWC evidence to determine that strategies are overwhelmingly ineffec- appeared equally effective whether provided in person or via tele- tive while also being potentially physiologically and psychologi- phone calls [40]. Furthermore, a web-based coaching program cally detrimental. The primary recommendation presented here is emphasizing motivational strategies and Internet meetings found to consider changing from conventional weight management (i.e., positive short-term outcomes regarding weight reduction [41]. diet restriction) to behavioral treatments such as NC. A growing number of studies suggest HWC strategies are effective for weight Coaching and obesity intervention loss both in short- and long-term maintenance. HWC also has the potential to reduce heath care costs and provide flexible interven- A recently published compendium of coaching literature cited tion styles, potentially allowing widespread application to poorly 33 peer-reviewed, data-based scholarly articles addressing HWC as served rural areas. HWC not only provides a prospective nutritional an obesity intervention or weight loss strategy [8]. Of these, intervention but also can be applied to physical, emotional, social, 14 studies were randomized controlled trials and 87% reported a intellectual, spiritual, and ecological aspects of health promotion. significant effect on weight reduction. Not all of the studies used Additional research on NC with longer-term follow-up, considering purely coaching strategies, so there is some question about the different intervention times and session durations, is needed. It is fidelity of these collective results. In general, however, the clear, however, that HWC is an effective approach for weight loss peer-reviewed HWC literature is growing rapidly and coaching and healthy behavior change. Specifically, NC is a promising strat- interventions frequently target obesity with highly consistent and egy and potentially far more effective intervention than prescrip- beneficial results. It does make sense to examine strict studies of tion of ERD. coaching interventions using primarily dietary behavior changes to affect body composition, that is, NC. References

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