When you have obesity, embarking on a weight management or maintenance plan can be full of peaks and valleys, and getting guidance from the right dietitian can help you achieve your goals. We asked L. Casey Flowers, MS. RD, LDN, a Program Dietitian at Morehouse School of Medicine, to guide us on what to look for in a dietician, the assessment process, goal setting, lengths of visits, and the insurance process so they have an idea of the process. Flowers was a panelist for our Winter 2024 Summit: Weighing All the Options: Let’s Speak Up About Obesity.
Check out our Q & A with her below:
How do people find someone like you?
L. Casey Flowers: With the expansion of telehealth in 2020, it’s been much easier to find a dietitian to work with. If you’re working with an endocrinologist for diabetes or a nephrologist for kidney disease, they usually have someone who works directly within their office. Or they can provide you with a direct referral, making things much more accessible. And your insurance company can give you a list of people as well.
No, not all dietitians are created equal. Some nutritionists may be personal trainers who took a course. Licensed dietitian nutritionists (LDNs) must take a licensure exam and meet continuing education hours to maintain their credentials through the state.
However, not all LDNs feel comfortable talking about weight management. Look for those with a CSOWM certification so you know they are Certified Specialists in Obesity and Weight Management. Most people will include it on their website.
What happens during the initial appointment?
LCF: If someone comes to me for weight management, our first visit will last 45 to 60 minutes. Our follow-up visits are generally 15 to 30 minutes. We do your anthropometrics, height, weight, and blood pressure. I will always ask if you have any specific questions because I will have many questions.
I will ask about your medical history. What if you’re on medication that causes weight gain? I must also know your diet history because every attempt lowers your metabolism. So, we will go through your whole diet, exercise, and weight history. Has it always been like this? Or is it an up and down?
The second half of the visit is the best part. “It is not, ‘Here’s this piece of paper, and you follow this plan,’ We take all the information you shared and make a specific plan to meet your lifestyle.
What you said is pertinent. For example, what has happened in the last six months or five years impacts what will happen now. I just had a death in my family or lost my job; that’s important for you to know.
LCF: Extremely. If your stress hormones have increased, and you haven’t done anything to help lower them, your weight will not go anywhere. So, we must ensure we’re addressing those kinds of baseline concerns.
What surprises patients about their first visit with a dietician?
LCF: We start with small changes. We usually focus on three goals to start and then set them up with a monitoring tool, like a food journal or an app, so that we can do regular check-ins. Today, for example, one of my patient’s three goals was to sleep seven hours a night. However, making that improvement will help in the long term.
How does sleep impact weight?
LCF: Sleep is so essential that I never thought I’d have to discuss it as much as I do. Many patients do not get their seven hours in, so their stress hormone, or cortisol, never has a chance to get lowered. When your cortisol is up, it automatically tells your body to start up, regulating your fat, absorption, and growing fat. It also increases your hunger, specifically for specific nutrients that will boost your dopamine. What’s going to do that is tryptophan, which comes from chocolate.
So, if you’re not sleeping well, many people start craving these simple carbohydrates to help get them through the day.
As a Certified Diabetes Care and Education Specialist, I always see this as a red flag. If somebody wakes up between 3 and 5 AM, that’s nighttime or reactive hypoglycemia time, and their blood glucose will drop during those hours. They will spontaneously wake up. We must fix their diet at nighttime so that doesn’t happen. Sleep tells you a lot about a person.
How often do you meet with your patients?
LCF: We’re supposed to meet every two weeks for the first month. Then, we can go every two to three months for maintenance. I am the only dietitian in my clinic and serve three clinics. So, I usually see patients every four weeks. We’ll meet once a month. I also do email check-ins to see how my patients are doing.
 When you keep your food journal, please be honest. I do not care. There is a suspicious amount of grilled chicken salad in people’s diets, but not all of us are eating them.
How long is a patient seen?
LCF: It depends on their insurance and what they’re willing to cover. Sometimes, insurance says you only get three hours of diabetes education a year. So, we make that work. Some people have come into the office and needed a brief education. I never saw them again. Other patients I have known for the last half-decade. At this point, invite me to your cookout; we’re family. It depends on what the person needs.
What if a patient came to you recently diagnosed with pre-diabetes? What advice would you give them?
LCF: This is my favorite question. I love pre-diabetes because these patients are in a great spot to make a huge change that will impact the rest of their lives. Many underutilized resources exist, such as the CDC’s Diabetes Prevention Program. Certain health facilities have grants within that program. I always educate my patients on that. Some feel more comfortable doing the one-on-one with me. We work on lifestyle intervention:
- Are you moving your body enough to burn off this extra blood glucose?
- Are you eating in a pattern that you know is conducive?
- Are you having more fiber than sugar?
This isn’t something that you can do well for a month, and now you don’t have pre-diabetes or diabetes; no, your pancreas has officially told us something’s wrong. You will have to pay attention to this forever.
What other conditions do you see in patients often?
LCF: The conditions I see most often include hypertension, high cholesterol, and those trying to get their heart health under control. I work with patients after bariatric surgery. The challenge is that although their stomach anatomy has changed, they see food with the same eyes and brain, so getting support as you make these adjustments is critical. I meet with them every one to two months during the first year.
If you are looking for a Licensed Dietitian, where should you start?
LCF: The Academy of Nutrition and Dietetics has a website, eatright.org. You can search for a practitioner based on preferences, including zip code, language, certifications, insurance, and in-person and telehealth options. Check directly with your insurance provider to see whether they have any LDNs or RDNs with CSOWM certifications and Google providers in your area with those certifications to see what comes up. Finding the right dietitian could be essential to maintaining weight loss once you achieve your goal.
Supported by an educational grant from Novo Nordisk Inc.Â
