Dietitians’ role in obesity care: insights from the Academy of Nutrition and Dietetics

Estimates suggest that by 2035, overweight and obesity will affect 54% of the global adult population, totaling 3.3 billion individuals (1). In the U.S., over 70% of adults are currently affected by overweight and obesity, with prevalence projected to exceed 80% by 2050, with obesity increasing at a faster rate than overweight (2). Considering that obesity is a chronic disease characterized by excessive adipose accumulation or distribution that presents a health risk and requires lifelong care, the Journal of the Academy of Nutrition and Dietetics published the “Position of the Academy of Nutrition and Dietetics: Medical Nutrition Therapy Behavioral Interventions Provided by Dietitians for Adults with Overweight or Obesity, 2024” (3,4).

The position is supported by a systematic review and evidence-based practice guideline that translates into 17 recommendation statements intended to guide registered dietitian nutritionists or international equivalents (dietitians) in delivering medical nutrition therapy (MNT) behavioral interventions to adults (aged 18 years and older) with overweight or obesity, when appropriate and desired by the client (5). The objective of the position is to describe potential benefits and concerns regarding dietitian-provided MNT behavioral interventions for adults with overweight and obesity and to inform dietitians on implications for practice.

Concerning the potential benefits for clients, the position emphasizes that MNT behavioral interventions can have a positive effect beyond anthropometric outcomes such as diet quality, physical activity (when is part of the intervention), physical health, mobility, blood pressure, glycemic outcomes, with additional benefits on mental health including reductions in symptoms of depression and anxiety, improvements in self-esteem, body image, and quality of life. Additionally, as pointed out by the position, the Nutrition Care Process provided by dietitians is comprehensive. It can identify other health areas that may need to be addressed and referred to, such as mental health, physical impairments or limitations, food and nutrition insecurities, and others. In this context, for clients who desire this treatment, MNT behavioral interventions may provide benefits and identify needs beyond weight management to improve overall health.

Despite the numerous benefits of behavioral and lifestyle interventions, which are the cornerstone of overweight and obesity management, it is important to note that most clients with these conditions have made multiple weight management attempts without sustained success (6). Dietitians must understand that obesity is a chronic, relapsing disease and that MNT behavioral interventions or lifestyle changes alone may often be insufficient. In many cases, adjunctive treatments such as pharmacotherapy and/or metabolic and bariatric surgery (MBS) are necessary, as the likelihood of maintaining weight loss solely through lifestyle modifications is very low (7,8). Misconceptions that individuals fail due to a lack of willpower often overlook the complex biological factors, making it difficult for patients to implement what they know they should do. Dietitians should be cautious to avoid an iatrogenic role and ensure comprehensive care for their clients. The current era of weight management requires all healthcare providers involved in the care of individuals with overweight or obesity to be well-informed and educated. Dietitians ensure clients receive the most effective treatment for overweight and obesity by recognizing when adjunctive treatments are necessary alongside MNT behavioral interventions.

The position highlights that weight bias is a significant concern for clients, as healthcare provided to adults with overweight and obesity may inadvertently increase stigma, be shame-based, and may overly focus on weight reduction. Research indicates that dietitians often exhibit implicit and explicit weight bias, frequently attributing obesity to internal factors while overlooking genetic and biological influences (9,10). Weight bias internalization is linked to maladaptive behavioral regulation, contributing to lower psychological well-being in individuals with overweight and obesity (11). Therefore, dietitians must avoid assuming treatment failures stem solely from non-compliance with dietary or behavioral recommendations, emphasizing a more nuanced, individualized approach to care that avoids stigmatizing judgments.

The position recommends that MNT behavioral interventions be inclusive, client-centered, and compassionate. However, it is important to consider whether dietitians are adequately prepared to deliver this approach, especially since these topics are often not thoroughly addressed in academic settings or appropriately integrated into the dietetics curriculum and training. Examples include how dietitians can create an inclusive and welcoming environment by focusing on effective communication, accommodating physical environments and equipment for clients with larger bodies, and addressing specific needs, such as budget-friendly healthy eating tools. Dietitians must cultivate empathy and maintain awareness of these critical elements to deliver client-centered care. Placing the client at the center of treatment for overweight and obesity in a respectful, non-judgmental manner demonstrates that dietitians understand the various contributors to these conditions. This approach enables the delivery of individualized, dignified, and science-based treatment that clients deserve and can effectively adhere to. The client-centered approach addresses each client’s unique and challenging journey. Although clients often understand what changes are necessary, they frequently struggle with implementation, mainly due to biological factors that contribute to weight regain. This highlights the importance of combining MNT behavioral interventions with treatments such as pharmacotherapy and/or MBS for clients with obesity or overweight with comorbidities, emphasizing a client-centered approach. For example, glucagon-like peptide-1 receptor agonists, such as semaglutide, have been shown to improve control of eating and reduce food cravings compared to lifestyle modifications alone, which may help support better food choices based on a dietitian’s recommendations (12). By enhancing adherence to MNT interventions, these medications make behavior change and food management more achievable for individuals with obesity who have struggled with long-term modifications.

Although the position recommends delivering compassionate care, it does not specify how dietitians should achieve this. While the term may appear straightforward, it requires further clarification within the healthcare context. Compassion in healthcare involves a deliberate effort to understand a person, discern their needs, and alleviate suffering through relational understanding and action (13). A lack of compassionate care can make patients feel reduced to a body or a disease rather than recognized as a whole person, emphasizing the need for a client-centered approach to prevent objectification (14). To alleviate client suffering, dietitians should address complex issues often overlooked but closely tied to overweight and obesity, such as guilt, shame, trauma, moral injury, lack of meaning, discrimination, financial stress, social isolation, and other factors that directly impact eating and self-care behaviors. Compassionate care is essential for promoting the health and well-being of clients with overweight and obesity, enhancing their satisfaction and quality of life. It should be further discussed and prioritized in healthcare settings and training programs.

The position highlights several potential benefits for dietetics, emphasizing that dietitians play a critical role in interprofessional healthcare teams due to the complexity of overweight or obesity management, as no other healthcare provider is specifically trained to deliver MNT. This presents an opportunity for dietitians to collaborate closely with other healthcare providers, increasing their visibility as valuable team members and fostering a robust referral network. Additionally, the position states that dietitians possess the skills to collect nutrition-related data that can enhance health equity, address health disparities, and support reimbursement for MNT access. Such engagement can help elevate dietitians into leadership roles and strengthen the overall prominence of dietetics within healthcare. Furthermore, according to the position, dietitians’ expertise in behavioral and lifestyle modifications remains a central component of overweight or obesity management, even when other adjunct treatments are used.

The position raises a potential concern for the profession, emphasizing that dietitians caring for clients with overweight or obesity must develop a wide range of competencies to meet client needs effectively. Achieving this goal requires comprehensive education and training in dietetics. To address this, the position highlights the importance of educational and professional development initiatives to equip dietitians with essential skills and ensure they are fully prepared to support these individuals. It also calls for higher educational institutions in dietetics to reevaluate their curricula and training programs, especially considering the global prevalence of overweight or obesity. Since dietitians are at the forefront of managing these conditions, basic dietetics curricula must reflect the complexity and magnitude of these topics, focusing on prevention and understanding the full spectrum of available treatments beyond behavioral approaches. Although credentialed institutions certify dietitians in obesity management, the high prevalence of these conditions worldwide, with rates exceeding 70% in the US, prompts a need for all dietitians, not just specialists, to adequately address these issues.

The position also underscores the need for dietitians to identify strategies to implement the Inclusion, Diversity, Equity, and Access (IDEA) action plan, noting that this is a complex challenge due to the homogeneity of the dietetics workforce in terms of race/ethnicity, gender, ability, and socio-economic status. It further recommends diversifying the workforce to reduce disparities and improve health equity by fostering client-practitioner connections that better reflect clients’ experiences, thereby reducing stereotyping and implicit bias. Given these challenges, incorporating IDEA principles into curricula through theoretical knowledge, clinical practice, and client testimonials may cultivate greater empathy, compassion, and resilience among dietitians.

Considering the above, dietitians are positioned as essential healthcare providers with the potential to advocate for and provide equitable, dignified, and effective care for individuals with overweight or obesity. Enhancing the education and training of dietitians is crucial to empower them to deliver the best possible care, emphasizing a person-centered approach while accounting for all internal and external factors contributing to overweight and obesity.

Acknowledgments

Funding: The work was supported by National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (P30 DK040561, U24 DK132733, and UE5 DK137285; to F.C.S.).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2024-672/coif). F.C.S. has received grants from NIH/NIDDK (P30 DK040561, U24 DK132733, and UE5 DK137285) and consulting fees from Eli Lilly, Novo Nordisk, Amgen, Currax, Pfizer, GoodRx, Doximity, MelliCell, Vida Health, Empros Pharma, Apnimed, Sweetch and Ilant Health, all outside of the current work. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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