Nutrition considerations

Written by Registered Dietician Sascha Landskron

The path to your patients’ sustainable weight loss may not be as traditional advice has previously led us to believe. The mantra of weight loss through fewer ‘calories in, versus calories out’ is misleading. The focus on only counting calories is erroneous and is based on outdated science that does not account for the thermic effect of food. In other words, some foods take more energy to consume and digest. Also, fewer calories are extracted from whole foods compared to ultra-processed foods. It is important to consider the total energy from the food consumed, but there are other nutritional factors which need to be considered. Furthermore, some people naturally have a higher resting metabolic rate, some regain weight more easily and some respond more to exercise for the purpose of weight loss. These factors are in part genetically predetermined, and they can be analysed with nutritional genomic testing.

Food addiction

Many people who carry extra weight, and are prone to overeating, experience feelings of negative self-worth. They often berate their own lack of willpower as the cause of their problem. The reality is that we live in an ‘obesogenic’ world, i.e. we are fortunate to have ready access to inexpensive and palatable food wherever we go. Patients need to understand more about the potentially addictive nature of food. Eating sweet and starchy foods (e.g. desserts, breads, pasta and potatoes) increases serotonin in the brain and makes us feel calm and happy. Sweet and creamy foods (e.g. chocolate and ice cream) raise endorphins levels. When we eat foods that raise our blood sugars (those that are high starch and sugar and lack protein and fibre) endogenous insulin is released from the pancreas, the excess sugar is converted to body fat and we experience a crash in blood sugars. This is associated with mood swings and lethargy. Furthermore, foods that are high in the ubiquitous combination of: fat, sugar and salt (e.g. salted caramel) raise our dopamine levels, and this has been shown to happen even with the anticipation of the food, before it is even consumed. In short, many foods that lead to weight gain are highly addictive. Our patients should have a clear understanding that their weight gain is not due solely to a lack of willpower or a deficiency of ambition.

Eating styles or types of ‘diets’

Your patients may present with a variety of eating styles, based on personal preference, religious or ethical beliefs or perceptions about what is healthy for them. The following table outlines the more common ‘diets’ or eating styles and the benefits and difficulties of each.

Eating style	Description	Benefits	Challenges
Vegan	No animal products (no meat, poultry, fish, eggs dairy, honey, etc.)	High in plant-based nutrients. May reduce risk of heart disease and certain cancers.   Environmental sustainability	Requires careful planning to avoid deficiencies in: vitamin B12, iron, zinc, iodine and omega-3 fats   Limited food choices
Vegetarian	No meat, poultry, fish (but eggs, diary and honey are included)	Similar benefits to vegan diet. Flexibility with dairy and eggs	Need for careful planning to avoid deficiencies in iron and zinc especially
Low fat	Exclusion of higher fat foods (e.g. some meats and diary) emphasising whole grains, legumes, fruits and vegetables	May support heart health and weight loss.	May lead to increased insulin levels and increased hunger.   Potential for fat soluble vitamin deficiencies (vitamins ADEK). May lead to dry skin and brittle hair   May negatively impact hormone levels. Difficulty with long term sustainability for some
Low carb	Reduction of foods high in starch and sugar	Effective for weight loss. Stabilises blood sugars. May improve markers of heart health	Needs careful planning to avoid deficiencies in fibre. Limited food choices
Paleo	Emphasises whole, unprocessed foods (no dairy, grains, or legumes)	May improve satiety and weight   Focuses on nutrient-dense, whole, unprocessed foods	Eliminates entire foods groups, careful planning is need to avoid risk of nutrient deficiencies. Limited food choices. Limited evidence on long-term health effects
Ketogenic	Very low carbohydrate, moderate protein and high fat	Rapid weight loss probable. Improved blood sugar control. Potential mental health and cognitive benefits. Over 100 years of clinical use and research	Challenging for vegetarians and vegans. Initial side effects (keto flu) and sleep disruption. May increase LDL cholesterol in some people. Difficulty with long term sustainability for some.
Animal based/ carnivore	Only meat, fish, poultry and animal-derived products such as organ meats   No fruits, vegetables, dairy, legumes, or grains	Simplicity in food choices. Potential for weight loss	Complete exclusion of plant foods. Nutrient deficiencies likely without careful management of the diet or supplementation. Environmental sustainability concerns. Limited evidence on long-term health effects
Mediterranean diet	Emphasises olive oil, fish, whole grains, nuts and vegetables   Excludes ultra-processed foods and added sugars	Rich in heart healthy fats. Linked to lower risk of heart disease and certain cancers	Potential for overconsumption of high-energy foods

Top nutritional reasons people carry extra weight:

• Eating ultra-processed food

Humans have been eating processed foods for over 1 million years, since we first harnessed fire to cook. Food processing includes: cooking, baking, canning, freezing, fermenting, and preserving. Ultra-processed foods (UFPs) are those that use ingredients or processing techniques that could not be replicated in the home. The ingredient lists of UFPs contain at least one ingredient that is difficult to pronounce and cannot be purchased in a supermarket. Ingredients such as emulsifiers, preservatives and flavour enhancers indicate ultra-processing. Food companies also remove the natural protein and fibre in ultra-processing techniques, to extent the food’s shelf-life. These foods are mass produced with the sole intent of being highly palatable and low satiety, which mean we eat more. They are designed to be overconsumed and therefore lead to weight gain. A high UPF intake has been unequivocally linked to a host of chronic mental and physical health issues and early death. Breaking the UPF cycle is difficult, but not impossible, and requires both behaviour modification (e.g. avoiding bringing the foods into the house or workplace) and increasing the satiety factor of the diet, by eating more protein, fibre and healthy fats.

• Not eating enough protein and fibre

This is linked with the above point. Whole foods are more satiating because they retain their natural protein and fibre. Protein and fibre slow down digestion and are more filling than starches and sugars. Furthermore, we are designed to eat until our protein requirement have been met, which is one of the reasons that a high carbohydrate intake leads to weight gain.

Some top tips for adding protein and fibre back into the diet: cook from fresh,  base each meal around a protein choice and include protein with each snack, leave the skins on vegetables and fruit and eat a food in its most natural source, e.g. an apple is a better choice than apple juice, a steak is a better choice than beef jerky.

• Not allowing for the switch between mTOR and AMPK

These are the two cellular signalling pathways that prevail where we are either fed (mTOR) or fasted (AMPK). When mTOR is triggered, we can build muscle. When AMPK is triggered, this stimulates autophagy and mitochondrial biogenesis. When we eat constantly and late into the night, we limit our own ability to make new mitochondria and clear out old and senescent cells. It is necessary to allow the body to switch between both fed and fasted states to allow for both systems to function. Almost without exception, everyone should have an overnight fast or ‘rest and digest’ phase that lasts 12 hours. Some people may find fasting for longer to be effective for weight loss and health optimisation.

• Choosing the wrong eating style for our genetics

We are genetically 99.9% identical to every other human being on the planet. The 0.1% difference between us is mapped in our genetic code, and these days it is becoming more and more easy and accessible to analyse and understand. Nutritional genomic testing is useful for finding the expected eating and exercising styles that will optimise our health and weight management.

• Consuming hidden energy in beverages

 While not everyone wants to drink only water all the time, it is important to consider the empty energy in many common beverages. The sugar and energy content in juices, fizzy drinks, alcohol and even cappuccinos can all add up.  Healthier substitutions include – Drinking coffee black, or with just a splash of milk, rather than drinking cappuccinos and other fancy coffees. Avoiding juice and fizzy drinks by flavouring water with fresh lemons, limes, cucumbers, berries or even a cinnamon stick. Opting for low sugar mixers with spirits, or lower carbohydrate wines and beers.

• Poor sleep

Sleep is essential to good physical and mental health, and to having a healthy weight. Establishing a good sleep routine is often the first and most effective step towards weight loss. When we have a night of poor sleep, our hunger and satiety hormones become dysregulated, and we are more prone to emotional eating. Tiredness leads to weight gain through overeating but also fatigue leads us to expend less energy. Fatigue and caffeine misuse are closely linked. Caffeine taken in large quantities, especially after midday, leads to further sleep disruption and a vicious, obesogenic cycle of hunger and satiety hormone disruption.

• Too much emotional stress and not enough physical stress

Emotional stress is rife in modern life and negatively impacts health. Physical stress however should be actively sought. Small amounts of physical or ‘hormetic’ stressors (e.g. fasting, high-intensity workouts, hot therapy and cold therapy) have been shown to extend longevity and improve health and waistlines.

Summary

When your patient is ready to consider weight management and make some lifestyle changes, you can help them best by diffusing their feelings of failure and guilt and focusing on the evidence based practices outlined above. For further information and reading see:

References

Van Tulleken, Chris. Ultra-processed people. the science behind food that isn’t food. W.W. Norton & Company, 2023.

Yeo, Giles, Why calories don’t count: how we got the science of weight loss wrong. Pegasus books, 2021.

Sinclair, David A., and Matthew D. LaPlante. Lifespan: Why we age—And why wedDon’t have to. Atria books, 2019.

Pelz, Mindy. Fast like a girl a woman’s guide to using the healing power of fasting to burn fat, boost energy, and balance hormones. Hay House Inc, 2022.

Palmer, Christopher M. Brain energy: a revolutionary breakthrough in understanding mental health—and improving treatment for anxiety, depression, OCD, PTSD, and More. BenBella Books, 2022.