1. Health At Every Size An Alternative Approach
Julie Rochefort, MHSc, RD
Jacqui Gingras, PhD, RD
Canadian Obesity Summit
May 1, 2013

2. “Opening oneself to the possibility for transformation is a profound act of courage.”
- Maureen Walker
“Accepting wider range of healthy weights and body sizes while discouraging social pressures for extreme slimness is not an easy task whether you are a parent, teacher or health care professional. Promote healthy eating (not dieting) and regular physical activity (not exercise).”
This is not going to be easy- there’s a lot of resistance from various disciplines. But by opening oneself to the possible of transformation we are one step closer to making a real change in our world.

3. Outline Overview Learning Objectives Introductions HAES 101
Activity 1: Shift the focus in Clinical Practice
Break

4. Outline
Summary
Activity 2: Barriers and enablers to practicing from a HAES perspective
Closing

5. Learning Objectives
At the end of this workshop, participants will be able to:
Clarify the tenets of HAES
Engage with case-based learning activities
Identify challenges and opportunities

6. Facilitator Introductions

7. Julie
&
Jacqui

8. History Failure rate of diet
Weight stigma and resulting health consequences
Responding to the incidence of ED/DE
Health promotion practice with low side-effects

9. HAES AS SOCIAL JUSTICE JG

10. This strategy ISN’T working.
Promoting weight loss
95% of those who lose weight regain it (Bray, 2005;Mann et al, 2007;Wing et al, 2001).
Nutritional inadequacy.
Difficulty sustaining low calorie intake.
Frustration
Weight cycling: “yo-yo” effect.
This strategy ISN’T working. JG
What do we know about people who lose weight? Refer to first bullet on slide.
In fact, a panel of experts convened by the NIH stated that: “One third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within 5 years” (NIH, 1992)
(NHLBI, 1998) “no prospective trials to show changes in mortality with weight loss in obese pts.” Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. (October 1998). JADA. Vol. 98 No.10. pp
We are encouraging a treatment that we know doesn’t work.

11. THE DIET TRAP CYCLE Weight Regain Decrease in calories
REPEAT
DIET
RETURN TO
OLD HABITS
Weight Regain
Decrease in calories
FEAST
RESPONSE
Increase in calories
Reduced metabolic rate
Loss of muscle
Regain weight from fat
FAMINE
RESPONSE
Lose weight from lean muscle and fat
Reduced metabolic rate
Increase in fat storage

12. “There’s a lot of money to be made out of the idea that every Australian man, woman, child and dog could lose some weight.” -Associate Professor Jenny O’Dea JG

13. OBESITY PANIC:
This is some examples of the fearful language used to treat and inform the public about obesity. I took these words from Canadian government weights, obesity practice guidelines. During my masters, I became aware that this language listed behind me is perpetuating more harm than positive health outcomes.
Campaigns: Obesity Campaigns: The Fine Line Between Educating and Shaming

14. Why now? Obesity panic Show obesity campaigns and emerging products
BMI Report Cards
Commercials/Billboards
Aspire Assist
Maggie Goes on a diet

15. Self-indulgent Unmotivated Repulsing Awkward Unattractive
Non-Compliant
Self-indulgent
Unmotivated
Repulsing
Trained RN/MD/RD and also students training within these professions.
Recent study: Journal: Obesity- a research journal: “Physicians build less rapport with obese patients”
There is evidence to show that after visits with more empathy, patients have improved clinical outcomes e.g. DM- BG, TG
Awkward
Unattractive
Brownless et al., (2006) Puhl RM and Latner JD (2007/2009))

16. Consequences of weight stigma- NOT WEIGHT.
Our efforts to help people to lose weight can unintentionally caused harm.

17. USA Anti-Obesity Campaign

18. Disney World: The "Bad Habits"
[UPDATE: 48 hours after this blog was posted, and after intense uproar in social media circles and in the press, Disney did the right thing and closed the exhibit for retooling. Kudos to them for responding quickly - I'm sure their intent wasn't to vilify children with obesity and am hopeful that Habit Heroes' next iteration will be a helpful ally in good health] 

19. Food Labelling: OMA

20. Your kids are listening campaign
Obesity Campaigns: The Fine Line Between Educating and Shaming
Peel Public Health & Toronto Public Health (2013)

21. Shift the focus

22. HAES 101

23. Listening to body’s hunger/fullness cues
Moving for pleasure
Accepting and respecting current state of well being
Speaking out
Promoting belonging

25. Evidence

26. Fat and Healthy? Reducing cardiometabolic risk:
“A healthy diet and exercise without (minimal) weight loss is NOT failure” (Ross & Janiszewski, 2007).
Health improvements can be achieved through changing health behaviours, even in the absence of weight loss (Bacon et al., 2005; Appel et al., 1997; Gaesser,2007).
Dr. Ross is a researcher in exercise physiology from Queen’s University. He is quoted as saying …. (refer to slide)

27. If weight was the ultimate indicator of health, we shouldn’t be seeing one third of normal weight individuals having ‘metabolic abnormalities”.
While we can’t ignore that abnormalities are occurring in high proportions in those overweight, weight may be more of an symptom of a larger underlying factor.
Also, strong research has demonstrated that individuals whether normal weight or obese can improve their metabolic profile without loosing weight.
Wildman et al. Arch Intern Med. 2008;168(15):

28. Obesity Paradox Assumption: Evidence: “Weight loss will prolong life.”
Mortality increased among those who lost weight & who were over 50 yrs. (NHANES Review, 2010).
Obesity associated with longer survival in heart disease, kidney disease, and stroke (Morse et al., 2010; Scherbakov et al., 2011).
Lucy Aphramor and Linda Bacon are 2 dietitians and researchers who wrote an extensive review paper of the obesity literature. They highlight some assumptions made about weight and fat:

29. Obesity Paradox Assumption: Evidence:
“Adiposity poses significant morbidity risk.”
Evidence:
Obesity associated with increased disease risk.
When fitness level, activity, nutrient intake, weight cycling or SES is controlled, increased risk of disease due to obesity disappears or is significantly reduced (Campos et al., 2005; Strohacker et al., 2010; Montani., 2006; Rzehak et al., 2007; Raphael et al., 2010).
Association does not equal causation.

30. What Else is going on? SES Psychological Status Endocrine System
Menopause
Sleep Apnea/Sleep Deprivation
Availability/Quality of Food
Stress
Environment
Chemicals/
Toxins
Lack of Exercise
Genetics
Medication: not just prednisone or SSRIs used to treat depression, but beta-blockers, prednisone, OHA like glyburide, diamicron and then of course there’s insulin.
Smoking: wt gain of 1-2 KG occurs in the first few weeks and often followed by additional 2-3kg weight gain over the next 4-6 months: average weight gain 4-5kg (9-11 lbs) or more (Bray & Champagne, 2005).
Sleep deprivation: releases peptides that produce hunger (pS20).
It’s widely known that the primary determinant of health is related to the social and economic environment in which people live.
SES is something that is largely out of the control of our patients. So to hear pts blame themselves for not being able to lose weight or keep it off, is only going to further perpetuate the problem.
Unfortunately, HCPs make assumptions and inflict this blame on them as well.
So what can we do? We can lobby those who have the power to better equalize the current situation.
SES
Medication
Co-morbidities
Quitting Smoking
Cultural Norms/Beliefs

31. Evidence of HAES
HAES approach associated with statistical & clinical improvements:
physiological measures (e.g. blood pressure, blood lipids),
health behaviors (e.g. physical activity, reduced eating disorder pathology), and
psychosocial outcomes (e.g. mood, self-esteem, body image).
To date, there have been seven randomized controlled trials using a non-diet approach to lifestyle change.
participants in the programs have experienced statistically significant improvements in mental health, self-esteem and body image vs. controls .
HAES approach associated with improvements
physiological measures (e.g. blood pressure, blood lipids),
health behaviors (e.g. physical activity, reduced eating disorder pathology), and
psychosocial outcomes (e.g. mood, self-esteem, body image). (11-20)
Improvements in self-esteem and eating behaviors (11-14,16,17,19,20).

32. Bacon et al, 2005 Study participants:
78 white, obese, female chronic dieters
Age: years
BMI: 30-45
Randomly assigned: HAES or Conventional Diet Program
DESIGN: weekly visits x 6 mo.; monthly visits x 6 mo.; follow-up 1 year later – no intervention
weekly visits x 6 months; then, monthly visits x 6 months

34. Bacon et al., JADA. 2005 – 2 year Follow Up
Diet group:
Weight lost was regained.
Psychological measures worsened.
HAES group:
Maintained weight
Sustained improvement:
metabolic health indicators, activity levels, eating behaviours & psychological measures.

35. Case Studies

36. Arianna, 25
Case Study

37. Arianna, 25 Self-referred to your care for annual check-up.
Mentions she needs to make changes in her diet because she dislikes vegetables.
Currently completing last year of her university degree.
Wt hx: BMI 33kg/m2
Labs-unremarkable

38. Recommendations Providing not depriving
Explore diet history, relationship with food and body
Sources of stress and coping strategies
“Do you feel like you can manage your stress?”
How much time, energy and resources she is spending dedicated to diet.

40. Frank, 44
Case Study
The 300 lb+ man with osteoarthritis who would benefit from weight loss would be done a disservice if he didn’t get feedback whether he was getting closer to a self-set wt goal to reduce his joint pain because we were worried about hurting his feelings.

41. 44 y.o Frank
Reveals that he is unable to do more than 5 minute on his recumbent bike without knee pain
Takes the bus to the nearest grocery store.
Income: Social Assistance
Medical hx: Lactose intolerance
Osteoarthritis in both knees
Scheduled R-knee replacement in 6 months
Wt hx: He reports that he has gained over 40 lbs in the last 5 years.
Lab data: Triglycerides, LDL and normal HDL
As an orthopedic surgeon my concerns are more with increased wear on weight -bearing joints and joint replacements. How does this affect your recommendations? I don’t really enjoy trying to force weight loss on prospective TJR candidates but the ortho literature enforces that approach. Any thoughts for me?
-David Heller, M.D., South Weymouth, Massachusetts

42. Recommendations Normalize his eating How does he cope with pain
Is he eating for reasons other than hunger?
How does his pain impact his hunger/fullness
How does he cope with pain
Explore pleasurable and appropriate physical activity
Explore social supports (isolated?)
Medications
How does this influence his hunger

43. Normalizing Eating 1) AWARENESS – INITIAL APPOINTMENT
Pay attention to hunger cues – NO changes
“When do you feel hunger’
“when do you start eating, when do you stop”
Could other substances (pop, coffee, cigarette, alcohol) mask hunger?
2) INTERVENTION- FOLLOW-UP
When you notice hunger, then ask yourself:
“what do I want to eat”,
“what will fulfill my appetite”

44. Frank states: “My doctor said I can feel less pain if I lose weight.”
WHAT CAN YOU DO NOW, FRANK?
That may or may not be true
Our concern if for your health and comfort right now
We know that prescribing a weight loss diet can lead you to gain more weight + feeling worst and deterring yourself from healthy behaviours

45. Elisa, 8
Case Study
Evidence: Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based Study
Katie A. Loth, RD, MPHa,
Richard F. MacLehose, PhDa,
Jayne A. Fulkerson, PhDb,
Scott Crow, MDc, and
Dianne Neumark-Sztainer, RD, MPH, PhDa
+ Author Affiliations
aDivision of Epidemiology and Community Health, School of Public Health, bSchool of Nursing, and cDepartment of Psychiatry, University of Minnesota, Minneapolis, Minnesota Abstract
OBJECTIVE: To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs.
METHODS: Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone.
RESULTS: Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status.
CONCLUSIONS: Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on children’s ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.

46. 8 year old Elisa Mom very concerned about weight
Child is not active in sports
Wt hx: Growth chart indicates weight for height moved from 90th  93rd percentile
Mother has been finding hidden food wrappers and finds a ‘dyiet’ note in her school agenda.
By a show of hands, how many of you had an encounter with Elisa?
Evidence: Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based Study
Katie A. Loth, RD, MPHa,
Richard F. MacLehose, PhDa,
Jayne A. Fulkerson, PhDb,
Scott Crow, MDc, and
Dianne Neumark-Sztainer, RD, MPH, PhDa
+ Author Affiliations
aDivision of Epidemiology and Community Health, School of Public Health, bSchool of Nursing, and cDepartment of Psychiatry, University of Minnesota, Minneapolis, Minnesota Abstract
OBJECTIVE: To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs.
METHODS: Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone.
RESULTS: Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status.
CONCLUSIONS: Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on children’s ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.

48. Recommendations (HAES)
Division of Responsibility
Reassure around eating competence
Reduce pressure to eat
Avoid food restriction
Promote self-regulation
“What makes you decide to stop eating?”
Asking, “How do you know when you need to eat?”
Striving for a particular weight outcome
undermines eating competence.- Ellyn Satter

49. Mom’s asks if she could take her daughter’s weight while at clinic
I hear that you are concerned about body weight. But from my perspective this is not the most productive way to proceed- provided that weight doesn’t capture your daughter’s health and well being.
We hear your concern.
We understand where its coming from.
Based on our research and years of practice- that concern is making matters worst.
Ask Alissa to wait outside to finish discussing
We have an amazing opportunity to set her on a course to happy and healthy.
Shift the focus from her well being to her happiness.

50. “Although weight loss strategies may seem desirable for overweight [youth], they are often ineffective and may actually result in weight gain and eating disturbances.”
Jones, JM et al. p.551

51. Following the clinical practice guidelines is always a choice
Following the clinical practice guidelines is always a choice. However, we have an alternative approach we should like to share with you?
Lets meet Elisa.
“We recommend an energy-reduced diet and regular physical activity as the first treatment option for overweight and obese children to achieve clinically important weight loss and reduce obesity-related symptoms.”
CMAJ (2007), Vol 176 (8)pp-88

52. Derick/Danielle, 17
Case Study

53. 17 y.o Derick (Danielle)
Transgendered youth, no sibs , live at home with both parents.
Med hx: Diagnosed with EDNOS following a healthy weights promotion at school.
Dietary recall demonstrates extreme hunger, binge eating, excessive exercise
Wt hx/Labs: BMI=27, blood work unremarkable

54. Recommendations Is the stress attached to the social-cultural context?
Normalize eating and exercise
Hunger/fullness – hunger metre
Moderating exercise/Readiness
“Are you happy with the current amount of exercise you are doing?”
“What is the benefit to you right now for exercising?”
“Is there anything you wish you could do that you can’t due to the amount of exercise you are committed to?”
Validate her food/exercise behaviour as coping strategy however discuss this does not sustain LT.
Emphasis on providing not taking away (Ellyn Satter)
Dignity

55. Biochemistry of Discrimination
Activation of SNS and HPA axis
 cortisol + inhibition of sex steroids + GH  abdominal adiposity + insulin resistance
 cortisol = hyperphagic, antithermogenic
? disrupt balance of leptin & NPY
HT from parallel activation of SNS/insulin
(Sumithran et al., 2011).
Butler, et al., (2002). Internalised racism, body fat distribution, and abnormal fasting glucose among African-Caribbean women in Dominica, West Indies. J Natl Med Assoc, 94(3),
*need to create Smart Art + animations ***

56. Recommendation (Advocacy)
Unlearning what she learned at the healthy weight’s initiative at the school
With permission from D, ask to share with parents and discuss the initiative with principal. Offer teachings to staff on next Professional Development day.

57. Mary, 57

58. 57 y.o Mary
Diagnosed with T2DM 7 yrs ago and afraid that doctor will put her on ‘needles’.
States not being a ‘big’ eater and stays away from sugars. Generally grazes most of the day and eats full meal at supper time with family.
Social hx: lives with husband and fosters 2 children (4 and 10). Participates in walking group 3x per week when 4 y.o is at daycare.
Family hx: T2DM (mother), CVD (uncle)
Labs: A1c= 10.2%, TG –Her FBS at clinic was 10 mmol/L
Medication: Metformin (BID), Calcium and Vitamin D

59. Recommendations
Examine source and coping of stress in her life (could be related to TG/FBS).
Discuss how she feels (emotionally, mentally, physically) when her blood sugars are high/low.
What are your energy level like throughout the day?
How does this relate to your activity and food intake?
Normalize eating-
Identifying hunger/satiety cues (hunger-scale)
Reduce any anxiety and guilt about eating.
May require re-distribution of meal throughout day; however important that it is not prescriptive
Important that changes are personally meaningful and freely chosen.
Discuss how she feels (emotionally, mentally, physically) when her blood sugars are high/low to enhance intuitiveness/biofeedback--physiological consequences.
Normalize eating Diabetes can feel like a betrayal by their body’s which can make it difficult to trust body signals (tool box). So if someone percieves that their body has betrayed them, how can this affect their self-care?
e.G Diagnosis of diabetes often means that food and eating can no longer be enjoyed.
 Redistribution of meals: this will be informed by our discussion around her energy levels experienced during the day when she grazes. We use the information she provides to suggest changes that are meaningful to her – aka patient centered care.

60. When discussing her goals, Mary states that she would like to lose 10-20 lbs.
Situation is: you are employing the HAES view of de-focusing on weight; however her goal and focus has gone towards weight, despite your discussion about food relationships/hunger cues.

61. Sharon, 40

62. Sharon, 40
Referral received from MD re: eating and PA. MD reports Sharon was interested in bariatric surgery. She states she would like to have more energy to play with her children.
Employment: Human Resource Coordinator
Lab values: TGs, HDL, WC >88cm, A1C 6.2%
Wt hx: reports struggling with her wt since she was a teenager.
MetS based on AdultTreatment PanelIII criteria

63. Hunger Meter Externalizing Inner Cues of Hunger, Satiety, and Fullness
Hungry 0
Satisfied 5
Full 10
Hunger Meter Externalizing Inner Cues of Hunger, Satiety, and Fullness

64. Recommendations
Establish a rapport – important for her to rely on you for help if she decided to have B/S
Assess readiness of change provided that the negative consequences of bariatric sgx are magnified if intake isn’t controlled.
Promote eating competence using Hunger Metre
“do you feel reliably confident that you could provide yourself with predictable (timing) meals and snacks?”
Sources of stress and coping strategies

65. What else is going on?

66. School-based Obesity Prevention Program
Public Health
Before the case study- here’s a little insight about the stated of weight-related bullying in canadian schools

67. Fat-so Tub of lard Pig Lazy 2x higher Worthless
In a canadian study on over 1500 youth living in the ottawa area weight-based teasing was significantly higher among overweight and obese youth than among normal weight youth (45% versus 22%; P<0.001). 2x more often
In addition to verbal bullying, obese individuals may also experience physical victimization.
Subsequently, an earlier study demonstrated that physical victimization such as hitting, kicking, pushing and shoving increased with increasing BMI (Janessen, 2004)
social (e.g., excluding others from a group, spreading gossip or rumours)--- > a cdn study showed that overweight/obese school children attributed their weight as the primary reason for
Cyber bullying
This
What gives kids permission to tease someone about their weight and why does this particular type of teasing/bullying affect kids so severely compared to lets say, being the only red head kid in the class?
While my professional scope isn’t in child psychology, my experience observing obesity messaging and seeing body dissatisfaction in the client I see back in my practice, I have a philosophical hunch, or as my fellow colleagues and I like to say “spidy sense” are pointing to the way in which professionals and non-professionals speak about obese individuals. [ I would go into the shaming public health campaigns].
Worthless
Eisenberg et al ; Puhl RM and Latner JD (2007))

68. Poorer school performance
body dissatisfaction
low self-esteem
depressive symptoms
suicidal ideation
avoidance strategies
Poorer school performance
Research has shown that some overweight youth attribute social rejection to their weight, and believe weight loss would increase their friends.
Body dissatisfaction/poor body image; Body-image refers to one’s feelings, attitudes, and perceptions towards one’s body and physical appearance. It is an important consideration in the development of eating disorders because it has been shown that disturbances in body-image increase the risk of dieting and bulimia (NEDIC,)
Suicide: Those who are teased about their weight report more suicidal thoughts than peers who are not teased.Puhl RM and Latner JD (2007)
Importantly, findings show that the more that adolescents reported negative health behaviours in response to weight-based victimization, the more they reported coping with avoidance strategies (e.g., avoiding physical activity), and using maladaptive coping strategies (Pulh, 2012)
Transition
And while the school environment is supposed to foster a safe learning environment and protect children from bulling, the ongoing pressure put on schools to “become one of the nation’s most effective weapons in the fight against obesity”. And while food policies in the schools are a step forward to promoting a an environment that is surrounded by healthier foods, a growing trend in school-based weight prevention programs is growing.
Puhl RM and Latner JD (2007; Pulh, 2012, NEDIC)
Eisenberg et al

69. Components of the report card would include:
You receive an from the principal and guidance counsellor from the local high school regarding an interest in initiating a health report card. Currently , 20% of the school’s students are overweight or obese.
Components of the report card would include:
Waist Circumference, BMI and Body Fat %
Blood Pressure
Blood Sugar
Screen Time
As the school nurse they are asking you to be part of the implementation process and data collection. The goal of this initiative is to ensure the health and well being of their students are maintained and to reduce obesity prevalence in the school by half in the next 5 years.

70. 10% 20% Diet pills Herbal supplements Restricting Skipping meals
Studies have also investigated the level of comfort and acceptability of school-based weight screening assessment. These studies demonstrated that students report being uncomfortable with being weighed at school (Kalich et al., 2008). Consequently, when these student’s were asked about their intentions to engage in weight management activities after receiving information regarding weight, close to 20% of students stated restricting food (diet) and skip meals or snacks with an additional 10% stating they would take diet pills/herbal supplements and visit a weight loss clinic (Kalich et al., 2008).
Moreover a recent article published in the Canadian Medical Association Journal states that school-based programs that collect weight measures may lead increase the prevalence of stigmatization and bullying (CMAJ, 2011).
Long lasting research both from the ED realm and public health has been sounding the alarm at these unintended consequences but for some reason or antoher, we’ve continuously ignored them, letting the public health message and interventions become more and more shaming and blaming.
Kalich et al., 2008

71. Recommendations

72. Critiques
Assumption: Anyone who is determined can lose weight and keep it off through appropriate diet and exercise
Assumption: The pursuit of weight loss is a practical and positive goal
Assumption: The only way for overweight and obese people to improve health is to lose weight
Assumption: Obesity-related costs place a large burden on the economy, and this can be corrected by focused attention to obesity treatment and prevention

73. Consider That…
As evidence-based competencies are more firmly embedded into standard practice, more attention given to the ethical implications of recommending treatment that may be ineffective or damaging. (5, 9)

74. Shifting Paradigms
Interventions will focus only on modifiable behaviors where there is evidence that such modification will improve health.
Weight is not a behavior and therefore not an appropriate target for behavior modification.
Lay experience will inform practice, and the political dimensions of health research and policy will be articulated.

75. Focus on Self care vs. prescriptive advice
HAES in
Practice
Avoid Wt bias
Consider SDOH
Body Diversity
Self-esteem
Promote
Holistic Approach
Compassion Centred
Focus on Self care vs. prescriptive advice
Interventions will be careful to avoid weight-biased stigma, such as not using language like "overweight" and "obesity.”
Interventions will seek to change major determinants of health that reside in inequitable social, economic and environmental factors, including all forms of stigma and oppression.
Support each other by focusing on health and well-being, NOT weight.
Show compassion & understanding for the difficulties that arise from living in non-relational society.
Provide a non-judgmental environment.
Help develop sustainable behavioural changes that easily fit into people’s busy lives.
Continually and rigourously evaluate effectiveness
Get active and involved in re-shaping attitudes, not bodies.
Bacon, Aphramor, 2011

76. Body positive

77. HAES Practice Resources www.shiftthefocus.wordpress.com

78. Discussion
What barriers and enablers do you predict as you transition from HAES theory to practice?
In what contexts can you advocate for HAES?
What resources are needed moving forward?
What research is required to explore HAES further, especially in your practice context?
Jacqui

79. Cultural value of thinness & individualism
BARRIERS
Barriers
Lobby Groups
Workplace
Weight =
Health
Research
Cultural value of thinness & individualism
Talk about the International HAES group
Demand for weight loss

80. Acknowledgements Current and previous Ryerson students
Colleagues & Clients – Noojmowin Teg Health Centre
Conference delegates! That’s YOU!
Rare opportuniyt and crisi

81. References
Bacon L. (2005). Size Acceptance and Intuitive Eating Improve Health in Obese Female Chronic Dieters. J Am Dietetic Association, 105,
Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 24(10), 9.
Bacon, L, Keim, NL, Van Loan, MD, Derricote,M, Gale, B, Kazaks, A and Stern, JS. (2002). Evaluating a ‘non-diet’ wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. International Journal of Obesity, 26, 854–865.

82. References
Bray & Champagne. (May 2005) Beyond energy balance: there is more to obesity than kilocalories. JADA. Vol 105 No. 5, Suppl. 1. PP S17-23.
Cohen, D., de la Vega, R., & Watson, G. (2001). Advocacy for social justice: A global action and reflection guide. Bloomfield, CT: Kumarian Press Inc.
Berke, D. L., Boyd-Soisson, E. F., Voorhees, A. N., & Reininga, E. W. (2011). Advocacy as Service-Learning. Family Science Review, 15(1),

83. References
Brown, I. (2004). Nurses’ attitudes towards adult patients who are obese: literature review. Journal of Advanced Nursing, 53(2), 221–232.
Puhl R and Heuer C The Stigma of Obesity: A Review and Update. Obesity, 17(5),
Puhl R; Warton C, Heuer Weight Bias among Dietetics Students: Implications for Treatment Practices. Journal of the American Dietetic Association, 109,
Rengasamy, S. (2009, June 26). Advocacy and lobbying. Retrieved August 12, 2009, from

84. References
Scherbakov et al., (2011). Body weight after stroke: lessons from the obesity paradox. J Am Heart Assoc. 42, 1-5.
Schwartz, M. (2001). Brain pathways controlling food intake and body weight. Experimental Biology & Medicine, 226(11),
Schwartz MB Weight Bias among Health Professionals Specializing in Obesity. Obesity Research, 11(9),
Sumithran et al. (2011). New Eng J Med, 365(17),

85. Recommended Reading
Aphramor L. (2009). Weight management as a cardioprotective intervention raises issues for nutritional scientists regarding clinical ethics. Proc Nut Soc, 67, E401.
Aphramor L. (2005). Is A Weight-Centred Health Framework Salutogenic? Some Thoughts on Unhinging Certain Dietary Ideologies. Social Theory and Health, 3, 315–340.
Aphramor L, Gingras J. (2009). That remains to be seen: Disappeared feminist discourses on fat in dietetic theory and practice. (pp. 97–105). In: The Fat Studies Reader. E. Rothblum & S. Solovay (Eds.). NY: NY University Press.
Bacon L. (2010). Health at Every Size: The Surprising Truth About Your Weight. Second. Dallas: BenBella Books.

86. Recommended Reading
Brownell, K., Puhl, R., Schwartz, M., & Rudd, L. E. (2005). Weight bias: Nature, consequences, and remedies. NY: Guilford.
Campos, P., Saguy, A., Ernsberger, P., Oliver, E., & Gaesser, G. (2005). The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiol, 35, 55–60.
Gaesser, G. (2002). Big Fat Lies: The Truth About Your Weight and Your Health. Carlsbad, CA: Gurze Books.
Gard, M., & Wright, J. (2005). The Obesity Epidemic. NY: Routledge.
Gingras, J. (2006). Throwing their weight around: Canadians take on Health at Every Size. HAES, 19(4),
Holm, S. (2007). Obesity interventions and ethics. Obesity Reviews, 8(Suppl 1):207–210.

87. Recommended Reading
Neumark-Sztainer, D. (2005). Can We Simultaneously Work Toward the Prevention of Obesity and Eating Disorders in Children and Adolescents? International Journal of Eating Disorders, 38,
Puhl RM, Andreyeva T, Brownell KD. (2008). Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in America. Int J Obes, 32, 992–1000.
Puhl R, Heuer C. (2010). Obesity Stigma: Important Considerations for Public Health. Am J Public Health, 100, 1019–1028.
Tribole E, & Resch E.(2010). Intuitive eating: a revolutionary program that works. New York: St. Martin's Griffin.

88. Microsoft Engineering Excellence
Save the dates
May 6th International No Diet Day
May 6-12, Mental Health Awareness Week
September Weight Stigma Awareness Week
Conferences/Gatherings
May 9th-10th Body-Image and Self-Esteem Conference-Toronto, ON
August 15th-17th 2013 Critical Dietetics Conference, Wolfville, NS
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