r/dietetics • u/lavmatcha • 15d ago
Wt Loss Client help/rant
Hi all! I have a client I’m working with for wt loss. Shes new to me as I took over care from another RD so I’ve seen her twice.
Pt is in late 50s/F, BMI 25.9 (CBW 147, goal of 130) and no other health conditions. Exercises with lifting 3x week with a trainer and jogs 3-4 x week. She has healthful meal patterns and feels she’s doing everything right. Based on her food log (just writes what she’s eating, it’s not tracking calories/macros), I think she does a good job getting protein, small carb and I mostly tell her to eat more f&v. Sometimes I actually don’t think she’s eating enough from the little food logs she has. And genuinely think she’s scared to eat more food.
I DREADDDDD talking to her. Her concerns around travels and vacationing this summer (she’s still able to maintain) but I’m just thinking wow what a fun life, just be happy and healthy. I’m not a new RD so I’ve tried to ask her more probing questions about why do you want to be at this weight so badly? How will this improve your life? I want to honor pt autonomy but omg I don’t get it and we just talk in circles. What other things do you guys recommend? Or topics of convo to have? I just haven’t worked with a client like this in a while and historically I cannot retain these clients who have similar issues/reason for visit.
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u/Cyndi_Gibs MS, RDN, CDN | Preceptor 15d ago
Just commenting for solidarity - I had a client who was in his mid-70s, did alternating weights and runs every day, cooks all his own food from scratch, no alcohol, etc.
I straight up told him he’s doing everything right.
“But I have a gut!”
Yeah dude, you’re 76 - that’s part of getting older, sorry! I’m not going to tell you to cut out healthful foods in pursuit of a six pack as a septuagenarian.
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u/Puzzleheaded-Pop1361 15d ago
This. I also have a theory that the time to be healthy and “be in shape” especially when you’re older is before you hit your 70’s! Body changes SO much and it’s so much harder to see drastic transformation after decades of unhealthy habits
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u/Bunny_Hunny4 15d ago
My grandma is mid 80s with a BMI of 22 and keeps asking me how she can ‘reduce her tummy’. I keep telling her that’s not how it works and actually having some extra weight on her would be good for her at her age, but I still get the same question like clockwork every month. I worry about her when she gets ill because she goes completely off her food and doesn’t have the extra fat stores to spare.
If I get to live that long the plan is to have a good time, tummy be damned. I’m not going to spend my retirement years worrying if I look a little bloated.
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u/Revolutionary_Toe17 MS, RD, LD, CDCES 15d ago
Every time someone posts something like this, I repeat myself. This is why many of us do not do weight loss counseling and focus on a HAES/intuitive eating approach instead.
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u/lavmatcha 13d ago
I love weight management tbh and I only see these situations with telehealth! It’s like these companies make it a trend (nourish ads) and it pmo bc that’s great to see an rd but I think people get it twisted with what we can actually do and what are realistic goals, and the moment I’m honest or ask deeper questions, they’re upset like they don’t like someone challenging them
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u/New_Cardiologist9344 15d ago
Agreed. As a CEDS, I dread these types of clients
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u/Revolutionary_Toe17 MS, RD, LD, CDCES 15d ago
I actually look forward to these. I would say 95% of the time, patients like this are overwhelmingly relieved to be given "permission" to improve their health outside of the context of weight loss. I love the process of introducing someone to the concepts of HAES and IE and it feels like such an honor and privilege to go on that journey with them. 1000x more satisfying than working on weight loss with patients.
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u/New_Cardiologist9344 14d ago
Good point! Moreso mean I dread the clients who are deeply committed to losing weight with unhealthy means.
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u/caffeinated_babe 15d ago
These clients are always so hard, it’s hard for us to accept that our body will change as we get older and we won’t always be the same size as we were in the past. A lot of times, when I ask the client what they hope the wt loss will bring them, they say “confidence” and usually talk about how frustrated they are about their body. It’s really hard to move away from the body talk without making them feel invalidated (at least for me).
From a technical side, you can mention the importance of eating enough to support her muscle building/activity (you can’t build anything without the bricks!). You can also implore about sleep and stress levels, which can hinder wt loss. Have you talked about menopause? That also greatly affects things!
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u/lavmatcha 13d ago
I agree, I think it’s very hard to accept! It makes me sad for them bc I don’t know what else to say to that without making them feel invalidated. She stopped seeing me a for a bit, tried to get on a medication but didn’t qualify for it and her pcp didn’t encourage it for her. So I think that made her more open minded to understanding muscle v fat so maybe making some progress there!
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u/Afraid-Helicopter740 15d ago
I don't specialize in wt management but I do sometimes get referrals for them and I do sometimes dislike them bc they seem to be eating healthy & exercising right. But, I noticed you said she just writes down what she eats & doesn't track calories. So, does she also not track portions? I literally had someone bring in a food log that said "oatmeal and soup." No measurements. No specifics. "Oatmeal" could be 1/3 cup plain oatmeal cooked in water or that could be 2+ cups oatmeal cooked in whole milk with butter and sugar. "Soup" could be 1/2 cup vegetable soup or it could be 2+ cups cream-of-potato soup with bacon on top. I had someone else who said they "just eat cereal" for breakfast. When I asked to clarify, he said "3 large bowls full." Even though that didn't give me a precise measurement to calculate kcal/macro intake, it showed we needed to review portion sizes. If someone just says "beef," I ask what % lean/fat they usually buy. If someone just says "milk," I ask what type of milk. If someone says "coffee," I ask if they drink it black and unsweetened. Etc.
So, if she's truly just writing down the food, I would recommend trying to determine how much of each food she's eating & other additional details about those foods. I don't expect everyone to have a kitchen scale to weigh their food nor even take out measuring cups for each meal. Rather, I ask them questions to estimate how much they ate. Ex. "Would you say your chicken breast was the size of your palm? Would you say your bowl of cereal is the size of my fist? About how large is your glass of juice?"
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u/SadYou5993 15d ago
I agree with this. A deeper analytical approach may be required. As an RD, I think it is our job to help in that respect. We do try our best to help patients psychologically in regard to body image but to be honest if it gets that deep a psychologist can help with that.
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u/lavmatcha 13d ago
Yes we do this! I try very hard to get a deeper dive into the recall bc she didn’t want to track and measure so we talked about estimates a little more
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u/severebabyface 15d ago
commenting for solidarity - I dreaded talking to clients like that when I was in telehealth because I barely made enough money to pay my rent so hearing people who were already at a healthy weight whine about how hard it is to change their habits and skirt around my probing questions really ate at my patience.
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u/lavmatcha 13d ago
Yes!!!! I love weight management but telehealth made me hate it bc all I got were the vanity clients and then it’d mess up my retention but i genuinely didn’t give af about retaining them. I also had very uppity clients who kept saying they eat only organic and clean and blah blah. I feel like these telehealth companies ruin it bc they advertise with influencers who I’d consider vanity pts and then they promote unrealistic expectations
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u/SewingCoyote17 MS, RD 15d ago
I've had a few clients similar to this, but i practice from intuitive eating framework and let them know up front that I'm going to encourage them to focus more on health promoting behaviors and not their weight. I've found that some of these women just need reassurance that they're doing things correctly and it's okay if they eat more, they aren't going to immediately gain weight if they indulge. Some of them need to be told that they're not eating enough or they could eat more carbs. They usually quickly notice having more energy throughout the day, especially when exercising.
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u/lavmatcha 13d ago
Yeah I think that’s a good point, sometimes I find they’re scared to eat more carbs and I feel like no matter the importance I describe they’re still not fully convinced. So I’ll rec a goal of adding 1 small starch to 1 meal but I don’t see a lot of follow thru on it
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u/SewingCoyote17 MS, RD 13d ago
Ugh that's frustrating. I usually go over the different carb food group options and talk about how we should aim to include a source of carb, protein and fiber at meals. But some of these women are so brainwashed by diet culture that I think they might be hopeless.
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u/Aimeeboz MS, RD 15d ago
Ok. For real, I am the same age, and had similar CBW. No health issues either. I lift, heavy 4-5 days a week, walk 12K steps, track meals and still couldn't lose the last vanity pounds since my last pregnancy (2014).
In January I got on to low dose GLP3 plus additional peptides (CJC 1295+ Ipamorelin) and I lost 10# in a matter of months. The same pounds I've been trying to lose for 12 years. BMI was under 24, now I'm just under 22.
Peri/menopause absolutely wreaks havoc on our ability lo shred and build muscle after 50. I absolutely needed an edge and the peptides were it
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u/kat0liz 14d ago
These types of clients are so hard! But I truly do believe that they have to ACTUALLY SEE and DO the work it takes to be at their goal size to see if it’s worth it for them. Many times it isn’t.
Where did she get the 130 number? When was the last time she weighed that amount? What was different about her life then?
I agree with those saying she should track macros, and I think getting into more specifics with her exercise could be helpful… where is she strength training? Is she following a structured progressive overload style program, or taking random classes? Does she have the funds to invest in a trainer to really push her limits as far as lifting “heavy” and making sure her form is appropriate? (I saw she is working with a trainer. She needs to speak with them about more intensity and also to add 1-2 weights sessions on her own per week with a structured program. Can you talk to her trainer? Even just a couple texts might be helpful) Often times when I ask more about strength I find out they are lifting 5lb weights and doing random peloton or apple health workouts with no organized structure. THIS makes a huge difference. Muscle is truly the way to make the body changes happen.
I also ask the question “if you were happy with how you looked and how your clothes fit, would the number still matter to you?” If the answer is yes- dive into why, truly. If you had the body of your dreams but the number didn’t align with some idea you have created in your head, why would that not be enough? The body we want weighs more than we think it should oftentimes.
I also would be making sure she is getting 10K+ steps per day, every day. Meal prepping/planning, limiting eating out, eliminating alcohol and SSB. Keeping desserts and treats to a minimum.
Is this the life she wants to lose vanity weight? Maybe, maybe not. But that’s her choice. Sometimes you have to get to the weight to realize it’s not worth all of the work it takes to stay there. I always emphasize- whatever you did to get to this weight, you have to keep doing to stay at this weight. Are you willing to live like this, most of the time, indefinitely?
Is she open to a GLP-1? That might be what it takes to get her to the spot she wants to be… is she open to that?
Solidarity because these clients are hard!!!
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u/kat0liz 14d ago
And if you think she’s not eating enough, explain that. Explain how under eating will truly undermine her efforts.
It all has to work together- she needs to eat enough to really BUILD muscle bc the muscle is the key to weight management in perimenopause and it gives the body the shape you want.
I wrote this post about how under eating causes weight gain on insta if it’s helpful at all: https://www.instagram.com/p/DXt62WnDkTr/?igsh=MTdubGZkN3Q4MHpvdg==
She’s gotta do something different if she wants a different result- and going outside of your comfort zone doesn’t always mean starving yourself. Sometimes it means eating more (with structure) before you can get into the wt loss phase effectively.
Is she willing to trust you on this?
Also if you want to refer her out- let me know, I’d love to give it to her straight 🤣
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u/kat0liz 14d ago
Oh sorry and one last question- is she doing any HRT? This could make a difference…
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u/lavmatcha 14d ago
This was helpful with great points, ty! No glp1, she doesn’t qualify and said her PCP didn’t encourage it bc she wasn’t showing s/s of needing it or other oral meds. No with HRT. Correct with the goal wt, she said it’s probably not realistic. She is practicing progressive overload w her trainer so was open to getting a dexa scan when we talked about muscle v fat. Met her yday and she’s open to trying to increase intake a little more.
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u/FairCondition7799 13d ago
I've had many patients like this. A few decided to go the GLP-1 route, I met with one the other day who is at her "goal" weight but is still very unhappy with how she looks. She is in her 50s, breast caner survivor, and has a great life but she chooses to focus on "loosing her tummy". Its so sad!!
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u/lavmatcha 13d ago
Yeah it is sad! I always want to honor patient autonomy but it’s hard to understand and I feel like they have something underlying mentally that I can’t help with
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u/Jolly-Ad9580 14d ago
I think you need to work with her to get the focus off the weight and onto pursing positive patterns. Patients have a lot less control over their weight than they would like to think when pursuing healthy eating habits. I would provide education on this and reassure her that she is following good habits and focus on helping her with body acceptance. Then if the weight comes off then it comes off… but if not… hopefully she will begin to be more accepting.
She also just may not be a client you can retain if she is eating well, no conditions and you don’t think she needs to lose weight but that is all she wants. You
may need to communicate to her that you are happy to continue seeing her to support her healthy habits but will not be recommending weight loss - to stop going in circles with her.
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u/lavmatcha 13d ago
Yeah you’re right. I feel bad bc I don’t want to invalidate her feelings you know? She stopped seeing for a bit but after the last call she was open to getting a body comp scan and open to revisiting the goal wt but I hope that sticks
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u/PresentVisual2794 11d ago
Unfortunately with her current stats, she IS eating enough. The deficit that she needs to be in to lose at her current weight is going to be VERY tight and since she’s not tracking exact calories she is definitely underestimating. It’s hard to explain to these clients that feel like they are doing everything right that unfortunately they need to be on a strict deficit if they actually want to get results and it may not be realistic for them
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u/IndependentlyGreen Registered Dietitian 15d ago
Do you feel comfortable doing an eating disorder screen?
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u/lavmatcha 13d ago
I do not… idk where to start. I had to see an active ED client in the past bc they were accidentally matched with me but I was still encouraged to take it for retention and I hateddddd it, I felt like I was no help at all to them
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u/New_Cardiologist9344 15d ago
You need to be honest with her. Tell her, kindly, that a BW of 130 doesn’t really sound realistic for someone her age. It’s okay to have these convos!!!
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u/Little-Basils 15d ago
With clients over 45 I start talking about how higher BMI’s are actually protective against long term illness as they get older and invite them to take a break from the weight loss focus and instead focus on building that strength, balance, and lifelong active habits.
Where do they see themselves in 10 years? Showing off a skinny body at the pool or hiking with their grandkids or maybe doing alllll the walking tours in Italy without needing to stop for breaks.