Question 1
Given that there is evidence of weight loss from most intermittent fasting regimens, but no strong conclusion such as metabolic effects, as a practicing RD, would you recommend intermittent fasting as a weight loss method to a client who has tried several other weight loss techniques and not yet had much success? Why or why not?
posted by Unknown @ 1:33 PM
16 comments
16 Comments:
For me, it would really depend on the traits of my client as to whether I would recommend intermittent fasting. Even though this study suggests modest weight loss, I don’t think it is an effective approach for everybody. For example, when looking at the results of the alternate day fasting studies, it was reported that the self-reported hunger on the fasted days was considerable and there were no signs that the feelings of hunger decreased over time. With that I would fear that it is not a realistic long-term approach for a client. With those feelings of hunger, we might find that a client is more likely to binge-eat later since they are feeling restricted and deprived. However, that is not to say that a diet like this could not be an effective approach for some people.
I agree that it would depend on the comfort and self control of the client and whether they would feel comfortable trying this approach. However, if other dietary methods have been trialed without success this would be a good option to try in my opinion. One of the benefits on Intermittent Fasting is that clients only have to think/worry about restricting calories on a limited amount of days. On the regular eating days, the client can carry out normal eating behaviors. For some clients this slight change in psychology may be the key factor to maintaining weight loss over time.
As Amanda stated, binge eating is a common concern with intermittent fasting. With a significant reduction of calories on fasting days, it is expected that individuals would consume a larger amount of calories on regular eating days. As a practicing RD, I would recommend that my clients aim for a well-balanced, healthy diet on their "feed" days. I would likely offer education on portion control to supplement. Since clients do not have to focus on avoiding certain foods EVERY DAY, this would hopefully allow them to normalize their eating habits to enjoy the foods they love while still losing weight.
I figured I'd chime in on this conversation for a continuing education hour or two!
Amanda brings up a great point about that hunger and satiety component. If the participants are continuously hungry on their fasting day, how long can they realistically maintain such a diet? I was looking at a 2005 study published in the American Journal of Clinical Nutrition (http://ajcn.nutrition.org/content/81/1/69.long) regarding alternate day fasting in non-obese subjects. The researchers found that the alternate day fasting did result in weight loss, but that many participants reported feeling hungry or irritable on their fasting days, possibly indicating that such a diet is not feasible for the long term (nobody likes a grouchy dieter!) In their conclusion, the researchers discussed that "Adding one small meal on a fasting day may make this approach to dietary restriction more acceptable."
When I saw this, the first thing that came to mind was the more recent research of Dr. Varaday from University of Illinois-Chicago who came in and spoke at ISU back in September of 2013 (Jen, I think you were there...I may be mistaken though). Her research utilizes an ad libitum feed day alternated with a fasting day whereby participants consume 25% of their estimated caloric needs. She has found such a protocol to be effective and beneficial in both obese (http://www.ncbi.nlm.nih.gov/pubmed/19793855?dopt=Abstract&holding=f1000,f1000m,isrctn) and normal weight/overweight participants (http://www.nutritionj.com/content/12/1/146#B1).
In her research, the participants are asked to eat their fasting day meal between 12 and 2 PM, which is right in the middle of the day. If a patient who had seemingly tried everything else and was interested in ADF asked me about an alternate day fasting protocol, this would probably be the method that I would recommend if any. Such a method may be more sustainable in the long-term, as it doesn't ask participants to completely fast on their "fasting day." As Dr. Varaday points out, much more research is needed to validate these findings using larger samples, but I think her research is a solid start. It'll be interesting to see if such dietary tactics catch fire and become more popular in the mainstream. I've seen quite a few patients looking to lose weight here in Minnesota, and nobody has mentioned intermittent fasting as something they've heard of or tried.
Jenn, I like your perspective about ensuring that patients are still educated about what contributes to a healthy, balanced diet on feed days. Obviously we don't want our clients to be chowing down on DQ Blizzards and Nachos every other day, even if they fast in between. It's still about balance, portion, control and moderation. Providing recipes to these patients that incorporate hunger-busting fruits and vegetables and lean sources of protein would be a good bet.
We wouldn't want participants to get bored thinking they have to eat the same old "chicken and broccoli" diet every other day on their feed days. Such a thought process may reduce compliance on their fasting or 25% intake days, so we'd have to work to prevent boredom and perceived monotony just like we do with every other client interested in weight loss or weight maintenance.
In my personal opinion I think an intermittent fasting diet can be very challenging and requires a lot of self control. For a client that has struggled with other weight loss options I could see this type of diet being hard to maintain for the fasting days let alone in the long term. I also think fasting can send the wrong message to dieters. We need food to survive and to allow our metabolism to remain effective. I worry that people on a fasting diet would see food as the enemy and if they have success on the fasting days might continue the fasting days more often than recommended, which could eventually lead to the development of eating disorders.
I think a great solution that Arthur mentioned was the diet where clients consume 25% of their recommended calories on the the fasting day. Therefore, we are not encouraging the client to completely restrict their food intake and hopefully making the fasting days more realistic.
I also agree with Jenn that it is important to educate the client on the importance of eating balanced meals on the non fasting days to avoid over consumption of non nutrient dense food items. I think in order for the client to have success with this type of diet the non fasting days are the most important days and where the client will see the most change if they consume the proper foods.
Amanda, I think you have the right idea by not considering this as a black and white answer and making it depend on the patient's personality before determining if this patient is a good candidate for an intermittent fasting diet to be used for weight loss. However, if they approached you with the idea, then maybe they already did some research and think they have the motivation to succeed.
Arthur, thanks for chiming in with all of your great input! I would have loved to listened to Dr. Varaday's explain the study. I think that having ad libitum days and days where the patient would consume 25% of their necessary calories is another interesting approach. Did the study mention if they did any nutrition supplementation? I think with any intermittent fasting diet, nutrition status should be a key concern. But overall, this would make those "fasting days" much more feasible and slightly more safe as well. Thanks again for sharing!
Stephanie, I hope your rotations are going great! To my knowledge, there was no supplementation provided or endorsed by Varaday et al. However, they did prepare each of the meals for the fast day (http://ajcn.nutrition.org/content/90/5/1138/T1.expansion.html) and and they also indicated that "...On each fast day, the subjects were allowed to consume energy-free beverages, tea, coffee, and sugar-free gum and were encouraged to drink plenty of water..." I guess it's possible that some of the participants were taking vitamin and mineral supplements, but neither study addressed such (that I can see anyway). That is an interesting perspective though. I would also be concerned with nutrient status (especially key nutrients like calcium, iron etc.) because participants are restricting intake to such a degree on their fasting day. I would want to ensure that their diet was healthy and balanced on their feed days and would also probably consider such a situation to be an appropriate time for vitamin and mineral supplementation.
I don't think I would recommend Intermittent Fasting as a weight loss technique right off the bat for a client but... but I certainly wouldn't be opposed to it. In the scenario posed in this question, the client has already tried other weight loss techniques unsuccessfully. Perhaps they have read about Intermittent Fasting online or a friend told them about it, in either case, if my client was really excited about trying Intermittent Fasting I would do my best to capitalize on their positive attitude regarding dietary change (hopefully their enthusiasm would translate into increased dietary adherence). I would be sure to integrate information from the most current literature and translate it into scientifically sound lifestyle change suggestions for my client.
After reading the articles, I think that the time-restricted feeding approach to Intermittent Fasting might have the most potential. Considering our country's culture of ever present hyper-palatable foods, I feel as though some clients might benefit from "stead fast diet rules" (in to form of predetermined "eating windows"). If a client is willing to happily comply to only eating during specific windows of time, then maybe knowing that it isn't their "eating time yet" will give them that extra boost of willpower to stick to their healthy eating plan. Jenn and Arthur, I couldn't agree more about the need to utilize our expertise to help the client make the best possible choices when they do eat. I like to call it "educated ad libitum eating behavior". Hopefully this type of dietary plan would help the client feel empowered to make healthful dietary choices, rather than feeling restricted.
I also think that Carly makes a very valid point. I think this type of diet does have the potential to be taken to an extreme, possibly resulting in an eating disorder. I think that is where knowing your client's personality, eating history, and attitudes towards food would really come in to play. Making sure each client had an individualized plan (and continuously monitoring) would hopefully guard against this type of outcome.
I am not a huge fan of this plan, but I would still consider it an option if a client was very interested in trying it. It would be better to give them the best information and guidance to pursue this option in the most healthful way possible rather than dismiss the idea all together. A concern I have with a diet plan such as this would be what level of activity the person is participating in over the course of their day. In high school, I had a volleyball teammate who observed Ramadan. She actually passed out during practice one time during that time period of observance. Many people who diet are also partaking in exercise as an additional way to accelerate weight loss. Heavy exercise and little to no food is not a good combination metabolically. Some people have very labor intensive jobs that could also be problematic with very low amounts of food. Providing the client with as much information as possible to allow them to make an informed decision would be my approach. Nothing in our profession is one size fits all. Critical thinking and an open mind are essential when making recommendations for what may or may not work for an individual client.
If I had a client with the situation described I would be very hesitant to recommend an intermittent fasting diet. While research has shown some benefits I worry about the psychological aspect as many people have mentioned. Even the social factors of limiting food when at work or around family. Restricting food consumption to that extreme could also have a negative impact on those who are more likely to develop an eating disorder.
I liked Des's comment about acknowledging your client's enthusiasm and recognizing how that can be incorporated into weight loss. Adherence to weight management plan plays a huge role in success, and understanding what could help your patient adhere to the plan is crucial.
I would explain the results of the trials and the process of intermittent fasting to my client to inform them and let them make the decision to try intermittent fasting as a weight loss method or not. I do think it is worth trying since most studies have found intermittent fasting to promote weight loss. Since my client is seeking weight loss and not focusing on metabolic markers, then informing my client about intertemittent fasting may be useful for them, especially when trials have concluded that intermittent fasting is not harmful.
Great point Amanda and Arthur on the hunger and satiety component. I did my "diet" project on Intuitive Eating. Supporters of this approach to healthy eating patterns look to a disconnect between our food thoughts and our inborn hunger and satiety cues; pointing at dieting and the pressure to be thin as a strong driving force in the expansion of that disconnect. Our body has a natural mechanism to manage our need for energy. When we lose touch with these cues we eat in response to other cues like time of day, the mere presence of food. How often do we eat something just because it is there? The disconnect is further fueled by the restricted feelings from dieting. If we rarely get to have something and feel like this is the only chance we will have at it for a while (the forbidden food concept), we are more likely to feel compelled to eat it and probably binge to some degree. If that food is always an available option, we take away the pedestal on which restriction has put it. Yes sweets will always have appeal, but we won't accidentally devour a pint of ice cream or the biggest piece of cake with the most frosting any time that item is in front of us. Restriction intensifies desire for whatever is being restricted.
There is a lot more to the Intuitive Eating approach, but my main point is about the concern I have for habitually overriding natural hunger cues by not eating on certain days. Ad libitum eating on the remaining days could disrupt the ability to sense satiety through potential binging. It seems like fasting could potentially take us farther away from being able to eat in appropriate accordance with physiological need. Appropriate client assessment would definitely be needed before offering fasting as an option for weight loss. Instead of trying to manipulate the system further, shouldn't we be trying to get back to being able to eat to meet our bodies needs or preventing the disconnect from happening to begin with?
My initial thoughts of this question before reading through the articles were that I would absolutely not recommend intermittent fasting as a practical way to lose weight. It may be effective perhaps, but not practical and it would be extremely difficult to fit within the average person's normal activities of daily living.
As Amanda and others have mentioned, I would be concerned about the long-term success of the client as well. Is this something that they will be able to adhere to in the long run in helping them to reach their health goals? Intermittent fasting may be proven effective in promoting weight loss and perhaps other metabolic benefits, however; I feel that it is still a less desirable approach. I think that an exhaustive look at the individual's previous weight loss attempts and current lifestyle behaviors would be more appropriate.
I think there have been several great points made. I do not think an intermittent fasting diet would work for everyone. Like Amanda mentioned, it is important to keep your client in mind and try to find if it would be realistic for them. Some people may like the idea of the intermittent fasting two days a week because it may seem more feasible and flexible for their schedule. Others who are in a weight loss plateau may be interested in trying this kind of regimen.
Jenn also mentioned the concern of binge eating, and I think that could be a big barrier to this type of meal pattern. It will also depend on the person and if they see this diet as being deprived of food. I think it would be worth mentioning intermittent fasting to clients, and see what their thoughts are about trying it.
I liked Arthur's idea of allowing one meal on the fasted day to avoid feeling too deprived. However, I was very much in agreement with Carly's statement about how intermittent fasting sends the wrong message to our clients. Overall, I think it would take more studies for me to feel comfortable counseling a client on intermittent fasting. I would much rather work with a client on becoming more in tune on the hunger and satiety cues that our body sends us and go towards a more mindful eating approach. I feel as if working towards something like that is more realistic in terms of weight loss maintenance. Also, what will happen in the long term in this person's life? Will they follow this diet on vacation? The holidays? I think developing a healthier relationship with food will take work, but will benefit the client more in the long-run.
I agree with Arthur that certain intermittent fasting protocols may be a better recommendation over others, such as those that include calories on fasting days although at a reduced percentage. Complete fasting may very likely result in feelings of deprivation and irritation as mentioned. As many mentioned above, if a patient has researched about the ADF diet and expresses interest in trying it, I would support my patient to try it and help them along the way to make sure they're doing it safely.
Stephanie brings up a very interesting point I hadn't considered previously about nutrition status! The ADF diet seems to focus on calorie consumption and not nutritional adequacy. It makes me wonder if participants who tried the ADF diet would have nutritional inadequacy at all. As an RD, we would have to make sure our patients are receiving their needed nutrients if they were to try intermittent fasting. I can imagine how many would struggle to reach daily RDAs for many vitamins and minerals when fasting or consuming 25% of daily calorie needs.
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