Science Space
The role of nutritionists at Endocrinology Units
Endocrinology and Nutrition are two essential fields of knowledge in the health sciences which share many common points and synergies. Accordingly, it was not by chance that the first push to setting up a Licenciatura (Honours) Degree in Nutrition Sciences (originally an Ordinary Bachelor Degree in Nutrition) was given by an endocrinologist, the much missed Dr. Emílio Peres, who is fondly acclaimed as the “father of Portuguese nutritionists”.
Nowadays, and due to the growing prevalence of the so-called chronic and metabolic diseases (obesity, diabetes, high blood pressure, and dyslipidemia, among others), Endocrinology Units are called upon to provide answers to an increasing number of patients who suffer from one or more of these clinical conditions.
Nutritionists and health professionals in general, possess quite valid scientific evidence with regard to the presuppositions and the effectiveness of lifestyle changes in the prevention and treatment of chronic and metabolic diseases, such as type 2 diabetes, arterial hypertension (HTN) and dyslipidemia disorders. The results obtained from lifestyle changes (in terms of diet and physical activity) in the prevention of diabetes noted in the ‘Diabetes Prevention Program’ (Tuomilehto J, 2001) constitute an example of this.
In the same light, the importance of nutritional intake modelling in dyslipidemia has been recognised (NCEP, 2002), as well as the benefits of adopting specific eating patterns for blood pressure values, namely the potential role of the DASH diet on HTN therapy. (Appel, et al., 1997). Still in the same context, the ENCORE study (Blumenthal, et al., 2010) has demonstrated the comulative role of the DASH diet and ponderal loss on blood pressure and biomarkers of cardiovascular risk in overweight individuals with high blood pressure. The positive influence of weight loss in metabolic control and in reducing the incidence of the disease had also been previously noticed with regard to diabetes (Tuomilehto J, 2001) and cardiovascular disease (NCEP, 2002).
Given that it is undeniable that only one a small percentage of overweight cases are caused by an endocryne pathology, Endocrinology Units and the professionals that work in them are usually seen as being more predisposed and apt to intervene in patients suffering from that condition. However, the therapeutic approach to obesity is frequently perceived as not being very effective, particularly in terms of medium and long-term results (Anderson JW, 2001). Indeed, the “therapeutic weapons” at the disposal of health technicians are scarce, chiefly in what concerns pharmacotherapy. Hence, it is amidst a potentially context that is adverse to effective intervention that the work of nutritionists may become significantly beneficial.
In order to attain the desired effectiveness, health technicians are required to be strongly committed, which implies constant updating and optimization of their interventions by resorting to valid scientific evidence. Within this context, nutritionists anchor their interventions on careful evaluation of the clinical condition of patients, interpreting them in the light of biochemistry and physiology presuppositions, with the aim of encouraging lifestyle changes leading to sustainable weight loss. The issue behind lifestyle changes of obese persons is simultaneously vital and subject to ample discussion (not in terms of the need for it, but the way to go about it). It is curious that, despite the abundant scientific research available, so many doubts still subsist regarding the adequate composition (level of caloric restriction, proportion of macronutrients, role of some micronutrients) and the structure of the diet (role of fractioning food intake, distribution of calories and nutrients throughout the day…) that lead to a sustainable and effective weight loss.
In fact, what is unquestionable is the requirement to reduce calorie intake (Sacks, Bray, & Carey, 2009), for which reason all additional criteria informing prescription of diets depend on the presence (or absence ) of comorbidities, and especially on the individuals in question and on the lifestyle changes (particularly diet) that they are willing to make and uphold.
On this, it is important to pinpoint the importance of presuppositions and quality of the therapeutic relationship. Given that resistance to changing habits and behaviours is a natural consequence of the therapeutic process, individual choices must be encouraged. When empathy lies at the basis of the therapeutic relationship, the constant confrontation of values and objectives (those of the health technician vs those of the patient) and disagreement must be replaced by reflection on the discrepancy between behaviours and the objectives set out by the patient, with the goal of strengthening the motivation that leads to the desired change.
In conclusion, the role of nutritionists in Endocrinology Units is to assist patients, in collaboration with other health technicians, using the best scientific evidence available. It is nutricionists’ role to delineate a “common agenda” with patients regarding the introduction of the necessary lifestyle changes – the same way a tailor adjusts a suit to the shape of his client – informed by a common objective that will translate into health gains.
José Camolas
Endocrinology, Diabetes and Metabolism Unit
jose.camolas@gmail.com
_______________________
Bibliografia:
Anderson, J., Konz, E., Frederich, R., & Wood, C. (2001). Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr, 74 , 579–84.
Appel, L., Moore, T., Obarzanek, E., Wolmer, W., Svetkey, L., Sacks, F., et al. (1997). A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med, 336, 1117-24.
Blumenthal, J., Babyak, M., Hinderliter, A., Watkins, L., Craighead, L., Lin, P., et al. (2010). Effects of the DASH Diet Alone and in Combination With Exercise and Weight Loss on Blood Pressure and Cardiovascular Biomarkers in Men and Women With High Blood Pressure. The ENCORE Study. Arch Intern Med, 170(2), 126-135.
NCEP Expert Panel (2002). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation , 106, 3143–3421.
Sacks, F., Bray, G., & Carey, V. (2009). Comparison of Weight-Loss Diets with Different Compositionsof Fat, Protein, and Carbohydrates. N Engl J Med, 360, 859-73.
Tuomilehto J, L. J. (2001). Prevention of Type 2 Diabetes Mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med, 344(18), 1343-50.
Nowadays, and due to the growing prevalence of the so-called chronic and metabolic diseases (obesity, diabetes, high blood pressure, and dyslipidemia, among others), Endocrinology Units are called upon to provide answers to an increasing number of patients who suffer from one or more of these clinical conditions.
Nutritionists and health professionals in general, possess quite valid scientific evidence with regard to the presuppositions and the effectiveness of lifestyle changes in the prevention and treatment of chronic and metabolic diseases, such as type 2 diabetes, arterial hypertension (HTN) and dyslipidemia disorders. The results obtained from lifestyle changes (in terms of diet and physical activity) in the prevention of diabetes noted in the ‘Diabetes Prevention Program’ (Tuomilehto J, 2001) constitute an example of this.
In the same light, the importance of nutritional intake modelling in dyslipidemia has been recognised (NCEP, 2002), as well as the benefits of adopting specific eating patterns for blood pressure values, namely the potential role of the DASH diet on HTN therapy. (Appel, et al., 1997). Still in the same context, the ENCORE study (Blumenthal, et al., 2010) has demonstrated the comulative role of the DASH diet and ponderal loss on blood pressure and biomarkers of cardiovascular risk in overweight individuals with high blood pressure. The positive influence of weight loss in metabolic control and in reducing the incidence of the disease had also been previously noticed with regard to diabetes (Tuomilehto J, 2001) and cardiovascular disease (NCEP, 2002).
Given that it is undeniable that only one a small percentage of overweight cases are caused by an endocryne pathology, Endocrinology Units and the professionals that work in them are usually seen as being more predisposed and apt to intervene in patients suffering from that condition. However, the therapeutic approach to obesity is frequently perceived as not being very effective, particularly in terms of medium and long-term results (Anderson JW, 2001). Indeed, the “therapeutic weapons” at the disposal of health technicians are scarce, chiefly in what concerns pharmacotherapy. Hence, it is amidst a potentially context that is adverse to effective intervention that the work of nutritionists may become significantly beneficial.
In order to attain the desired effectiveness, health technicians are required to be strongly committed, which implies constant updating and optimization of their interventions by resorting to valid scientific evidence. Within this context, nutritionists anchor their interventions on careful evaluation of the clinical condition of patients, interpreting them in the light of biochemistry and physiology presuppositions, with the aim of encouraging lifestyle changes leading to sustainable weight loss. The issue behind lifestyle changes of obese persons is simultaneously vital and subject to ample discussion (not in terms of the need for it, but the way to go about it). It is curious that, despite the abundant scientific research available, so many doubts still subsist regarding the adequate composition (level of caloric restriction, proportion of macronutrients, role of some micronutrients) and the structure of the diet (role of fractioning food intake, distribution of calories and nutrients throughout the day…) that lead to a sustainable and effective weight loss.
In fact, what is unquestionable is the requirement to reduce calorie intake (Sacks, Bray, & Carey, 2009), for which reason all additional criteria informing prescription of diets depend on the presence (or absence ) of comorbidities, and especially on the individuals in question and on the lifestyle changes (particularly diet) that they are willing to make and uphold.
On this, it is important to pinpoint the importance of presuppositions and quality of the therapeutic relationship. Given that resistance to changing habits and behaviours is a natural consequence of the therapeutic process, individual choices must be encouraged. When empathy lies at the basis of the therapeutic relationship, the constant confrontation of values and objectives (those of the health technician vs those of the patient) and disagreement must be replaced by reflection on the discrepancy between behaviours and the objectives set out by the patient, with the goal of strengthening the motivation that leads to the desired change.
In conclusion, the role of nutritionists in Endocrinology Units is to assist patients, in collaboration with other health technicians, using the best scientific evidence available. It is nutricionists’ role to delineate a “common agenda” with patients regarding the introduction of the necessary lifestyle changes – the same way a tailor adjusts a suit to the shape of his client – informed by a common objective that will translate into health gains.
José Camolas
Endocrinology, Diabetes and Metabolism Unit
jose.camolas@gmail.com
_______________________
Bibliografia:
Anderson, J., Konz, E., Frederich, R., & Wood, C. (2001). Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr, 74 , 579–84.
Appel, L., Moore, T., Obarzanek, E., Wolmer, W., Svetkey, L., Sacks, F., et al. (1997). A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med, 336, 1117-24.
Blumenthal, J., Babyak, M., Hinderliter, A., Watkins, L., Craighead, L., Lin, P., et al. (2010). Effects of the DASH Diet Alone and in Combination With Exercise and Weight Loss on Blood Pressure and Cardiovascular Biomarkers in Men and Women With High Blood Pressure. The ENCORE Study. Arch Intern Med, 170(2), 126-135.
NCEP Expert Panel (2002). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation , 106, 3143–3421.
Sacks, F., Bray, G., & Carey, V. (2009). Comparison of Weight-Loss Diets with Different Compositionsof Fat, Protein, and Carbohydrates. N Engl J Med, 360, 859-73.
Tuomilehto J, L. J. (2001). Prevention of Type 2 Diabetes Mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med, 344(18), 1343-50.
