The Non Diet Approach - the weight neutral approach to dietary management

by Anne Myers-Wright RD/APD

Posted on Jun 4, 03:49 PM in and . No comments.

One of the most challenging and, perhaps, polarising concepts for Dietitians at this time would be the emergence of weight neutral approaches to dietary management. For an outcome focussed profession, trained in the quantitative skills of energy requirement calculations and “diet plans”, the potential change in this focus to a weight neutral approach can be one that is either readily embraced or rejected as a “step too far”. Weight loss currently remains the primary recommendation for health improvement in individuals with high body mass index (BMI) despite limited evidence of long-term success. Weight neutral approaches have now emerged as a result of building evidence that “dieting” with a weight loss goal does not result in significant health improvements, regardless of weight changes. (1,2) and that dieting as a weight loss strategy proves unsuccessful in terms of long term maintenance.

HAES ®, (Health and Every Size), is a trademark held by the Association for Size Diversity and Health. HAES® promotes wellbeing through equality and compassionate self-care. It recognises that people of all weights benefit from healthful behaviours and being treated with respect and so shifts its focus from weight-control for some to health-gain for all.
The Non Diet Approach, (also encompassing mindful eating/intuitive eating), is a strategy which sits within the HAES ® paradigm and is part of the anti- dieting movement.(3)

The Non Diet Approach

In simplistic terms, the Non-Diet Approach is a flexible, gentle way of choosing what to eat and when with no guilt, body shaming or restrictions. It goes against the traditional view of achieving weight loss via dieting/energy restriction. The primary aim is to banish the practises of dieting and instead promote a more holistic approach that encompasses emotional and physical health. The Non-Diet Approach focuses on optimising health and well- being through health related behaviours. At its core are building skills in responding to internal eating cues, developing self-care and a non- judgemental attitude towards self and food. It is a weight neutral approach.

The main features of the Non-Diet Approach (3) are:

• Accepting and Embracing body cues
- hunger/fullness awareness, mindful eating
• Accepting and Embracing all foods
- debunking diets, normalising eating, elimination of demonization of foods, dealing with binge foods
• Accepting and Embracing body shape
- acknowledging size diversity, reject body and weight goals, dress with pride
• Accepting and Embracing movement
- finding enjoyable movement
• Accepting and Embracing non diet nutrition
- enjoy food variety

Whilst working with clients using the Non-Diet Approach, each of these features is addressed using a series of skill building exercises. The Non-Diet Approach works well with patients with a chronic dieting history, emotional and non-hungry eating behaviours with associated guilt and for those with body image issues and rigid notions of “good” and “bad” foods.
Weight and weight loss goals/outcomes are not assessed discussed or included in the approach.

Outcome measures

So without weight as a focus, where do we look for our outcome measures with the Non-Diet Approach? Working with the Non-Diet Approach, in fact, does not preclude a practitioner from being able to provide measurable outcomes which are in line with the BDA model for Dietetic outcomes.

Measures which are in-keeping with the BDA (British Dietetic Association) outcome measures include:

• Biochemical measures
• Psychological measures – such as quality of life scores and eating behaviour score (Dutch Eating Behaviour Score)
• Behaviour change measures – restrictive eating, dietary quality changes, physical activity changes
• Symptom change measures

Evidence for the Non Diet Approach

To date, the majority of Non-diet approach intervention studies have focused on exploring the use of this paradigm in group settings. In one such RCT, (4), obese subjects who were chronic dieters, participants were split into two groups – those who received group education around non diet wellness methods and those who received traditional weight loss group education. Both groups were held weekly for six months with both receiving six months after care. After one year period, those in the “diet” group demonstrated an increase in cognitive restraint whilst there was a decrease in non-diet group. Both developed significant improvements in both metabolic fitness, psychological and eating behaviour variables. A significant weight loss was achieved in the traditional group but not in the non-diet group. Attrition rates were 41% in the traditional diet group vs. 8% in the non- diet group.

A more recent, 2016, study (5) involved eighty women, all with a BMI over 30 Kg/m2. The women were randomized to six months of facilitator-guided weekly group meetings using structured manuals that emphasized either a weight-loss or weight-neutral approach to health. Health measurements occurred at baseline, post-intervention, and 24-months post-randomization. Measurements included blood pressure, lipid panels, blood glucose, BMI, weight, waist circumference, hip circumference, distress, self-esteem, quality of life, fruit and vegetable intake, intuitive eating, and physical activity. Results at the end of intervention showed that the weight-neutral program had larger reductions in LDL cholesterol and greater improvements in intuitive eating; the weight-loss program had larger reductions in BMI and weight. Significant positive changes were observed in both groups between baseline and 24-month follow-up for waist-to-hip ratio, total cholesterol, physical activity, fruit and vegetable intake, self-esteem, and quality of life. These findings highlight that numerous health benefits, even in the absence of weight loss, are achievable and sustainable in the long term using a weight-neutral approach.

Evidence is positioning weight-neutral programs as a viable health promotion alternative to weight-loss programs for women of high weight. More research is being undertaken in order to demonstrate long term effectiveness especially in individual interventions.

What about weight loss with the Non Diet Approach?

Given that the Non-Diet Approach is a “stand- alone” strategy, there is some controversy around whether or not this approach should only be used within a HAES® paradigm. Even though there are many Dietitians reporting their use of the Non-Diet Approach for weight loss, the approach should not, when used within the HAES ® paradigm, be used with a weight loss goal in mind. It is important to note that HAES ® and the HAES® Approach are trademarked terms and that a Dietitian cannot represent themselves as being a HAES ® practitioner if they also offer any weight loss services alongside.

The Non-Diet Approach should not, in any case, be confused with avoiding weight loss. Often, weight loss can, indeed, be a result of using the Non-Diet Approach as clients “find their own healthy weight” by reducing unhealthy eating behaviours.

The Non-Diet Approach should also not be mistaken for an eating “free for all”. Accepting and embracing all foods and Non-Diet Nutrition is a vital part of the approach as is learning to recognise body cues. Patients following the Non-Diet Approach learn to increase food variety and to recognise how foods affect their feelings of well-being. The ultimate aim is to improve health indices and dietary quality.

The understanding that weight loss may be a “side effect” of the approach can initially appear somewhat contradictory. Additionally, some Dietitians already incorporate some of the non-diet techniques, such as mindful eating, into their weight loss programmes.
The use of the Non-Diet Approach as a weight loss tool has sparked much debate. There is no ownership to the approach and it does continue to be used with different goals in mind.

The main point to note is that, with the Non-Diet Approach used within a HAES ® paradigm, intentional weight loss should not be included as a goal of therapy.

The Future for Dietitians?

The Non-Diet Approach has been used widely in other countries such as the US and Australia for some time and has a growing number of UK based Dietitians training and working as Non-Diet practitioners. With the current poor long term success rate with the traditional approach to weight loss and the potential negative consequences caused by restrictive diet plans, this may indeed be the kinder approach to dietary management and health promotion for our clients into the future.

Refs:

1. Mann et al. Medicare’s search for effective obesity treatments: diets are not the answer. Am J psychology 2007
2. Bacon and Aphramor Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal 2011
3. Willer, F. The Non Diet Approach Guidebook for Dietitians 2013
4. Bacon, L. Evaluating a ‘non-diet’ wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. International Journal of Obesity and Related Disorders. 2002.
5. Mensinger, J. A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial. Appetite 2016

Tags: Non Diet Approach, Outcome Measures, Weight Neutral

About the author

Anne Myers-Wright RD/APD

Anne is a Health Professions Council (HPC) registered dietitian (RD), an Accredited Practicing Dietitian (APD- Australia), a fellow of the Higher Education Academy (FHEA), a member of the British Dietetic Association, The Nutrition Society and of The Dietetics Association of Australia.

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