Gerry Gajadharsingh writes:

“Below I make comments on a recent article from Medscape with an interview with Dr Ellrot a physician and director of the Institute for Nutritional Psychology at the University of Göttingen.

In the past 40 years, everyday energy expenditure has decreased significantly due to increased reliance on machines and transportation. Additionally, constant oversupply of food and frequent snacking contribute to higher calorie intake, often with high-calorie snacks. Obesity research shows that people with obesity respond more to external stimuli and have disrupted satiety signals. External cues, like meal times, override internal hunger signals, necessitating behavioural therapy to relearn internal cues. Nutrition information alone isn’t enough to change eating habits; it requires skills in finding, understanding, evaluating, and applying information.

Ellrott also emphasized the issue of high-calorie liquid intake, which many people still overlook (and this for me also includes fruit juices and vegetable juices).

The psychology of our relationship with food is complicated. It is not simply a case of developing a bespoke, individualized nutritional program for a patient and expecting them to follow it 100% and achieve brilliant results.

I am very selective about which patients I offer the best nutritional program I know of, Metabolic Balance. An initial consultation is critical to take a history, past medical history, and, in my case, a clinical examination (although this is usually not the case with Nutritional Therapists). This helps us come to a mutual decision with the patient, deciding together if an individualized nutritional plan, such as Metabolic Balance, is warranted. Sometimes the key is to explore psychological and behavioural patterns, as well as other patterns like deregulated breathing, which often impact the autonomic nervous system. The parasympathetic, or relaxation, part of the autonomic nervous system is critical to gastrointestinal function. Addressing these issues often needs to happen before I am willing to offer a patient a nutritional program.

Of course, some patients simply want to change their diet. Occasionally, new patients will contact our practice asking if I would be willing to generate an individual Metabolic Balance plan from Germany without my support and guidance. The answer is no. Without any understanding of them, their psychology, their behaviour, their medical history, etc., why would I take clinical responsibility for organizing a nutritional intervention?

The internet is awash with commercial companies providing supplements and lab testing with incredibly little clinical oversight. Because of marketing, so-called convenience, and sometimes cost, it’s not surprising that some patients want to follow this route.

The issue with testing is not the ability to order particular tests, such as certain blood panels, but more about the interpretation and what you are going to do with that information. This requires experienced clinical input.

I looked at some Trustpilot reviews for one such company today supplying lab testing, which had 40% 1-star reviews and 20% 2-star reviews. The main complaint was that after patients requested a particular test, they were given very scant information on what the results actually meant. They then had to find a clinician to deal with them. I don’t see NHS GPs, given the time constraints, looking favourably on this, and talking to my private medical colleagues, very few are willing to spend the time necessary to look at random test results without a clinical understanding of the patient and what the tests might mean.

There was also a recent article in the media about a man who runs an online health company. He was surprised to find that after taking statins for a while, his testosterone was low and he had no insight as to why. Statins lower cholesterol, and high cholesterol is a known cardiovascular factor. However, low cholesterol is sometimes physiologically unwise; for example, cholesterol is a substrate for steroid hormones such as testosterone. I guess the man who runs the company is not a clinician.”

 

Medscape

Ute Eppinger

Germany is getting heavier. Does that mean that Germans are eating much more? It’s not that simple, said Dr Thomas Ellrott, a physician and director of the Institute for Nutritional Psychology at the University of Göttingen. “There is a mismatch between energy intake and energy expenditure.”

On one hand, Germans have high energy intake. But the average weight of the population can also increase if energy intake remains the same but energy expenditure decreases. “In the past 40 years, everyday energy expenditure has decreased significantly, because every bit of physical activity nowadays is taken over by machines or we use transportation instead of walking,” said Ellrott.

“The constant oversupply [of food] certainly also plays a role,” said Ellrott. Many people not only eat at the three main meals, but also have developed the habit of snacking throughout the day. The trend toward snacking is evident in the fact that fewer and fewer people eat a hot meal every day. In 2008, this proportion was 55%; 10 years later it was 45%.

Satiety Signals ‘Overlooked’

The way we eat influences the feeling of satiety, said Ellrott. “The problem with snacking is that it typically happens on the side. If you don’t focus on the food itself while eating, but do other things at the same time, the likelihood is high that you will overlook internal signals of hunger and satiety. Then external signals play a role, such as whether the plate is empty or whether the package is empty.”

Not only do you consume more calories overall by constantly eating small meals, but also the snacks themselves are often high in calories. “It’s rarely an apple or a banana, but rather a pastry from the bakery,” said Ellrott.

Stimulus Response 

Nutrition research indicates that patients with obesity react more strongly to external stimuli and have a disrupted feeling of satiety. Babies eat and drink entirely according to internal stimuli and stops when they are full. Throughout life, internal stimuli are overwritten by external signals, such as family mealtimes or lunchtime at work, to synchronize the daily routine.

In patients with obesity, however, an additional factor is significant: “the constant willful counteracting of internal signals of hunger and satiety,” said Ellrott. “Many have had literal diet careers and have completely unlearned to listen to their internal signals because they constantly counteracted them.”

But eating according to real, biological hunger does not automatically protect against obesity. In obesity centers, one can find patients with a body mass index of 40 who have always eaten according to their internal signals of hunger and satiety.

What is the key to healthy eating? For Ellrott, it lies in acquiring the ability to control food decisions, including the flexibility to let things slide sometimes.

Patients who are healthy and slim even without following restrictions are doing other things right, said Ellrott. “Exercise and sports not only directly increase energy expenditure but also have an influence on internal hunger and satiety regulation. That is an additional benefit.”

Behavioral Therapy 

Behavioral therapy that helps people relearn to listen to their internal signals would be an important factor. “The behavior that needs to be changed must first be made visible and thus changeable,” said Ellrott. This does not automatically mean that one will eat more mindfully, but it is the “first step.”

This step must be followed by further steps such as stimulus control. This also includes rearranging the living environment so that one does not constantly come across high-calorie snacks, but instead prepares healthy meals and snacks, thereby focusing on meal prepping. “A high frequency of repetition is needed for this actively controlled behavior to become a habit,” said Ellrott.

Because psychotherapy appointments are scarce, digital behavioral therapies could be an alternative. “The data on digital psychotherapy are quite promising,” said Ellrott, although app-based therapies are not quite as effective as traditional face-to-face therapy.

Complexity Hinders Change

Measures to change eating behavior often fail to yield the hoped-for success. These failures are related to the complexity of the issue, said Dr Eva Hummel, head of the Socio-Ecological Nutrition Transformation Working Group at the Max Rubner Institute in Karlsruhe, Germany, and her colleague Ingrid Hoffmann.

On the basis of current literature, expert consultations, and instruments for dealing with complexity, Hummel and Hoffmann have developed a cause-and effect model that reflects eating behavior. The model shows cause-and-effect chains, feedback loops, multicausality, and side effects. “Analyses based on the model can improve understanding of eating behavior and help identify starting points for changing food consumption,” they wrote.

Can the desired eating behavior be promoted through nutrition information? “In individual cases, maybe yes. Overall, no,” said Ellrott. He referred to the results of the Regensburg planetary health literacy model. It describes four competencies that are necessary to change behavior. Reading the information on the package is not enough.

One must also have the following skills:

  • Finding information;
  • Understanding information;
  • Evaluating information; and
  • Applying information and transferring it to other situations.

Especially in complex consumer societies, individual responsibility and self-directed living are often overwhelming, said Dr Christel Rademacher, a nutritionist and head of the Institute of Applied Nutritional Sciences at the Niederrhein University of Applied Sciences in Mönchengladbach, Germany.

A multitude of options, information overload, and high personal and societal expectations contribute to the sense of being overwhelmed. Distorted risk perception also plays a role. Every day, people are confronted with abstract and diverse, often distorted, risks in their eating decisions, in relation both to their private well-being and to the planet’s limits.

Obesity Prevention 

Good infrastructure for pedestrian and cycling paths would be part of successful obesity prevention, said Ellrott. “This not only is ecologically sensible but also promotes health because people are more physically active in everyday life.” Limiting screen time and taking steps to address the sedentary lifestyle also are important. “Standing, walking, moving around: all of this is better for weight and health than sitting,” said Ellrott.

In terms of nutrition, Ellrott sees various strategies that can reduce calorie consumption. “Liquid calories are particularly problematic,” he said. “This has not yet been understood by everyone.”

In sodas, juices, and alcoholic drinks, “there are many liquid calories in them that hardly make you feel full,” Ellrott continued. From 500 to 1000 calories a day can accumulate through consumption of such drinks, which often are overlooked. Water or highly diluted sodas should ideally also be the cheapest drinks to consume. For example, they could be exempt from sales tax.

Ellrott also suggested focusing on community catering in daycare centers, schools, cafeterias, and company cafeterias. If the food is prepared according to the quality standards of the German Nutrition Society, with more nuts, legumes, whole grains, and vegetables in the recipes, “then you are already doing many things right and reaching many people.”

“It is particularly important that the eating situation be pleasant and appreciated by children. Then the children find the served food great and delicious, and that also changes the children’s preferences,” said Ellrott.

Good Nutrition Education

The way we eat and produce food influences not only human health but also that of our planet. Therefore, the right nutrition can significantly contribute to a more sustainable future. To shape this transformation, nutrition education is essential, said Rademacher. With her colleagues from the DGE Nutrition Education Working Group, Rademacher has developed the following recommendations for forward-thinking nutrition education:

  • Incorporate nutrition education into the general education curriculum.
  • Make nutrition education part of the training for all educational professionals.
  • Develop a quality assurance system for nutrition education.
  • Strengthen independent communication centers for nutrition issues.
  • Enact political measures to foster sustainable food environments.