Diet vs. Non-Diet Approaches in Nutrition Counseling

Dr. David Wiss

May 20, 2021

Eating Disorders

We are all familiar with the conventional approach to making nutrition-related behavioral changes (most people still associate nutrition with losing weight). The “diet approach” is a targeted manipulation of one’s food intake to achieve a desired outcome and is still the most common form of intervention in the United States. This method has become entrenched largely through government-issued nutrition guidelines, which typically single out nutrients in a reductionistic way (e.g., target grams of fat per day), and is perpetuated by a nearly $300-billion-dollar weight-loss industry. Unfortunately, this approach is notorious for promoting “diet culture” messaging and can even perpetuate weight bias and weight stigma, which is discriminatory ideology toward individuals who live in larger bodies.

The use of the word “diet” itself has a long history, is often medicalized, and has been applied widely in fitness circles over decades. Even the titles of the leading nutrition professionals: Registered Dietitian Nutritionists (RDNs) and their parent organization: Academy of Nutrition and Dietetics, have the word diet embedded. The very definition of the word—both as a noun: “a special course of food to which one restricts oneself, either to lose weight or for medical reasons” and as a verb: “to restrict oneself to small amounts or special kinds of food to lose weight.” —has the concept of weight loss through intentional restriction built-in! It should then come as no surprise that there is much controversy and debate about the use of this word!

The term “obesity” has even become controversial. Many practitioners have transitioned to using the term “living in larger bodies” because of the connotation connected to the word obesity. In scientific articles, we still use the term “obesity” but in the clinic we are much less inclined to do so.


What Does the Data Say?

In the last ten years, it has become increasingly apparent (for many of us) that intentional weight loss through dietary restriction is simply not practical. For example, in a large study of individuals with obesity in the UK, the annual probability of attaining normal weight (based on a BMI of 18.5-24.9) was 1 in 210 for men and 1 in 124 for women [1]. This translates to less than 1% of people going from obese to normal during the 9-year follow-up period. Among those with class III obesity, the annual probability of achieving even a 5% weight reduction was 1 in 8 for men and 1 in 7 for women. The authors concluded that the probability of attaining normal weight or maintaining a weight loss is low; therefore, weight management programs may be ineffective. Given these findings, the argument can be made that putting people on a calorie-restricted weight loss program is not only ineffective, but perhaps even unethical. This explains why there is anger and tension in online communities and in some treatment circles about the use of low-calorie diets (emerging as “us” vs. “them” narratives). If you have been put on diets by doctors and other practitioners and found that it only makes your relationship with food worse (e.g., binge eating or symptoms of bulimia), it’s time for a new approach!

Of course, proponents of dieting may interpret this data as “they are doing it wrong” or “they did not try hard enough.” The diet approach appears to rely on the concept of “personal responsibility”: that it is up to the individual to make the right choices (e.g., nutrition and exercise) to control their body weight. This perspective has begun to fall out of favor, particularly given the data that socioeconomic status, the neighborhood food environment, and exposure to stress, trauma, and adversity (particularly early in life) can all play a role in weight-related outcomes [2,3]. More ethical solutions include helping people with body image by discussing the role of weight stigma in society, and ultimately helping people to improve their relationship with food through practices such as mindful eating, and being better in touch with hunger and fullness cues. Paying attention to your body is so much more effective than dieting, particularly when feeling stressed.

It has become clear that theories of weight loss based on low-calorie dieting are failing, likely due to neurochemical, endocrine, and gastrointestinal factors, which simple models of energy balance do not adequately capture. Additionally, many practitioners and researchers have begun to think beyond individual characteristics and to consider broader contextual factors, including the rise in addiction-like eating of ultra-processed foods [4,5] and psychological factors such as weight stigma and dietary restraint [2,6]. Emerging evidence suggests that the composition of our gut microbiome can also play a role in eating behaviors [7]. Taken together, the “calories in, calories out” model is failing and is associated with diet approaches, whereas non-diet approaches are more effective for mental health, particularly for binge eating disorder treatment or for individuals seeking help with other forms of disordered eating such as bulimia nervosa.


What About Food Addiction?

The concept of food addiction has often been associated with a diet approach because many assume that addiction recovery necessitates excluding certain foods, the pursuit of weight loss, body negativity attitudes, restriction, and shaming. However, this is not always the case. The conventional eating disorder approach (which is frequently considered the “non-diet” approach) appears to be the opposite: focusing on food inclusion, weight neutrality, body positivity, moderation, and non-stigmatizing practices. Most clinicians who work in mental health are likely to endorse a more inclusive approach. In contrast, many individuals (including those in 12-Step communities) appear drawn to a more food-exclusive method. If you can afford it, talking to a mental health professional such as a nutritional psychologist, or a registered dietitian nutritionist (RDN) specializing in behavioral health may be worth the investment, especially if you are bingeing and purging.


Which Approach is More Effective?

In our opinion, it is essential to not limit oneself to a single food philosophy. Food philosophies must be dynamic, continually incorporating new findings, especially related to trauma. If all you have is a hammer, everything starts to look like a nail! We recommend that practitioners learn to diversify their toolkits! The non-diet approach is a critical part of any toolkit because reducing shame is a crucial component to recovery for many. Given that caloric restriction leads to preoccupation with food, a dieting approach may cause harm to specific individuals by promoting binge eating [6]. Thus, the non-diet approach can be conceptualized as a form of harm reduction. Most importantly, the non-diet approach empowers people to get in touch with their intuition around food, rather than relying on an external source of guidance.

Having a single “food philosophy” that gets extended to all people regardless of their biology, psychology, or social conditions is non-scientific. In other words, some people will benefit from having a more exclusive dietary approach that does emphasize the biological impact of certain foods. This is consistent with recent evidence emerging from the field of nutritional psychiatry, which tends to emphasize the biology of certain foods. Choosing not to eat certain foods does not always mean it is “diet culture” although in some cases it may be. This scenario should include having an expert provide guidelines during the healing process to empower the person to become more intuitive over time. Recently an 8-step assessment process to help with individual-level discernment has been published, which helps to determine if someone has an actual food addiction or if their symptoms are merely just a relic of dietary restraint [8]. Either way, it is critical to address issues related to body image in any treatment for disordered eating.

At Wise Mind Nutrition, we generally favor a non-diet approach to nutrition intervention. However, we acknowledge that more deliberate methods can still have a place, particularly for those with food addiction and other mental health issues (e.g., depression). This position does depend somewhat on semantics (i.e., how one defines diet). We believe that the word “diet” can extend beyond weight loss and therefore does not have to be a “bad word”. It can include concepts related to eating for mental health. Our motto is “food for mood and brain health” which may require some deliberate and intentional eating. Our method can help show how to stop stress eating without counting calories or getting lost in the math. It’s so important to feel satisfied with your meals and engage in behaviors that are sustainable over the long term.


Summary

There is nothing wrong with changing your diet to improve your mental health! However, in the case of eating disorders and unhealthy relationships with food, it is wise to consult with a professional before making any drastic changes (particularly if it involves forms of restriction). Tailor-made hybrid models between inclusive (non-diet) and exclusive (diet) approaches have been helpful in our clinical experience. We tend to favor guiding principles rather than rigid rules. Still, we have positioned ourselves to help people with a wide range of dietary and psychological needs. Psychotherapy is individualized, and nutrition should be too! This is often referred to as nutritional psychology.

The era of personalized nutrition is here! One size does not fit all! Take the journey with Wise Mind Nutrition! Learn what works for YOU, and don’t ever let anybody tell you that you cannot recover! Dietary improvement for mental health has finally arrived. You can absolutely eat for gut health and brain health without going on a diet. It’s the best of all worlds and probably the best ways to reduce stress, and build a healthy relationship with food that feels sustainable.

References
1. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health. 2015;105(9):e54–9. 2. Wiss DA, Avena N, Gold M. Food Addiction and Psychosocial Adversity: Biological Embedding, Contextual Factors, and Public Health Implications. Nutrients. 2020;12(11):3521.
3. Wiss DA, Brewerton TD. Adverse Childhood Experiences and Adult Obesity: A Systematic Review of Plausible Mechanisms and Meta-Analysis of Cross-Sectional Studies. Physiol Behav. 2020;112964.
4. Wiss DA, Avena N, Rada P. Sugar Addiction: From Evolution to Revolution. Frontiers in Psychiatry. 2018;9:545. 5. Wiss DA, Criscitelli K, Gold M, Avena N. Preclinical evidence for the addiction potential of highly palatable foods: Current developments related to maternal influence. Appetite. 2017;115:19–27.
6. Wiss DA, Avena NM. Food Addiction, Binge Eating, and the Role of Dietary Restraint: Converging Evidence from Animal and Human Studies. In: Frank KW, Berner LA, editors. Switzerland: Springer Nature; 2020. p. 193–209.
7. Gupta A, Osadchiy V, Mayer EA. Brain–gut–microbiome interactions in obesity and food addiction. Nat Rev Gastroentero. 2020;1–18.
8. Wiss D, Brewerton T. Separating the Signal from the Noise: How Psychiatric Diagnoses Can Help Discern Food Addiction from Dietary Restraint. Nutrients. 2020;12(10):2937.