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July 2, 2021

By Robin M. Eickhoff, MD, MPH

This blog first appeared in San Antonio Medicine in May 2021

My entire life, I have battled weight. My mother says she named me after a bird because I always had my mouth open for food. It makes me smile, because I know there is truth to it. I love food. I love thinking about it, reading about it, cooking it and definitely eating it. The downside is the false perception that I must decide between being overweight and enjoying my life the way I want, because there is no middle ground. This is the battle many fight every day: “It’s all or nothing.”

As with most things in life, when we try to be perfect and inevitably fail, we quit. Healthy eating and nutrition isn’t an all-or-nothing proposition. We must give our patients and ourselves the gift of imperfection.

The topic of healthy eating can fit in two buckets: metabolic (nutrition) and behavior (dietary). The two buckets are on each end of a continuum with a myriad of conditions that may (or not) be influenced by intervention. I will address each, how pathology can influence them, including a bit on eating disorders, and then offer suggestions for interventions in an office setting that I believe improves patient outcomes.

Nutrition, the metabolic bucket, requires the balance of macronutrients and micronutrients to maintain and manage good health. Macronutrients are carbohydrates, proteins and fats. Micronutrients generally refer to vitamins and minerals, which come with a balanced diet. Media influence has led many to believe that carbohydrates are bad, proteins good and fats are “it depends.” In reality, we need all three for normal metabolic function, or disease ensues. Chronic diseases, particularly in more advanced stages, can result in deficiencies and inadequate nutrition, although sometimes it’s the treatment of those diseases that cause the malnutrition. Medications can cause weight loss and malnutrition (chemotherapy) or weight gain and over-nutrition (antipsychotics, insulin). When malnutrition is due to a disease state, it’s rarely desired, so patients strive to correct the deficiencies to the best of their abilities. When a patient is suffering from malnutrition, I am more inclined to tell them to eat whatever they prefer until their nutrition has improved. Success depends on the cause, end-stage diseases are more likely to result in the catabolic state of cachexia, which rarely improves.

Weight loss that is intended and results in malnutrition is more commonly due to an eating disorder, and much harder to treat. Eating disorders are mental health disorders defined by the DSM 5 as:  “characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.”

These fall more into the behavior or dietary bucket, but can cross over into the metabolic bucket affecting nutritional status when not responsive to treatment. The most common eating disorders seen in a primary care setting are anorexia nervosa, bulimia nervosa and binge-eating disorder, and tend to have higher prevalence in post-industrialized, higher-income countries. Risk of developing anorexia or bulimia tends to be more likely in cultures that appear to value thinness, and as one would expect, higher risk in occupations such as those that focus on thin as healthy, like modeling, elite athletics. Going into specifics about each of these eating disorders is well worth its own article and will hopefully be addressed in a future edition.

Most patients we encounter do not have an eating disorder, but instead struggle with being overweight or obese. With that often comes a sense of shame and personal failure. We want to help patients overcome these barriers to health by empowering them with knowledge and tools about nutrition and healthy eating, but how? There are recommended nutritional guidelines, but we also must individualize what will work for each person. As noted earlier, there are numerous eating plans but no one-size-fits-all plan. And whatever the recommendation, it has to be sustainable.

The science of nutrition changes based on new data and studies, but the benefits of quality, whole, natural food do not. We need carbohydrates, but ice cream and broccoli are not created equal. Fats are necessary for living, but unsaturated fats are best. Complete proteins are required. The daily American diet typically contains more protein than necessary, but protein can be obtained from many surprising sources. For example, mushrooms, have the same amount of protein per gram as carbohydrates. Recently, the USDA released updated Dietary Guidelines for Americans with some criticism around protein amounts, but overall, recommendations appear to be reasonable. Guidelines focus on the intake of nutrient-rich, high-value foods and minimal amounts of sugar and processed foods, while acknowledging the need for customization and moderation. Up to 15% of daily calories may include saturated fats and/or sugar-rich foods and beverages. This allowance is more likely to result in long-term success for changes in diet and improved nutrition.

In addition to trying all of the above diets, I’ve tried Green Smoothie diet, Weight Watchers®, pre-made meal plans like Jenny Craig®, Atkins®, South Beach®, and my last and most successful… counting daily macronutrients. This worked for me because I had choices and maybe more importantly, an accountability coach that I reported to weekly with my successes and challenges. I was never shamed or made to feel inadequate, only asked possible reasons for why I made a poor choice and how to prevent it from happening again. In other words, I was given permission to be less than perfect. My best effort was enough.

If we want to ensure success in our patients, we need to provide them with accountability. That can be difficult when working in a busy clinic, managing schedules and keeping up on documentation and billing. Accountability can take many forms, however; it can be weekly weights and measurements with an MA, or even just a phone call from staff obtaining home readings and reviewing the weekly successes and challenges. Patients, just like us, want to be successful. Information is important, but as I am finding in my own life, accountability is what motivates me to change. Once progress is seen, motivation often becomes internal, but being accountable, when supportive, can be the pivotal factor to push success. Over time, less external accountability is needed, because personal accountability develops. How we provide that accountability will be up to us and our patients.

A healthy diet includes balance between the metabolic component (nutritional) and the behavioral component (dietary). Each of these, when not in harmony, adversely affects the other. Poor dietary choices can cause undesirable nutritional outcomes that can cause disease or influence existing disease. Disease, whether chronic or acute, physical or mental, can adversely affect metabolic state and require dietary changes to minimize poor outcomes. Considering this when advising and treating patients, along with placing an emphasis on personal preferences, moderation of less nutritional foods and providing supportive accountability, can help patients be successful. When helping patients with an eating plan that will result in permanent change, most importantly, give permission to be less than perfect. And while you’re at it, do the same for yourself in whatever changes you want to make in your own life, dietary or otherwise. After all, we are all human.

(For more detailed resources on Dietary Guidelines for Americans, including infographics, visit

Robin M. Eickhoff, MD, MPH, is a senior medical director for WellMed. She earned her medical degree from Tulane University in New Orleans, Louisiana. Dr. Eickhoff completed her family practice residency at John Peter Smith Hospital in Fort Worth, Texas. In addition, she served as a flight surgeon in the United States Air Force, for three and a half years, at Dyess Air Force Base in Abilene, Texas.

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